Sensible Medicine

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Here is the profile for Harvard Professor Robert (Bobby) Yeh. His most recent Circulation paper: Bringing the Credibility Revolution to Observational Research in Cardiology. We referenced a paper by Professor Miguel Hernan: The C-Word: Scientific Euphemisms Do Not Improve Causal Inference From Observational DataPaper referenced on left ventricular assist devices: Comparative Effectiveness of Percutaneous Microaxial Left Ventricular Assist Device vs Intra-Aortic Balloon Pump or No Mechanical Circulatory Support in Patients With Cardiogenic ShockSensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.I learned a lot from this conversation. One of the main lessons is that no matter how well the authors avoid causal language, the intent of an observational comparison study is causal. And if that is so, the main thrust of these efforts ought to be simulate, as close as possible, a randomized clinical trial. One of my favorite parts of our chat was Bobby’s now famous explanation of immortal time bias using Cheetos. Let us know what you think. I hope to do more of these types of conversations. JMM This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

BW was a 66-year-old woman who presented for an urgent visit to the general medicine clinic. She reported that she had been having dizziness for the last four days. When pressed, she said it occurred intermittently, being present more than absent. She could not identify any palliative or provocative features, and when asked about associated symptoms she said that she felt “bad and scared” when it was present. The doctor encouraged her, many times, to characterize the dizziness, and she could only say that when she had it, she felt dizzy.Sensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber.Many a medical trainee has been humiliated on morning rounds after proclaiming that their presentation was wanting because the “patient was a poor historian.” Any attending worth her white coat will respond in one of the following ways:“There are no poor historians, just poor history-takers.”“You do realize, don’t you, that the patient is not the historian? You are the historian.”“Did you consider the differential diagnosis of why you were unable to obtain a useful history?”I admit that, going for pith over constructive criticism, I employ the former two more than the latter one. There is a differential diagnosis for the patient who cannot describe the history of their medical concerns.Often, the inability of a doctor to obtain a history is actually a physical exam finding – an extremely non-specific finding, but a finding nonetheless. Psychiatric disease, dementia, and delirium (whose differential diagnosis itself is practically a textbook of medicine) will render a patient unable to provide an accurate history. I can recall dozens of “poor historians'' who became Robert Caro-esque once their hypercapnea, uremia, or alcohol withdrawal was treated.There are three other reasons that obtaining reliable and informative histories might be a struggle.1. We think with languageThe first — the saddest, most troublesome, and probably most common – reason that patients are unable to provide a reliable history is because of their impaired language skills. Not only do we use language to communicate, we also use language to think. George Orwell wrote, “…if thought corrupts language, language can also corrupt thought.”[i]Those of us who failed to master language, usually through inadequate education, are unable to express their health concerns clearly. Sometimes, listening to a patient try to describe symptoms, I get the sense that the problem is more than expressive.BW was not an especially striking example of this for me, she was just one of the more recent. She also presented with a problem for which an accurate history is critical. The history of a patient's dizziness radically alters the differential diagnosis. We teach trainees that the first question to pose to a patient with dizziness is, “What do you mean, dizzy?” We tell the trainee to ask the question and then sit back and listen. More often than not, patients will describe their dizziness in a way that can be interpreted as lightheadedness, vertigo, unsteadiness, or a non-specific feeling of being unwell.[ii]As I interviewed BW, my sense was that she not only struggled to articulate what she was feeling but to figure it out herself. Beyond my frustration in having trouble caring for her, I considered the lifelong impact of leaving people educationally impoverished. Sure, we limit people’s earning potential, but we also limit their internal life and their healthcare.2. Anxiety affects how we experience symptomsVG is a patient I have seen for years, from his mid 30’s to his early 60’s. He has a few very mild chronic medical conditions and very severe anxiety disorder. He is a successful professional but struggles with intermittent episodes of health-related anxiety.Our interactions usually begin with an email or a phone call. VG will have become anxious about a new symptom. The symptom is real – joint pain, a rash, a new floater. The symptom has generated a web of worry about what it could portend. The worries are always baseless and would be amusing if they were not so clearly painful and disturbing to him.I have learned that for VG, as well as for many patients like him, these concerns require a visit. An accurate history cannot be obtained without seeing him. The anxiety clouds VG’s experience of the symptom. The knee pain becomes excruciating, the rash ubiquitous, the floater debilitating. The response to simple questions -- Is the knee pain worse coming down the stairs? Where is the rash? Do you see the floater in one or both eyes? -- become unreliable. Seeing VG, providing some reassurance, and obtaining objective physical data is imperative.3. Secondary gain“Listen to your patient; he is telling you the diagnosis” is is an Osler (or merely Oslerian) quotation. From the earliest days of our training we are taught to listen to our patients and believe what they are telling us. Our greatest sin in hist

There is something valuable about learning to adapt old skills to novel situations. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Adam and I discuss three topics I) The MIND Trial published in NEJM. Does a special diet reduce the future risk of cognitive decline?II) HFpEF — I am speaking at a congress on heart failure with preserved ejection fraction this week, and Adam helps me out with some pointers. III) NYT published a Sunday front page story on potential overuse of procedures for peripheral artery disease. JMM This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Four pieces of advice nobody asked for. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

KW was a 58-year-old man with long standing type 1 diabetes mellitus and hypertension. He came to an appointment one Friday afternoon with chest pain. The pain had been present intermittently for 10 days. It was on the left side of his chest and beneath his sternum. It did not radiate anywhere, it was not related to exertion, nor was it associated with diaphoresis or shortness of breath. It was also not positional and there were no areas of tenderness.Sensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber.When I was a kid, we often played “Would You Rather?” to pass the time during a car or bus ride. This game had remarkable staying power. When we first started playing, at about age ten, the questions were mostly things like:Would you rather eat a cicada or a cricket?As we aged, the questions progressed through the usual male adolescent fare to more profound philosophical quandaries:If you managed the Mets, would you rather pitch Seaver or Koosman?Would you rather have a Ferrari or a Porsche?Would you rather date Lauren or Lizzie?Would you rather visit the past or the future?From a professional standpoint, there is no question that my answer to the final question would be, “the past.” There are a dozen or so patients that I want a second chance at. I wonder if, knowing what I know now, would I manage things differently?[1] Would the outcomes be different? Would some of the people still be here?I should not have admitted him. For my entire career I have had a clinic scheduled on Friday afternoon. My reasoning is two-fold. First, I know that if I didn’t have patients scheduled Friday afternoon, I’d probably kick off early. Having a full schedule on Fridays assures that I stick it out to the bitter end, thus making me more productive each week. Second, most people opt not to see patients Friday afternoon so I tend to get more support as one of the few doctors working. The downside of this is that I am seeing patients when my management options are somewhat limited. Patients present with troublesome symptoms that they “just want checked out before the weekend” and I’m left either worrying about them all weekend or admitting them to the hospital where I know little will happen for the next two days. There was a lot about KW’s chest pain that was not concerning for symptomatic coronary artery disease. It was not exertional. The episodes sometimes lasted minutes and sometimes hours. It was not accompanied by shortness of breath, diaphoresis, or a feeling of impending doom. He also had had a normal stress test a couple of years before. On the other hand, KW was a middle-aged American man with chest pain and significant risk factors for coronary artery disease – hypertension and diabetes – neither of which had ever been terribly well-controlled. I made the decision that I felt was safest for him and the one that would let me sleep best all weekend; I admitted him to the hospital. I called the admitting resident; I let her know that I was (a little) worried that he had unstable angina and that I was admitting him so that he could be observed until he could get an assessment of his coronary arteries.The resident (not incorrectly) decided that if he might have unstable angina, he should be started on a blood thinner – heparin.In the end, KW did not have unstable angina, a coronary angiogram done weeks later was normal. Why did it take weeks to complete the angiogram? Because after being started on heparin, he had an intracranial hemorrhage – a bleed in his brain.I should have admitted her.PH is a woman I have written about in the past. She presented to me early in my career having lost about a third of her body weight to an undiagnosed, metastatic cancer. She did not require hospitalization. She was well hydrated and her vital signs were normal. She had walked into the office that first day and would need only a wheelchair to come and go to her last visit 6 months later. She did not require hospitalization for evaluation or treatment. There would be little we could offer her beyond the palliative care that I could direct at her home.I managed her evaluation and her care while she remained an outpatient. By the time she died, this management had included intravenous fluids, pain medications, antiemetics, and seizure medications. My memory was that what drove my effort to keep her out of the hospital was more my philosophy than her and her family’s wishes. At the time, I believed that unnecessary hospitalizations were an anathema. They wasted money, put patients at risk, and were the refuge of lazy or unskilled physicians. I do remember that PH wanted to avoid aggressive care, but I cannot remember her explicitly resisting hospitalization. I do remember her brother once asking, “Shouldn’t she be in the hospital?”From my current vantage point, my efforts to keep her out of the hospital seem, at best, ill-advised. It seems my management decisions were mo

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This ghost panel is made up of people who used to be my patients but no longer are — people who left my practice without telling me. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Links The Case for Being a Medical Conservative https://www.amjmed.com/article/S0002-9343(19)30167-6/fulltextELAN Trial https://www.nejm.org/doi/full/10.1056/NEJMoa2303048Mandrola on NYC Residents’ Strike https://www.medscape.com/viewarticle/992607 This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

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I visit the binder to pay my respects, to learn, to reminisce, and to trace the arc of my career. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Medicine in America will be better, more humane, and more affordable with more good, smart, dedicated primary care physicians. Be part of the solution. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Why did it take years for me to reach a time in my career when I am comfortable admitting knowledge gaps? This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

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When patients meet a new doctor, both patient and doctor should be aware of each other’s philosophy. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Chat GPT - Medical Journals - Preventive medicine This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

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Mandrola, Prasad and Hoeg are back to talk about a new exercise study— can you do too much— and then COVID19 pandemic errors. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Prasad, Cifu, Mandrola, Hoeg, Makary are back for a discussion. Next week we will only have 3 guests. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

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Check out this all star line upCifu/ Mandrola/ Hoeg/ Foy/ Damania/ Prasad - talk about equipoise, randomization, and more This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

A Guest Friday Reflection: On Death and Its Futility This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe