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beware of the bio plausible

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  • Avatar Tangler 
    Participant
    Status: Physician
    Posts: 358
    Joined: 08/23/2018

    Good points. I see what you mean. I probably over-reacted & misinterpreted.

    I don’t have any magic answers and i hear what you are saying.

    It is a tough job.

    #219231 Reply
    Liked by Zaphod
    portlandia portlandia 
    Participant
    Status: Physician
    Posts: 401
    Joined: 07/07/2017

    If everyone practiced perfect evidence-based medicine, the American public would hate their healthcare even more and feel like nobody was doing anything.

    Click to expand…

    “The art of medicine consists in amusing the patient while nature cures the disease.”

    #219241 Reply
    Avatar burritos 
    Participant
    Status: Physician
    Posts: 494
    Joined: 04/23/2018

    Yikes, i hate being wrong. Sometimes it is hard being a biased overconfident pattern seeking primate.
    One reason to become FI is to potentially feel more empowered to say no. A position where you can tell folks : “Sorry, that won’t help” or “sorry that is more likely to harm than help”. Do no harm. Easier said than done. Especially if you are an indentured servant.
    The investment correlation is in the second link. investing Podcast looking at same idea (flawed science/evidence) and the investor.

    http://getpocket.com/explore/item/when-evidence-says-no-but-doctors-say-yes

    https://podcasts.apple.com/us/podcast/invest-like-the-best/id1154105909?i=1000439925357

    Click to expand…

    You must be a young doctor. We all know this, don’t we? You’ve never heard of treating the well worried?

    Patients who ask whether they need something, I respond with, “We can either ‘Do SOMETHING or Do NOTHING.’ What you have is 75-99%(depending on ailment) likely going to improve/resolve, but if you happen to be in the 25-1% where you got worse, I don’t want to be the doctor who DID NOTHING. So I’m going to write you this RX/MRI/referral/high radiation imaging study/PT/etc.. and you can decide whether you want to take it/do it.”

    #219244 Reply
    Liked by Zaphod
    Avatar Tangler 
    Participant
    Status: Physician
    Posts: 358
    Joined: 08/23/2018

    But, my point, and the point of the article is that if the “do something” is really risky (ex cardiac stent in stable angina) and of NO benefit, then doing nothing should be commended, and doing risky procedures/treatments appalling. I am naive, a little unrealistic, a little idealistic, but not super new to this game; finished residency in 2004. I get it, sometimes the path of least resistance is harmless pandering to the patient’s wishes, but make sure your not taking bitcoin type risks.
    The article is worth a read. See if you feel like i am crazy when you finish it.

    #219279 Reply
    Liked by portlandia, Zaphod
    Avatar GPGP 
    Participant
    Status: Physician
    Posts: 186
    Joined: 05/02/2017

    Lordosis- re unnecessary lab tests, ekg, etc. the latest our insurers are doing is denying a lab (say vitamin d or tsh done at a physical just because) — while simultaneously not allowing us to charge the patient. I’ve asked if “patient requested test” lets us bill the patient. Otherwise, I’m starting to tell people to go down the street to any lab test now and get what they want. I do work with them and it’s a reasonable request, do stuff that lacks evidence. (Absence of evidence is not proof of ineffectiveness or harm). With Medicare it’s easier with unneeded labs. Once patients see that ABN that their vitamin D is a couple hundred, they tend to say “um, never mind”.

    #219294 Reply
    Liked by Lordosis
    Avatar highdoseamox 
    Participant
    Status: Physician
    Posts: 16
    Joined: 05/18/2019

    For example, did you know they dont wear masks in the OR in the UK, or rather its optional? Crazy right. How about booties in the OR? Neither have any evidence of infection risk or deterrence and the booties have no realistic plausibility anyway.

    I would still wear both if only for personal protection though.

    Some of these things arent harmful and some are cheap, but theyre still lacking in evidence or firmly disproven. This is exceedingly common in medicine and life in general. Dont fight it to much you will drive yourself mad.

    Click to expand…

    No masks in OR? Interesting.

    I would be happy if we could get rid of the yellow MRSA gowns in the hospital. No way those are doing anything other than causing docs, Rns hassle.

     

    Click to expand…

    The lack of the yellow gowns is one of the biggest  differences from an inpatient heavy residency to outpatient primary care career. Good hand hygiene and so far no one has passed on their MRSA. Now if you’re vomiting then mask and gloves for me all day.

     

    OP, very interesting article. This is the stuff I try to gingerly tell my one high healthcare utilizing parent. If you keep going, things will keep getting ordered and yet symptoms never seem to improve, now so caught up in poly-specialist medicine that she is missing out on life to compare what the allergist said to what the pulmonologist said to what the PCP said.

    #219308 Reply
    Liked by Anne, Zaphod
    Zaphod Zaphod 
    Participant
    Status: Physician, Small Business Owner
    Posts: 6186
    Joined: 01/12/2016

    But, my point, and the point of the article is that if the “do something” is really risky (ex cardiac stent in stable angina) and of NO benefit, then doing nothing should be commended, and doing risky procedures/treatments appalling. I am naive, a little unrealistic, a little idealistic, but not super new to this game; finished residency in 2004. I get it, sometimes the path of least resistance is harmless pandering to the patient’s wishes, but make sure your not taking bitcoin type risks.
    The article is worth a read. See if you feel like i am crazy when you finish it.

    Click to expand…

    I think this should be the baseline regardless. Im constantly in awe of how peoples risk/reward mechanisms get skewed to the risk side just because of our familiarity and comfort level with it. That doesnt make it any less risky and just because you get it, doesnt mean the pt really does.

    Have had this mismatch problem with other docs too and have several times refused to operate on people who were otherwise cleared by pcp or specialists. Not that they were high risk, but when the operation you’re being cleared for is 100% elective and unnecessary, the threshold for acceptable risk taking needs to be much higher, which no one seems to understand though it should be obvious at first glance.

    We get used to our roles of interveners and comfortable with risk.We should every now and then look at the whole situation and reassess and make sure it makes sense.

    Otoh, what I find truly difficult is the flip side benefit. These pushing of the envelopes and doing things that may not be useful (in hindsight) or aggressive at the time (but appropriate in hindsight) is how medicine evolves and improves. If we did nothing new and just what we knew worked we may not progress. A conundrum.

    #219309 Reply
    Liked by billy
    Avatar HikingDO 
    Participant
    Status: Physician
    Posts: 345
    Joined: 03/09/2017

    Exactly. An evidenced based physical on a healthy adult would take me all of about 30 seconds. Instead I do the song and dance of listening to the heart and lungs, palpating the abdomen, etc, because without it I’d be ripped to pieces on my patient evaluation scores.

    Click to expand…

    Again, really? Perhaps talk to the patient and explain to them what you are looking for and why? Example, ortho doc only looking at the concerned joint might say: “I am going to focus on your knee today, if that is ok with you, if there is something else we need to focus on, let me know” or the Anesthesiologist listening to the heart and lungs and doing a detailed airway examination prior to surgery.

    Like investing, perhaps have a reason for doing what you do? Why do I do this?

    If you are doing a “song and dance”, I don’t want you for my doc. Ok, that is a little harsh and I am guilty too, but we should be thinking about these things, I think. The article is long, but worth a read.

    Click to expand…

    Of course I’d prefer to do an evidenced based physical, but as a family medicine doc who practices in a large hospital owned corporation, sees 25 patients a day, and has to deal daily with patient satisfaction scores, I unfortunately have to live in the world of reality. If you’re an FM or IM doc who does a physical on a patient without touching them, since in their age group there may be no evidence that there’s a benefit to doing it, and your patients are OK with that, I want to work in your practice.

    #220697 Reply
    Liked by Zaphod
    Avatar Anne 
    Participant
    Status: Physician
    Posts: 1168
    Joined: 11/07/2017

    Exactly. An evidenced based physical on a healthy adult would take me all of about 30 seconds. Instead I do the song and dance of listening to the heart and lungs, palpating the abdomen, etc, because without it I’d be ripped to pieces on my patient evaluation scores.

    Click to expand…

    Again, really? Perhaps talk to the patient and explain to them what you are looking for and why? Example, ortho doc only looking at the concerned joint might say: “I am going to focus on your knee today, if that is ok with you, if there is something else we need to focus on, let me know” or the Anesthesiologist listening to the heart and lungs and doing a detailed airway examination prior to surgery.

    Like investing, perhaps have a reason for doing what you do? Why do I do this?

    If you are doing a “song and dance”, I don’t want you for my doc. Ok, that is a little harsh and I am guilty too, but we should be thinking about these things, I think. The article is long, but worth a read.

    Click to expand…

    Of course I’d prefer to do an evidenced based physical, but as a family medicine doc who practices in a large hospital owned corporation, sees 25 patients a day, and has to deal daily with patient satisfaction scores, I unfortunately have to live in the world of reality. If you’re an FM or IM doc who does a physical on a patient without touching them, since in their age group there may be no evidence that there’s a benefit to doing it, and your patients are OK with that, I want to work in your practice.

    Click to expand…

    Agree the non-targeted physical exam is generally a waste.  But haven’t you noticed that some people might open up to you more after you spend some time with and examine them?  One recent example–patient with vague msk/neuro c/o, didn’t make sense, history and findings were inconsistent from the start, I felt like I was doing a song and dance too but I did my usual thorough msk and neuro exam, which gave time to build rapport.  At the end she broke down and told me about the domestic violence situation she was in and I was able to connect her with resources.  Sometimes what brings people to the doctor can’t be detected on exam/lab work etc. but if we don’t go through the motions the patient won’t be comfortable enough to tell us the truth.   Not that we can always help…

    #220814 Reply
    Liked by Zaphod

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