Impella RCT aborted, Mammography, Medical School Limitations - Cifu/ Prasad/ Mandrola
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- čas přidán 23. 06. 2024
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Vinay Prasad, MD MPH; Physician & Professor
Hematologist/ Oncologist
Professor of Epidemiology, Biostatistics and Medicine
Author of 500+ Peer Reviewed papers, 2 Books, 2 Podcasts, 100+ op-eds.
If you want to contact me, do it here: www.vinayakkprasad.com/contact
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Twitter @vprasadmdmph - Věda a technologie
Your videos should be accredited for continuing education hours.
So true!! 😅❤
I can take category 2 credit (but still need 50 hours category 1, as a PA)
As a practicing physician these discussions are so refreshing - facts and data instead of great sounding stories. Stories get you 'started' - but stories NEVER can be the final decision making pathway...
What I hear in so much of what you all say here and on Sensible Medicine is how ridiculous the processes and procedures that have developed around supposed “best practices” have in fact fallen short of actually defining what is best for most people. We don’t need to know about every benign tumor in our bodies. Rather, we need to know how to manage the things that actually impact our quality of life! Thanks for that.
Great interviews & discussion. I really enjoy Dr. Prasad's candor & critiques of clinical practice & research. I'm subscribed!
Mammograms should be required wherever a clinician approves at ANY age
If you think there's something amiss, you should take it to your GP. If they agree it looks suspicious, it shouldn't matter what age you are - or gender. The test is a no-brainer.
Vinay makes a terrific point: the cost of the test is trivial
Cost of cancer treatment is RUINOUS - both financially for the patient, and for the hospital/health care system in financial terms and in terms of resource allocation. Clinical resources are always constrained. It's insane to limit use of low-cost trivial tests & pretend that's saving the system. This is MBA disease: optimize a specific budget cost without regard to total cost outcomes to patient, treatment center & system overall.
Men too
I mentioned gender. Breast cancer occurs in men too - rarely. 1 in 100 cases of breast cancer are male. Just as unpleasant, treated the same way, and is equally fatal if not caught soon enough. In fact, the mortality rate is a higher for men than for women:
1) it's often not caught as soon - no one expects it is a possibility;
2) clinicians may discount the likelihood - doctors have told me they've never seen a case in their career, but my GP - who caught mine - says she's seen three in recent years. You don't see what you don't expect to see;
3) Treatments have been scientifically tested on women, and don't appear to work as well on men. We don't know why, but whatever's working on women, the same treatments don't seem to work as well on men: mortality is significantly higher. But we're not going to see studies done on men: cases are so rare & dispersed over time & geography, that no one's going to be able to assemble a group to study.
So if you find a lump, get it checked. Doesn't matter what age or gender you are.
_______________________
I really appreciate Vinay's closing comments on medical culture. He's refreshingly candid about the failings of clinical education. I hope the system is listening.
With respect to John Mandrola (& it's warranted) I beg to differ with his stereotyping of clinical practice as "not static" but constantly changing. I'm sure it matters a lot who you are & where you practice. If you're teaching in a medical school, "the culture of learning" may well be present. Wonderful.
Reality ain't med school
But if you're working outside an actual teaching hospital, not so much. If you work waaaaay out in the boonies - 10 miles away! - standard practice hasn't changed in two decades. I've documented this in a major hospital for a variety of medical practices over decades.
They all stop reading!
Again, I get that Dr. Mandrola practices - & I'm sure he teaches - a culture of learning. But for most clinicians your average patient will see - in ANY specialty (& I'm including specialists here too) - the stereotype that applies is this: they all stop reading/learning once they graduate.
This situation is normal
One classic example: the discovery that stomach ulcers are bacterial in etiology dates back to a landmark 1982 article in the Lancet - completely ignored at the time. In 2005, Barry Marshall and Robin Warren were awarded the Nobel Prize in Physiology or Medicine for their discovery (23 years prior) that peptic ulcer disease (PUD) was primarily caused by Helicobacter pylori - and immediately & effectively resolved with a simple course of antibiotics. On the occasion of their Nobel award, the Toronto Star investigated clinical practice at hospitals across the Greater Toronto Area (4 million pop.) - including the teaching hospitals! - & documented that very few patients were being treated in any institutions with antibiotics. I had been tracking this with a personal study at Richmond Hill Hospital for a decade already. The norm was treatment with Zantac or Tagamet: from a patient's point of view, high-strength Rolaids (& just as effective). Long-term unresolved infections are mutagenic: unresolved ulcers absolutely DO cause cancer, so this situation was beyond reprehensible.
This is the norm
Clinical practice is widely acknowledged to lag research findings by a good 15 years. And I'd assert that clinical practice in Canada traditionally lags US practice by another 10. So we're 20-25 years behind the times in Canada (not always, but too frequently). My own experience in the past year concerning cancer treatment suggests that at my two hospitals (3 different specialties involved) we're maybe only 5 years behind US practices, at least in oncology. In neurology & endocrinology it's closer to 10, but one of those two (neuro) is concerned & looking to catch up. Yay. The other is not just indifferent but irritated & determinedly resistant: they've achieved perfection already.
Not just doctors: it's the system
TBF it isn't just that doctors are resistant to change (& let's face it, we ALL are); sometimes the resistance to change is baked into the field or into the system.
The field actively resists change. Clinical treatment centers don't want doctors winging it with new & novel ideas all the time: there are rules that mandate patient care should adhere to "the standard of care", and it takes time for that to change in the profession. A lot of time. So doctors may be constrained in their choices, at least in their default choices. I think the profession provides them with the ability to step outside the lines, carefully, with patient consent, where it's warranted. Off-label treatment using approved medications is beyond normal, after all.
And the system resists change. In Canada we have a single-payer system. There are myriad situations where a patient will be told we have a medical solution (drugs) for a problem the insurance Plan covers only for surgery - an older, less medically-sound alternative that has poorer outcomes & MUCH higher costs, but which is already approved. So a surgical solution is covered; the newer medical alternative is not, and may require significant cost to the patient. Sometimes it's a change in surgical treatment (in Toronto a Dr. Shouldice invented a vastly-improved minimally-invasive surgical technique for hernia repair. Left Sunnybrook Hospital when he couldn't get them to see reason, set up his own specialty hospital up the street. It still provides world-leading hernia repair; his techniques were only grudgingly adopted by the Ontario medical system decades after he'd decamped.
More commonly there are new medical options, either for existing ones or as alternatives to surgery. Same problems prevail. There may be no malice involved: the bureaucracy is slow at updating coverage charts. But it imposes real constraints on care.
What to do?
Patients need to get militant when they discover they're dealing with this.
If you need a specialist, ask your GP to refer you to one they KNOW is up to date & committed to staying current. If your GP cannot do that, ask to be referred to one under 30. So they've recently graduated to the specialty, and at least they're up to date for the present. 'Cause in 10 years they won't be.
Dr. Prasad: what else can we do?
Are there other - perhaps better - ways to deal with this?
THANK YOU
We need more motivated doctors like these three!
My grandfather had breast cancer. He was discharged from hospital on my wedding day ☺️. He was a breast cancer survivor and lived a long life after, died in his late 90’s. His daughters weren’t son fortunate and many of them passed away young. My mother was the youngest of the sisters to die,
at the age of 36. Many of her brothers have had prostate cancer, but most of them are still living. It was a big family of 6 girls and 6 boys.
Compassion is absent among trainees. I trained in medicine and pediatrics in a country and did the USMLE tests. However, some family matters took me away for 10 years. Now, that I am ready to go back to training they won't accept me because I have been away for too long. I did observership with an attendant, and I saw how students act. They lack compassion, just want to be done and leave. Yet, they are the ones chosen , not me. They were literally concerned that I didn't remember the forearm muscles. Anyways, goodbye medicine. I am at peace with it and starting a new endeavor.
I love listening to you all. Thank you
Put physical exams on curriculum. Doctors don't do physical exams anymore, X-rays and MRIs and Ct's and echoes should be prescribed to confirm physical exam, not because doctors are lazy, they don't want to get their butt out of the chair, not because they don't want to get their hands dirty, or simply not because they just don't know how to do physical exams.
Visad! Please give us your analysis of gadolinium necessity and the data on safety.
Great discussion. Thank you!!! Looking forward to more!
Excellent, as always. Shared it to family to watch.
Modeling at the metabolic level is better than most diet trials. Chemistry is a math based science. Models needs to be accurate.
Dr. Prasad makes disturbing comments (~40:00 min. & again at 43:15) about cultural failings in medical education.
Wow - cultural awareness; that's not normal
Kudos to him for mentioning lack of empathy. He is more concerned about medical decision-making: that's disturbing to hear, but not generally something we'd see as patients the way Vinay does as a peer reviewing patient files. If he's concerned, I'm really concerned! I hope the problem isn't so much generational as specific to his institution.
Med School culture compared
Would Vinay be willing to comment on a specific educational issue that may have a bearing on this?
Engineering at my University (U of Toronto) has a 35% fail rate year one. 30% year two. And ANOTHER 30% year three. They don't kick you out of school, just counsel you to perhaps consider another career option, do mining or general science or... medicine even. Here's the thing: they need you to be able to do the math. If your algebra isn't up to par, you're out. Blow the math & a building falls down, people die. The Engineering Society gets REALLY cranked up when someone blows the math & people die. So there's a fail rate.
How about Pharmacy? I checked: same fail rate years 1, 2 & 3. Interesting. And as with Engineering, if you make mistakes on the job & people die, they strip you of your credential - you'll never practice again - and may even call the police & say "Whack this guy." Seen it done. Mistakes aren't tolerated.
Medicine is different
What do we call the guy with the lowest grade in Med School? "Doctor." I know: unfair joke, but it's true. I get that medicine is NOT like engineering: you can't constrain the field, limit the variables, control for all eventualities & outcomes. Medicine is inherently unlike engineering. Human bodies aren't as consistent as inanimate materials & structural elements; diseases don't follow hard rules; doctors treat in a medical system on teams with other professionals; reality is variable & unpredictable. I get it. But - to a patient - the attitude towards medical errors appears beyond cavalier.
Cultural indifference causes REAL harm
The stats are NOT good. One third of all patients admitted to residential care for more than one night will suffer at least one medical error - most probably inconsequential, but they SHOULD NOT OCCUR. And one third of all hospital mortalities are CAUSED by a medical error.
How is it dealt with?
If you raise an error as an issue with a clinician, they call it "Medical Complications." NO: it's an error! Want to make an snit about it? (I've had occasion to do so more than once): They have malpractice insurance for that. And in Canada (don't know about the US) the policy doesn't even name the doctor: it's in the name of the hospital. Doesn't reflect on the MD at all, unless something sufficiently egregious occurred resulting in a review by the College of Physicians or the CMA. And that won't likely happen unless the patient (or family, if they're dead) launches resolute legal action.
Acknowledged: service delivery is hard
I've worked in management consulting on quality improvement initiatives for services delivery. As acknowledged above, services delivery of any sort is always hard - a much less predictable field than engineering - and inherently subject to difficulties outside the control of individual service delivery agents (in this case, doctors).
But not impossible - we do it all the time
There IS an ISO standard & system for measuring & managing quality assurance in business systems. And - hard as it is to implement - it DOES work: you can vastly improve quality of service, of care, in difficult & multi-disciplinary systems.
Unfortunately it isn't apparent to the public that the field of medicine has heard of this. If that's true, they're about 50 years behind the times. Even for medicine, being 50 years out of date is extreme.
An underlying problem of indifference
From a patient's perspective, it's the sociopathy of medical culture we experience. And yes: I chose the word deliberately.
Doctors DO care
I realize most doctors share the attitudes & motivation driving Vinay & his two peers interviewed here: they work incredibly hard to qualify in a difficult & demanding profession because they care.
It's a culture problem
Doctors call "clinical detachment" an ethic. No. It's inculcated - trained sociopathy. THAT is too often how it comes across to patients.
This attitude is inculcated in the training process, in Med School
Clinical detachment used to be discussed formally - for 10 min. - in the Clinical Practice course during your first 2 years of med school. But where it's trained - where, I've been told "it's beaten into you" - is in Internship & Residency. And dear god, they all get it. It's trained sociopathy. And it's pathological.
Culture kills
It's undeniable - as Vinay acknowledges - that this compromises quality of care & clinical decision-making.
It's also proven to directly affect patient outcomes psychologically. One specific change instituted to deal with this in the UK made one tiny, 5-second change in clinical practice - that's all! - but caused significant documented reduction in the incidence of patient suicides. THAT clinical outcome is every bit as real & significant as improvements in clinical decision-making - and it turns out, very much easier to improve.
Wow, I would've given you a series of 👍 if I could. As a potential patient with the determination "they won't get me alive" the thought of ever having to see a medical professional is more like knowing to have to fight to preserve my health than expecting care. You are very right about the practice of "clinical detachment", calling it trained sociopathy. It hurts at the time when you need empathy the most.
Main Public Interest as i said before and often about the Doc V.P. and Friends.
thanx a lot Guys !!!!
A great evidence based discussion!
I think an important part of medical education is actually instilling an attitude of service with self-sacrafice with the idea that with great power comes great responsibility. Being a doctor is a vocation similar to priesthood and not just a job. I think we are forgetting to do this in medical schools more recently.
My doc asks me almost every time I see her if I have gone for my mammogram, I’m 63, no family history of cancer on either side. No the other side, I have to beg to get her to test my fasting insulin along with my fasting glucose and a full lipid panel as there is major cardiovascular disease on both sides of my family. I live in Canada, many Americans think we have such great healthcare because it is free, I have to see my naturopath to pay for the blood tests that I need done to monitor what I feel is most beneficial.
Interesting. Thanks. Aussie Bob
I try to encourage people to look at numbers *first* to help them ask the important questions. P=0.4 does not inspire questions aside from, “why would we pursue this right now?”
In the trial p=0.04, but many other issues as discussed.
Need more information and insight on PSA harming someone. Wish that would have been discussed a little deeper.
There's a foundational oversight in medical education when it comes to ignorance of nutrition. But it's not really an honest oversight, the healthcare industry would be shattered if we educated doctors and took nutrition seriously, a number of medical specialties would barely need to exist if not for that.
Not to mention big food lobbying, that may have a bigger impact than medical education (or lack thereof).
@@ben.tanner Definitely a problem, but imo much more a problem is ignorance/conflicts of interest in healthcare. Just take a look at the dental industry for example, and that is one of many.
I was personally unimpressed by DANGER-SHOCK for many of the reasons mentioned here. Why they do not want a confirmatory study is beyond me.
The benefit of scut is that it is work! You learn doing scut that you have to get work done and how to be efficient and that medicine is hard work. You learn how to interact with patients nurses and other staff. It is very important. It also gives you a status. You are not just a student. Also empathy is over rated. If you over empathize the patients fear can metastasize to you and result in paralysis. I would much rather a be reffered to as the "liver in room 204" by a competent physician then having a mediocre physician empathize with me about how bad I must feel about having liver failure.
Could you gentlemen have a discussion about the recent 2023 Danish study by Gyldenkerne, et al, in which it was found that STATIN therapy is worthless in type 2 diabetics with KNOWN coronary heart disease? This study appears to put another "nail in the coffin" of the "lipid-heart hypothesis."
Dr. Prasad, I’m looking for an undergraduate biostatistics course. Can you recommend one please.
Send them out from 1st year on to free clinics in poor areas without fancy equipment to see and deal with all sorts of people and get some life experience under their belts. But that doesn't exist in this country does it?
Why do we use the word scut to describe the physical care of the patient? Med school should be a time when you take the patient to procedures and see how they are done. It gives you a real feel for the pt experience and how your orders affect the patient.
How many MCC questions were on my boards - who knows or cares? Important question - how do you work up X prob? What’s the dangerous thing it could be? How do you know which pathway to follow? My classic is MCC of postmenopausal bleeding - who cares? Bad thing cancer, how do you workup - U/s with bx based on endometria thickness. Who cares if fibroid or polyp is more common - the u/s will tell you which matters for this pt. Board questions are sooooo bad.
dr school should be having to help nurses for 4 years.
Lack of equipoise due to results of a trial with “may be” positive results? What sort of tortured logic is that? The interventional cardiology field is now full of procedures of unproven benefit. Regulatory agencies with oversight need to clean up their act and demand demonstration of benefit before allowing implementation.
Medical school in 2024 is twitter before Elon made X.
Cancer screening should be increased for all ages. The overwhelming majority of our food supply and water have become contaminated with cancer-causing agents. I'm shocked they want to decrease screening for cancer. In addition new ways to screen for cancer needs to be developed as the current is not good enough.
the homeless population needs psych wards back.
democrats closed all of the psych buildings for some reason