Imagine how much it would have disarmed both medical authoritarian sycophants ("trust the science") AND rabid antivaxers if we had applied these principles to the pandemic.
Rule 3. The risk of life-threatening complication from a heart catheterization may be 1 in 1000. The odds of winning the lottery are 1 in 300,000,000. Your patient is checking the lottery ticket convinced they can win the lotto. The 1 in 1000 devastating stroke, that will happen to someone else. I used this exact example when I had patient sign the consent. Thankfully after 40 years and retirement no one died or had that in my case, but I watched a coronary tree dissection after the use of ergonovine something we used to think was a great idea. Not many remember those days.
Nuanced expansion of #1: If you apply a Baysian approach, A "positive" finding from a test with high sensitivity and specificity will only increase your post-test probability to "Intermediate" if you have a low pre-test suspicion.
Thanks for the great sage advice John. Though I believe there should be a more open interpretation to the first rule. I.e: Ordering baseline labs before starting a treatment, say, a lipid panel before starting statin for secondary prevention.
As a recently retired retinal surgeon, I have fought endless battles against repeated exceptions imposed by anesthesia and hospital policy, with regard to pre-operative testing. Armed with the Choosing Wisely initiative and ample literature demonstrating the exceptional low yield of pre-operative testing, I would try to reason with them, to no avail. I would ask the anesthesiologist: what can a BMP, CBC, ECG etc, reveal that would justify postponing emergency retinal detachment surgery to save the vision of a healthy 28 year old woman? Their inadequate response was 'hospital policy' or 'state regulations'.
The questions seem out of order. If you would not contemplate an intervention why should you do the test especially if the options are binary? (I.e. do nothing or intervene).
These 2 Basic Rules are the questions I would ask our medical students and residents countless times over my 30 years in academics. Amazing how often clinicians still don't consider these essential prerequisites — :)
Common sense is expressed differently in different disciplines. In economics this thought has been expressed as: “There are no solutions. There are only trade offs.”
Imagine how much it would have disarmed both medical authoritarian sycophants ("trust the science") AND rabid antivaxers if we had applied these principles to the pandemic.
Rule 3. The risk of life-threatening complication from a heart catheterization may be 1 in 1000. The odds of winning the lottery are 1 in 300,000,000. Your patient is checking the lottery ticket convinced they can win the lotto. The 1 in 1000 devastating stroke, that will happen to someone else. I used this exact example when I had patient sign the consent. Thankfully after 40 years and retirement no one died or had that in my case, but I watched a coronary tree dissection after the use of ergonovine something we used to think was a great idea. Not many remember those days.
Exception to these rules? None. The unfortunate fact is that they are broken ALL THE TIME.
Thank you so much for being the voice of reason and not putting revenue / money before the patient
Thank you....could not be more clear. Dana
Nuanced expansion of #1: If you apply a Baysian approach, A "positive" finding from a test with high sensitivity and specificity will only increase your post-test probability to "Intermediate" if you have a low pre-test suspicion.
AND, if you have a high pre-test suspicion, a negative finding will never "clear" your patient, even if the sensitivity and specificity is high.
Another one for me:
We do things to make patients:
1. Live longer
2. Feel better.
If you’re doing something without evidence for 1 of those 2 things, ask yourself why you’re doing it.
or look better :). That is the Billy Crystal rule " Better to look good than feel good"
Thanks for the great sage advice John. Though I believe there should be a more open interpretation to the first rule. I.e: Ordering baseline labs before starting a treatment, say, a lipid panel before starting statin for secondary prevention.
I would say even that would influence what I do with the patient - and how ‘hard’ I pursue follow up and optimisation?
As a recently retired retinal surgeon, I have fought endless battles against repeated exceptions imposed by anesthesia and hospital policy, with regard to pre-operative testing. Armed with the Choosing Wisely initiative and ample literature demonstrating the exceptional low yield of pre-operative testing, I would try to reason with them, to no avail. I would ask the anesthesiologist: what can a BMP, CBC, ECG etc, reveal that would justify postponing emergency retinal detachment surgery to save the vision of a healthy 28 year old woman? Their inadequate response was 'hospital policy' or 'state regulations'.
The questions seem out of order. If you would not contemplate an intervention why should you do the test especially if the options are binary? (I.e. do nothing or intervene).
Amen
These 2 Basic Rules are the questions I would ask our medical students and residents countless times over my 30 years in academics. Amazing how often clinicians still don't consider these essential prerequisites — :)
Common sense is expressed differently in different disciplines. In economics this thought has been expressed as: “There are no solutions. There are only trade offs.”
Sage advice for clinicians of any branch of medicine or length of practice
„Salus aegroti (non curiositas medici) suprema lex“
(in brackets is what my first senior added, teaching me in my first year of neurology)