Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

[alfablue]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

The one knock against some medical experiences is that they don't bring a 360 degree look...when a 360 degree look is helpful.

For example, I was treated for an internal medicine condition that required specialist attention. The second specialist did a great job (the first was not direct enough...and so I didn't know my problem was serious). But I had to request a simultaneous diet and physical exam regiment at the same time - the doctors did not do that. My insistence turned out to be a key aspect of the whole recovery.

Every medical provider should have a complete solution tree from the top down for designated hospitalization conditions...and a referral on a personalized diet and exercise regimen should be a default.

+ a lot.

A similar story with relatives I know- where an original "accident" was ignored, and just the easy button for the symptoms were treated. It was finally looked at closer over a month later, which lead to immediate surgery. A month earlier would have made the recovery easy. A month later, and death due to a totally missed, but pretty obvious, injury.

It's hard to trust people who don't listen and don't pay attention.

[WisconsinWildcard]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

The one knock against some medical experiences is that they don't bring a 360 degree look...when a 360 degree look is helpful.

Absolutely. Every experience is different, but it is not always the practitioners fault. I think a good physician has to be able to read a room. You have to know what level to speak at to be understood but not insulting. You need to assess what to focus on, in an efficient manner. The more things you tell someone they should be doing, the less likely they are to do them. People forget about 80% of what you tell them and often misinterpret the rest. Not that you used it but I do hate the term "holistic" as I think every good physician should be taking the whole patient into account, regardless of the specialty.

Every medical provider should have a complete solution tree from the top down for designated hospitalization conditions...and a referral on a personalized diet and exercise regimen should be a default.

That is really unrealistic. It vastly underestimates the complexity of the patient. It can work for certain conditions that are more amenable for "cook book" medicine initially like chest pain or straightforward stroke but that approach can lead to trouble. You need to take into account many variables, resources at hand, etc and use prior plausibility based on your available clinical information to properly treat a patient, and there is no way you can have a complete solution tree for "designated hospitalization conditions." I think you also underestimate the click box fatigue of an EMR. If I admit 5-10 patients a day, I am clicking several hundred click boxes. The more you add, the more likely they are auto piloted. Bloat of EMR is a huge problem and it is not getting better (remember, the EMR was designed for billing, no clinical efficiency).

I agree that diet and exercise is probably the most important health factor in the majority of conditions but I disagree that it should be a default (at least in the current system). I think that is a very privileged position to take. I am happy for you that you can afford the time and effort for that but that is not the reality of most Americans. Good dietitians are not abundant nor are they covered by most insurance for many things. People cannot afford to join a gym or exercise if they have a 2 jobs that they are trying to keep to feed their family and they just suffered a medical setback (both in time and financially). Many people cannot afford to get a second opinion because their insurance only covers one network.

Lastly, there are many personalized diet programs that are not at all evidence based. People have dietary ideas for nearly everything but that does not necessarily mean they improve outcomes. If outcomes are not improved, we should not be spending our money on it. The dietary literature is well known to be lacking in rigor, but hopefully this will improve.

[WisconsinWildcard]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

A similar story with relatives I know- where an original "accident" was ignored, and just the easy button for the symptoms were treated. It was finally looked at closer over a month later, which lead to immediate surgery. A month earlier would have made the recovery easy. A month later, and death due to a totally missed, but pretty obvious, injury.

You have to be careful not to run too far with this idea. Take TIAs (Transient Ischemic Attacks). In the right setting, it is a neurological emergency where you should be admitted and receive an expedited work-up. On the otherhand, certain factors can predict that it is less serious and that the patient can be worked up as an outpatient. Say we use the ABCD2 score https://en.wikipedia.org/wiki/ABCD%C2%B2_score

Now I have a patient with a score of 1. Their 7 day risk of stroke is 1% and thus is low. I discharge them home for outpatient workup (in the next 2-3 days). Lets say they have good insurance, I should be able to get it done without an issue. That night, they have a large stroke and I look like an incompetent physician. Family and friends now have a story to tell how this heartless and stupid doctor discharged a patient from the ED when they were going to have a massive stroke.

When I discharge that patient, I know their risk, for every 100 patients I do this to, 1 will have a stroke. It is an accepted risk, and it should be discussed with the family. However if I were to admit all 100 of those patients to prevent 1 stroke, I would bankrupt the system. Insurance would not cover the admission...patients would foot the bill. Most patients cannot afford an uncovered hospital admission and the hospital would go unpaid.

The system is complex but you have to be careful. For most people, an anecdote can trump significant amounts of data. We all remember that patient we missed something on when following the standard of care. However we have to take into account what is best for the patient, best for the system, and best for society. Extensive work-up is often harmful. False positives are frequent when you test multiple things. You have to take into account prior plausibility to make clinically meaningful decisions.

[walrus]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

Lastly, there are many personalized diet programs that are not at all evidence based. People have dietary ideas for nearly everything but that does not necessarily mean they improve outcomes. If outcomes are not improved, we should not be spending our money on it. The dietary literature is well known to be lacking in rigor, but hopefully this will improve.

I do a specialized diet for Colitis, My GI says diet doesn't matter. I say he should start reading the research Seattle Childrens, Rush University and Umass Boston have been doing.

[WisconsinWildcard]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

I do a specialized diet for Colitis, My GI says diet doesn't matter. I say he should start reading the research Seattle Childrens, Rush University and Umass Boston have been doing.

I am not an expert in GI so I will not directly comment on the research. But as long as the diet does not seem to present a harm or interfere with treatment, they should be OK with it. Sometimes research is preliminary and your GI is right to be skeptical. They could also be behind the current literature and are wrong to be skeptical. I think the most important thing is to be able to have an open conversation, and to not shame patients for doing their own research or trying things. The worst case in that situation is to come off as arrogant* or make the patient feel stupid and then stifle dialog. I have plenty of patients doing things that I do not think there is strong evidence for. If I think it is not efficacious but not harmful, I usually tell them but in a way that is hopefully non-judgmental and respects their autonomy. If I think it is harmful, I am a bit more forceful in my recommendation.


*I do recognize the irony that I probably come off as arrogant at time on here but know this: 1. None of you are my patients 2. Everyone has a different tone in person vs online and 3. Like many physicians with blogs (respectful insolence, neurologica, etc) or comment sections, I do use this as a break from the madness of medicine and as a way to vent

[walrus]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

I am not an expert in GI so I will not directly comment on the research. But as long as the diet does not seem to present a harm or interfere with treatment, they should be OK with it. Sometimes research is preliminary and your GI is right to be skeptical. They could also be behind the current literature and are wrong to be skeptical. I think the most important thing is to be able to have an open conversation, and to not shame patients for doing their own research or trying things. The worst case in that situation is to come off as arrogant* or make the patient feel stupid and then stifle dialog. I have plenty of patients doing things that I do not think there is strong evidence for. If I think it is not efficacious but not harmful, I usually tell them but in a way that is hopefully non-judgmental and respects their autonomy. If I think it is harmful, I am a bit more forceful in my recommendation.


*I do recognize the irony that I probably come off as arrogant at time on here but know this: 1. None of you are my patients 2. Everyone has a different tone in person vs online and 3. Like many physicians with blogs (respectful insolence, neurologica, etc) or comment sections, I do use this as a break from the madness of medicine and as a way to vent

He is ok with it, he didn't like me stopping a biologic for it. It's been 6 years, my bloodwork is fine, no active disease via colonoscopy. I've had a flare every year for the 25 years previous to the dietary changes. Specific Carbohydrate Diet

Sent from my SM-G950U using Tapatalk

[alfablue]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

You have to be careful not to run too far with this idea. Take TIAs (Transient Ischemic Attacks). In the right setting, it is a neurological emergency where you should be admitted and receive an expedited work-up. On the otherhand, certain factors can predict that it is less serious and that the patient can be worked up as an outpatient. Say we use the ABCD2 score https://en.wikipedia.org/wiki/ABCD%C2%B2_score

Now I have a patient with a score of 1. Their 7 day risk of stroke is 1% and thus is low. I discharge them home for outpatient workup (in the next 2-3 days). Lets say they have good insurance, I should be able to get it done without an issue. That night, they have a large stroke and I look like an incompetent physician. Family and friends now have a story to tell how this heartless and stupid doctor discharged a patient from the ED when they were going to have a massive stroke.

When I discharge that patient, I know their risk, for every 100 patients I do this to, 1 will have a stroke. It is an accepted risk, and it should be discussed with the family. However if I were to admit all 100 of those patients to prevent 1 stroke, I would bankrupt the system. Insurance would not cover the admission...patients would foot the bill. Most patients cannot afford an uncovered hospital admission and the hospital would go unpaid.

The system is complex but you have to be careful. For most people, an anecdote can trump significant amounts of data. We all remember that patient we missed something on when following the standard of care. However we have to take into account what is best for the patient, best for the system, and best for society. Extensive work-up is often harmful. False positives are frequent when you test multiple things. You have to take into account prior plausibility to make clinically meaningful decisions.

Sorry, but that just screams as an excuse for not paying attention. I see your point, but my issue was a head injury (fall), which manifested itself into nausea. And when one talked to the person, it was clear that they were not 100% lucid.

I'm not a doctor, but know enough that all of those things add up to a rather nasty head injury which may be causing other damage.

Instead, they gave stomach medicine, and was told to eat easier food.

Not paying attention until a real check of the head was done almost killed him.

This isn't about the further risks of what is going on, this is just not paying attention to all of the symptoms and/or being smart enough to consider putting them together.

Unless there is a paragraph in the system that suggests that when someone falls and hits their head, gets sick for it, that you should address the symptoms instead of what caused the symptoms, as it's cheaper to wait...

[WisconsinWildcard]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

Sorry, but that just screams as an excuse for not paying attention. I see your point, but my issue was a head injury (fall), which manifested itself into nausea. And when one talked to the person, it was clear that they were not 100% lucid.

I'm not a doctor, but know enough that all of those things add up to a rather nasty head injury which may be causing other damage.

Instead, they gave stomach medicine, and was told to eat easier food.

Not paying attention until a real check of the head was done almost killed him.

This isn't about the further risks of what is going on, this is just not paying attention to all of the symptoms and/or being smart enough to consider putting them together.

Unless there is a paragraph in the system that suggests that when someone falls and hits their head, gets sick for it, that you should address the symptoms instead of what caused the symptoms, as it's cheaper to wait...

I was not talking about your specific case but in general because I do not know enough information about individual cases to speak on them. One needs to see the patient, take the history. It was not intended as an excuse. I was detailing how you can pay attention, know the risks, follow standard of care, and still have someone have a bad outcome. It is a calculation we make on a daily basis, and if we screw up, we can lose our job, our license, and be in significant financial issues. It does not matter if you made the right call in 1000 patients, if you miss that 1001st patient, you are going to get sued.

Again, not directly addressing your case but speaking generally, in most adults (if not all) who fall with hitting their head will get a head CT, maybe neck CT. If you added nausea and AMS (altered mental status), I would argue it would be malpractice not to. CT of head rules out hemorrhage, fracture (99% sensitivity or so). It also is a very good assessment of ventricular megaly, obstructive hydrocephalous, etc (things you should be worried about with nausea and AMS). If all of that is OK, it might be reasonable to send a patient home. You should also address their symptoms.

It is also not just cheaper to wait, but sometimes safer. Take the above example in a child or young adult. If they are improving, seems just like a concussion, you may wait on a head CT. There is a lot of radiation and you are non-trivially increasing someone who is young's chance for brain cancer. If they have reliable parents, or good support, you may send them home without the scan with instructions to return if it is not better or see your PCP in the morning.

The point is procedure trees, decision trees, etc have a somewhat limited use and need to be implemented carefully. They can lead to cookbook medicine, which is unthinking, and often can lead to harm. Checklists are important, and have been proven to improve outcomes. But implementing strict algorithms across the board lead to overtesting, undertesting, and doctors who shut their brain off.

[joecct]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

The Ring of Fire waking up??

@FoxNews: Japan hit by 6.2 earthquake off coast of Honshu, day after Alaska quake http://www.foxnews.com/world/2018/01...ska-quake.html

There was one in the Indonesia area a few days before the Alaska quake.

[alfablue]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

I was not talking about your specific case but in general because I do not know enough information about individual cases to speak on them. One needs to see the patient, take the history. It was not intended as an excuse. I was detailing how you can pay attention, know the risks, follow standard of care, and still have someone have a bad outcome. It is a calculation we make on a daily basis, and if we screw up, we can lose our job, our license, and be in significant financial issues. It does not matter if you made the right call in 1000 patients, if you miss that 1001st patient, you are going to get sued.

Again, not directly addressing your case but speaking generally, in most adults (if not all) who fall with hitting their head will get a head CT, maybe neck CT. If you added nausea and AMS (altered mental status), I would argue it would be malpractice not to. CT of head rules out hemorrhage, fracture (99% sensitivity or so). It also is a very good assessment of ventricular megaly, obstructive hydrocephalous, etc (things you should be worried about with nausea and AMS). If all of that is OK, it might be reasonable to send a patient home. You should also address their symptoms.

It is also not just cheaper to wait, but sometimes safer. Take the above example in a child or young adult. If they are improving, seems just like a concussion, you may wait on a head CT. There is a lot of radiation and you are non-trivially increasing someone who is young's chance for brain cancer. If they have reliable parents, or good support, you may send them home without the scan with instructions to return if it is not better or see your PCP in the morning.

The point is procedure trees, decision trees, etc have a somewhat limited use and need to be implemented carefully. They can lead to cookbook medicine, which is unthinking, and often can lead to harm. Checklists are important, and have been proven to improve outcomes. But implementing strict algorithms across the board lead to overtesting, undertesting, and doctors who shut their brain off.

Again, I agree that there are risks, even doing the "right" thing.

But you need to recognize that not all doctors are good. They don't pay attention to all the symptoms. There are many who lord over their patients as if they barely matter.

That's the real issue- just because you spent the time getting a Dr put in front of your name, that does not always mean you are really that smart or that ethical. And that's why people don't trust doctors. You being a doctor can help clean that crap up, but instead, you just make excuses for them- because your example of leading to "cook book medicine" is more valid than others experiences. You should pay attention to what people are actually saying about doctors instead of assuming whatever it is that you are assuming.

[WisconsinWildcard]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

But you need to recognize that not all doctors are good. They don't pay attention to all the symptoms. There are many who lord over their patients as if they barely matter.

I do. They are also a minority. I also argue state medical boards should have more power to go after those physicians.

That's the real issue- just because you spent the time getting a Dr put in front of your name, that does not always mean you are really that smart or that ethical. And that's why people don't trust doctors. You being a doctor can help clean that crap up, but instead, you just make excuses for them

I do not think I made an excuse for anyone. I even gave you an example where I would argue malpractice was performed. Also this is a message board, this is not what I "do." In the grand scheme of things, I probably spend less than 1% of my total time on here.

I am active on our institutions quality improvement board. I teach medical ethics and evidence based medicine to a large residency program. I train people to be better, more compassionate doctors.

- because your example of leading to "cook book medicine" is more valid than others experiences. You should pay attention to what people are actually saying about doctors instead of assuming whatever it is that you are assuming.

I am not trying to invalidate your experience. I am trying to show you the other side. There is much of medicine that is very difficult to comprehend unless you see it first hand so I was attempting to show you how a physician might think about a patient and how every day we send people home knowing a "known" percentage will have a bad outcome.

Just an FYI. if I admit a patient that does not meet "inpatient criteria" as deemed by insurance or medicare, insurance does not cover it and the patient is left with the entire bill of the hospitalization. You can financially destroy someone very easily as a physician and you can do so even if you are only being "sure" nothing is wrong. It is not a responsibility I take lightly.

[alfablue]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

If they were really that much of a minority, then the distrust of doctors would not be so high. Just want to point that out.

Most of the distrust of people have a source. And in this case, it's the doctors not being THAT trustworthy.

[unofan]

If they were really that much of a minority, then the distrust of doctors would not be so high. Just want to point that out.

Most of the distrust of people have a source. And in this case, it's the doctors not being THAT trustworthy.

I disagree to the extent the Internet has led to a general mistrust of experts and the concept of expertise in general. "That (doctor/lawyer/engineer/mechanic/professor) doesn't know what he's talking about; look what I found after a 2 minute Google search."

Healthy skepticism had been replaced by outright disbelief.

[alfablue]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

I disagree to the extent the Internet has led to a general mistrust of experts and the concept of expertise in general. "That (doctor/lawyer/engineer/mechanic/professor) doesn't know what he's talking about; look what I found after a 2 minute Google search."

Healthy skepticism had been replaced by outright disbelief.

While I 100% agree with the people who are like that, I also don't think that the numbers are nearly as high as you think they are. I think those people have enough of a voice that they seem more important, but real interactions with real people would suggest that they don't have nearly that much influence.

[FlagDUDE08]

Re: Science: Everything explained by PV=nRT, F=ma=Gm(1)•m(2)/r^2

I disagree to the extent the Internet has led to a general mistrust of experts and the concept of expertise in general. "That (doctor/lawyer/engineer/mechanic/professor) doesn't know what he's talking about; look what I found after a 2 minute Google search."

Healthy skepticism had been replaced by outright disbelief.

WebMD told me that I have cancer.