John, Good piece and very close to the mark. Consulting (hematologically) on an 85 year old scheduled to have a Whipple just caused my head to spin, spewing vomit. Yes, it is easiest to tell the family "We are doing something". (This is exactly the same idiotic behavior that drove well-known-to-be-worthless masking and antisocial distancing during covid. As with the surgery, doing something is usually worse than doing nothing if there is nothing to be done.) But the medical students ask, when we leave the room, "Why are we doing this?". And there is no good answer.
As others in the comments have noted, profit matters. There is no group to say "do not do that...it is likely that the non-cure is worse than the disease" because on Medicare the hospital will make a lot of money from the Whipple...and none if the patient is sent home to expire from their widely-spread pancreatic cancer. One can protest all one wishes...this economic sword of Damocles hangs over every decision. It is easier to make the decision that makes lots of money (none of which is actually paid by the patient so no intelligent economic decision making is made there) and that leaves everyone glad that "the doctors are doing something".
As noted above, this bothers lots of those entering the profession, but then we beat it out of them. Some of the beating we bring upon ourselves by trying to find (as you point out often) generally specious research that supports what we want to do. Cifu's recent article about the spikeshots saving millions of lives is solely based on a highly flawed (call it garbage) modelling study and no actual facts. But I am sure it made him feel better to quote it because he likely recommended lots of the genetic engineering to his patients and facing the fact that we were all lied to and propagated those lies to our patients is really difficult. Not picking on Adam; I just use this as an example because it applies to LOTS of things we do TO patients, putatively FOR them.
The question is "how does one begin to address this"? It would be of value for Adam to contemplate his reliance on bad science (the model designed to show a particular result [as are all models] but this one is consonant with what he wants to believe) in an article on how bad science is as an archetype of the kind of soul searching that we all need to do if we are ever going to put medicine back on decent footing. Otherwise, I see patient trust eroding daily...and I am not sure that it should not. This seems a very sad way to end my career.
There needs to be an awakening that matters. Perhaps you can help drive that.
I was sent an 85 yo woman pre op total knee. I asked her when it hurt. She said after she bikes 5 miles on her stationary bike. She takes one Tylenol and it resolves. Fraud ? Money?
No its the train of overwhelmed docs, mid levels and paper shuffling ( or EMR messages)
She tells the pcp- who orders an xray
Radiology reads the xray as an end stage joint ( she is 85)
Report comes back- someone writes "ortho consult" and MRI
Ortho sees patient with MRI report and writes "cardiology consult"
I stopped the train because I was the traveling cardiologist to a rural town and literally took care of everyone over 20 years there.
PCP was happy and ortho probably could care less as they finish their 50 -60 person per day clinic
You have to stop the train. It could mean less referrals but it never did for me.
Ortho writes cardio consult because he/she wants to do surgery. That IS about money.
The PCP ordering x-ray and then MRI and ortho consult was afraid to say: "You're over 85, your knee might hurt when you get older." That is just PCP malfeasance not "being overwhelmed". Ordering unnecessary x-rays and then an MRI is MORE work than just saying: you're old and if tylenol or advil resolves it let's circle back to next time you see me.
Thanks for stopping train. One less potential DVT during recovery period.
My mother-in-law went thru similar train. I said you're over 70 what the heck do you need a TKR for? She has it any way - ends up in ICU after aspirating vomit post-surgery, then after 2 weeks in ICU has to go to rehab hospital where she gets c. diff. A year later MI, RIP.
You are bringing a lot of baggage to the table. What kind of physician calls the INITIAL series of C19 vaccines: "Spikeshots"? As soon as anybody reading your response got to paragraph 3, it is patently clear that you are not actually serious about the problem that Dr. Mandrola correctly is trying to address.
The major problem with the initial series was not prioritizing (under scarcity) by age and pre-existing co-morbidity, but instead prioritizing younger healthcare or other "ostensible" essential workers (regardless of prior infection status). To the lifeboats: doctors and capitalist machine first. It was a failure of triage in an emergency.
The problem with subsequent boosters was and is lack of RCTs to understand properly efficacy and effectiveness with an appreciation of heterogeneity.
Two different problems and circumstances. Your inability to understand the difference and the weird attempt to suggest that the initial series of vaccinations was not beneficial but some kind big "lie" is patently unthoughtful and not scientific.
You use the phrase "Putting medicine BACK on decent footing". Please tells us what date in the past that medicine was on its decent footing.
" There are people in every time and every land who want to stop history in its tracks. They fear the future, mistrust the present, and invoke the security of a comfortable past which, in fact, never existed." ~ Robert Kennedy
You misread my comments. I was opining only on the millions of lives saved. I use spikeshots because everyone knows what they are. They clearly are not vaccines since the CDC had to change the very, very long standing definition of vaccine to include these short-term boosters of antibodies. They are, in that regard, different from anything that has previously been called a vaccine. So I will not dignify them by using that word which was chosen because no one would have signed up for "genetically altering RNA (with DNA fragments) producing shots".
It is clear that under some age (65? 60?) the shots have negative value, especially for those under 35 or so. The total study population was studied for a couple of months. THEN THEY DESTROYED THE CONTROL POPULATION quite deliberately. The results of the control population (until they made it go away) incidentally were modestly better than the test population...but let us ignore that.
We have NO data on long term effects, but we are discovering more every day, none good. It does not prevent disease occurrence or transmission. The more boosters taken, the more likely one is to get a reinfection (ADE?). All of these things militate against the entire project.
I was caring for substantial numbers of obese, old men (primarily) with serious covid lung disease at the peak times. (I am a hematologist and a microbiologist; covid was in many patients a largely hematologic disease with pulmonary expression.) As with the limited-action antibody infusions, the spikeshots likely had some positive, but very short lived, effect in the elderly (remember the average age of death from covid is older than life expectancy). These people may not live long enough to experience whatever side effects we may discover, so there is a balancing to be made there.
Having said all the above, had Adam said "some number of elderly lives were likely extended by the shots" you would not have heard from me. The millions of lives he quotes are from a flawed model as showed if you read beyond the conclusions. (Let us remember that the models were predicting 5% death rates in the US for a disease that actually turned out to have an IFR of 0.03...less in younger populations and as high as 0.3% in very old populations (about the same as influenza).
I am at least as serious as you are about addressing these issues. The fraud about which Vinay has written extensively is rife in the covid literature which managed to get published. It was utterly mishandled by the public health apparatus and the effects of the response will dwarf the effects of the disease for decades to come. I agree that since the only people who could have possibly profited were the very old/comorbid the priorities should have been different. But for that matter, 95% of the shots given should not have been given at all...very little evidence to the contrary.
I think if you go back and read the original Pfizer study (the submission to FDA...not many of the fawning articles written later -- many up there with the "could not possibly be a lab leak" kind of progeniture) you will find yourself much less sure of what this is all about. I have and it is a complete failure of both science and regulation in my opinion. I hope that conversations like this help to tease it out.
Dr. K--I am a retired surgical nurse with open heart experience and I have seen the impractical surgeries , as you mentioned with the Whipple, on an 85 year old with advanced cancer. In most of these cases the surgeon didn’t make the decision to do the surgery it was the family because even though they knew the surgery wasn’t a cure and would most likely cause their loved one more discomfort they just couldn’t let go. We put G-tubes in comatose 90 year olds because the family couldn’t say goodbye. So when the medical student asks “why are we doing this?” the answer is because the family can’t let go. Perhaps more information , education and empathy for our patients and family and less --much less, advertising on television that leads the public to think that medical science has the cure for everything. The studies that the public have access to are so skewed and may only consist of a population of 10 but are enough to convince lay people of their accuracy. Hopefully, the work of Dr. Mandrola will expose these studies and give us more sensible decision making information.
Thanks for your response. FWIW, I am on the side of being real with my church members who will let me be there for them when these decisions need to be made. Our Christian faith does not require physicians to act in the place of God; and we Christians believe (or say we believe) this truth.
I heard your podcast about p values and statistical significance.
Im really worried about trusting too much on the p values and not seeing the hole picture.
How do you interpret the results from the FOURIER trial with Evolocumab or the CLEAR OUTCOMES trial with Bempedoic acid where the total number and the cardiovascular number of deaths was higher on the treatment group??
I was one of the first Paramedics in Arizona way back in 1975, and I taught all of the standards that later became ACLS, practiced until my lumbar vertebrae could take no more. I taught human anatomy and physiology for the better part of 30 years and tried to stay current for my future PA, RN, and whatnot students. Now I am a Lutheran Pastor and at age 70 I am looking back on my earlier life and wondered why my doc doesn’t treat my unifocal PVC’s, and my own parishioners are on the receiving end of these ridiculous treatments that have zero chance of improving their quality of life. I often translate their physician decisions for them (and occasionally get to meet some if I can get to visit them before they are discharged) and just shake my head in disbelief.
Whatever happened to “evidence-based practice” that I read so much about back in the day? I now routinely advise those of my parishioners who are older than me to have their desires known....do they have their “orange card” ACLS Prehospital Directives so our Paramedics know what the end of life care decisions have been made by them and their physicians. To be fair, it is a hard sell to get those who would most likely not benefit from a full ACLS full-court press only to end up spending their last hours on a vent in a CCU....just sayin’
One brief comment. CCTA on elderly patients on statins is useful to see whether statins or other treatment plans are working--but without "angina" the calcium scan helps get the CCTA in my experience.
We win this thing with words. Check out my new word, coincidist, describing people who blame medical harm on coincidence. Coincidism is a filthy thing that goes right along with fascism and communism. Fake science is coincidism. We counter coincidism with creativity, humor and love.
John, Good piece and very close to the mark. Consulting (hematologically) on an 85 year old scheduled to have a Whipple just caused my head to spin, spewing vomit. Yes, it is easiest to tell the family "We are doing something". (This is exactly the same idiotic behavior that drove well-known-to-be-worthless masking and antisocial distancing during covid. As with the surgery, doing something is usually worse than doing nothing if there is nothing to be done.) But the medical students ask, when we leave the room, "Why are we doing this?". And there is no good answer.
As others in the comments have noted, profit matters. There is no group to say "do not do that...it is likely that the non-cure is worse than the disease" because on Medicare the hospital will make a lot of money from the Whipple...and none if the patient is sent home to expire from their widely-spread pancreatic cancer. One can protest all one wishes...this economic sword of Damocles hangs over every decision. It is easier to make the decision that makes lots of money (none of which is actually paid by the patient so no intelligent economic decision making is made there) and that leaves everyone glad that "the doctors are doing something".
As noted above, this bothers lots of those entering the profession, but then we beat it out of them. Some of the beating we bring upon ourselves by trying to find (as you point out often) generally specious research that supports what we want to do. Cifu's recent article about the spikeshots saving millions of lives is solely based on a highly flawed (call it garbage) modelling study and no actual facts. But I am sure it made him feel better to quote it because he likely recommended lots of the genetic engineering to his patients and facing the fact that we were all lied to and propagated those lies to our patients is really difficult. Not picking on Adam; I just use this as an example because it applies to LOTS of things we do TO patients, putatively FOR them.
The question is "how does one begin to address this"? It would be of value for Adam to contemplate his reliance on bad science (the model designed to show a particular result [as are all models] but this one is consonant with what he wants to believe) in an article on how bad science is as an archetype of the kind of soul searching that we all need to do if we are ever going to put medicine back on decent footing. Otherwise, I see patient trust eroding daily...and I am not sure that it should not. This seems a very sad way to end my career.
There needs to be an awakening that matters. Perhaps you can help drive that.
I was sent an 85 yo woman pre op total knee. I asked her when it hurt. She said after she bikes 5 miles on her stationary bike. She takes one Tylenol and it resolves. Fraud ? Money?
No its the train of overwhelmed docs, mid levels and paper shuffling ( or EMR messages)
She tells the pcp- who orders an xray
Radiology reads the xray as an end stage joint ( she is 85)
Report comes back- someone writes "ortho consult" and MRI
Ortho sees patient with MRI report and writes "cardiology consult"
I stopped the train because I was the traveling cardiologist to a rural town and literally took care of everyone over 20 years there.
PCP was happy and ortho probably could care less as they finish their 50 -60 person per day clinic
You have to stop the train. It could mean less referrals but it never did for me.
Ugh.
Ortho writes cardio consult because he/she wants to do surgery. That IS about money.
The PCP ordering x-ray and then MRI and ortho consult was afraid to say: "You're over 85, your knee might hurt when you get older." That is just PCP malfeasance not "being overwhelmed". Ordering unnecessary x-rays and then an MRI is MORE work than just saying: you're old and if tylenol or advil resolves it let's circle back to next time you see me.
Thanks for stopping train. One less potential DVT during recovery period.
My mother-in-law went thru similar train. I said you're over 70 what the heck do you need a TKR for? She has it any way - ends up in ICU after aspirating vomit post-surgery, then after 2 weeks in ICU has to go to rehab hospital where she gets c. diff. A year later MI, RIP.
Parrhesia.
You are bringing a lot of baggage to the table. What kind of physician calls the INITIAL series of C19 vaccines: "Spikeshots"? As soon as anybody reading your response got to paragraph 3, it is patently clear that you are not actually serious about the problem that Dr. Mandrola correctly is trying to address.
The major problem with the initial series was not prioritizing (under scarcity) by age and pre-existing co-morbidity, but instead prioritizing younger healthcare or other "ostensible" essential workers (regardless of prior infection status). To the lifeboats: doctors and capitalist machine first. It was a failure of triage in an emergency.
The problem with subsequent boosters was and is lack of RCTs to understand properly efficacy and effectiveness with an appreciation of heterogeneity.
Two different problems and circumstances. Your inability to understand the difference and the weird attempt to suggest that the initial series of vaccinations was not beneficial but some kind big "lie" is patently unthoughtful and not scientific.
You use the phrase "Putting medicine BACK on decent footing". Please tells us what date in the past that medicine was on its decent footing.
" There are people in every time and every land who want to stop history in its tracks. They fear the future, mistrust the present, and invoke the security of a comfortable past which, in fact, never existed." ~ Robert Kennedy
You misread my comments. I was opining only on the millions of lives saved. I use spikeshots because everyone knows what they are. They clearly are not vaccines since the CDC had to change the very, very long standing definition of vaccine to include these short-term boosters of antibodies. They are, in that regard, different from anything that has previously been called a vaccine. So I will not dignify them by using that word which was chosen because no one would have signed up for "genetically altering RNA (with DNA fragments) producing shots".
It is clear that under some age (65? 60?) the shots have negative value, especially for those under 35 or so. The total study population was studied for a couple of months. THEN THEY DESTROYED THE CONTROL POPULATION quite deliberately. The results of the control population (until they made it go away) incidentally were modestly better than the test population...but let us ignore that.
We have NO data on long term effects, but we are discovering more every day, none good. It does not prevent disease occurrence or transmission. The more boosters taken, the more likely one is to get a reinfection (ADE?). All of these things militate against the entire project.
I was caring for substantial numbers of obese, old men (primarily) with serious covid lung disease at the peak times. (I am a hematologist and a microbiologist; covid was in many patients a largely hematologic disease with pulmonary expression.) As with the limited-action antibody infusions, the spikeshots likely had some positive, but very short lived, effect in the elderly (remember the average age of death from covid is older than life expectancy). These people may not live long enough to experience whatever side effects we may discover, so there is a balancing to be made there.
Having said all the above, had Adam said "some number of elderly lives were likely extended by the shots" you would not have heard from me. The millions of lives he quotes are from a flawed model as showed if you read beyond the conclusions. (Let us remember that the models were predicting 5% death rates in the US for a disease that actually turned out to have an IFR of 0.03...less in younger populations and as high as 0.3% in very old populations (about the same as influenza).
I am at least as serious as you are about addressing these issues. The fraud about which Vinay has written extensively is rife in the covid literature which managed to get published. It was utterly mishandled by the public health apparatus and the effects of the response will dwarf the effects of the disease for decades to come. I agree that since the only people who could have possibly profited were the very old/comorbid the priorities should have been different. But for that matter, 95% of the shots given should not have been given at all...very little evidence to the contrary.
I think if you go back and read the original Pfizer study (the submission to FDA...not many of the fawning articles written later -- many up there with the "could not possibly be a lab leak" kind of progeniture) you will find yourself much less sure of what this is all about. I have and it is a complete failure of both science and regulation in my opinion. I hope that conversations like this help to tease it out.
If I see one more Jardiance commercial I’ll scream...
To throw another perspective out there, it helps to look into the origins of modern medicine. I've done some work in this piece (https://unorthodoxy.substack.com/p/donating-to-a-good-cause-how-billionaires), but I think the underlying issue is that much of our medicine is profit first then patient care. We're seeing this play out with obesity and the GLPs that I discuss here: https://unorthodoxy.substack.com/p/the-hidden-struggle-in-health-care
Dr. K--I am a retired surgical nurse with open heart experience and I have seen the impractical surgeries , as you mentioned with the Whipple, on an 85 year old with advanced cancer. In most of these cases the surgeon didn’t make the decision to do the surgery it was the family because even though they knew the surgery wasn’t a cure and would most likely cause their loved one more discomfort they just couldn’t let go. We put G-tubes in comatose 90 year olds because the family couldn’t say goodbye. So when the medical student asks “why are we doing this?” the answer is because the family can’t let go. Perhaps more information , education and empathy for our patients and family and less --much less, advertising on television that leads the public to think that medical science has the cure for everything. The studies that the public have access to are so skewed and may only consist of a population of 10 but are enough to convince lay people of their accuracy. Hopefully, the work of Dr. Mandrola will expose these studies and give us more sensible decision making information.
Thanks for your response. FWIW, I am on the side of being real with my church members who will let me be there for them when these decisions need to be made. Our Christian faith does not require physicians to act in the place of God; and we Christians believe (or say we believe) this truth.
We all know where the bodies are buried. How many call the feds to let them know? How can you when they are in the same organization that employs you?
Dr Mandrola :
I heard your podcast about p values and statistical significance.
Im really worried about trusting too much on the p values and not seeing the hole picture.
How do you interpret the results from the FOURIER trial with Evolocumab or the CLEAR OUTCOMES trial with Bempedoic acid where the total number and the cardiovascular number of deaths was higher on the treatment group??
I was one of the first Paramedics in Arizona way back in 1975, and I taught all of the standards that later became ACLS, practiced until my lumbar vertebrae could take no more. I taught human anatomy and physiology for the better part of 30 years and tried to stay current for my future PA, RN, and whatnot students. Now I am a Lutheran Pastor and at age 70 I am looking back on my earlier life and wondered why my doc doesn’t treat my unifocal PVC’s, and my own parishioners are on the receiving end of these ridiculous treatments that have zero chance of improving their quality of life. I often translate their physician decisions for them (and occasionally get to meet some if I can get to visit them before they are discharged) and just shake my head in disbelief.
Whatever happened to “evidence-based practice” that I read so much about back in the day? I now routinely advise those of my parishioners who are older than me to have their desires known....do they have their “orange card” ACLS Prehospital Directives so our Paramedics know what the end of life care decisions have been made by them and their physicians. To be fair, it is a hard sell to get those who would most likely not benefit from a full ACLS full-court press only to end up spending their last hours on a vent in a CCU....just sayin’
Yes, direct fraud is a low hanging fruit easy to pinpoint. 🍎
The wider methodological fallacies are much deeper issues that are not well understood or acknowledged.
Medical 🏥 and social sciences widely and firmly deviated from truth and usefulness.
Hard sciences and economics are holding quite well though.
One brief comment. CCTA on elderly patients on statins is useful to see whether statins or other treatment plans are working--but without "angina" the calcium scan helps get the CCTA in my experience.
We win this thing with words. Check out my new word, coincidist, describing people who blame medical harm on coincidence. Coincidism is a filthy thing that goes right along with fascism and communism. Fake science is coincidism. We counter coincidism with creativity, humor and love.
https://open.substack.com/pub/coincidism/p/ive-created-a-concept-i-call-coincidism?