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

[walrus]

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]

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]

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]

The Ring of Fire waking up??

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

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

[alfablue]

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]

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]

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]

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]

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.

[Kepler]

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.

My guess is that is nothing new. It just used to be that the day you shipped off to college -- if you were lucky, the day you moved into the honors track in high school -- you left these people behind forever except when you wanted to one night the cuter ones (JFC, use protection!!!). There were plenty of these people in my high school. University admissions ended my involvement with them. But now you still hear from them if you go on the internet. Every meeting now has 8-year olds at the back who think they're clever. And they're as loud -- really, louder -- than the adults.

The cumulative stupidity of the species continues to decrease and will as long as access to a good diet and information improves and military personnel are the majority of major war fatalties. What's changed is public discourse used to be a gated community that you gained access to with education (or, to be fair, money). There was a public discourse of the stupid in the bloids or the bars or High Weirdness by Mail, but it was very easy to ignore.

Now, public discourse is close to a democratic mob where in Asimov's words "my ignorance is just as good as your knowledge." At some point the smart people will need to secede into our own gated community again.

[WisconsinWildcard]

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.

Bad experiences get much more exposure than good experiences. It only takes a small minority given that the inherent trust in doctors has to be very high by the nature of the work they do. I can tell you the far majority of the physicians as well as other health care workers I work with are hard working, compassionate, and trustworthy. I know a few that I would not let care for a pet bird.

I am basically on your side. I think there should be no tolerance for what you are describing. But there is also a lot of nuance to individual situations and without medical training and a complete set of facts, it can be extremely challenging to determine if there is blame to be had.

[5mn_Major]

My original thought was that there should be a more broadbased approach to healthcare than what sometimes occurs - heart surgery and other serious internal medicine conditions/procedures should always recommend a broadbased, detailed, personalized lifestyle consultation (diet, water, exercise, stress evaluation based on bloods, etc). It doesn't matter what the strategic framework is or how its executed that gets the system there.

Can everyone afford that? No. But that doesn't mean that you just leave a patient with out the means to actually solve the underlying causes long term.

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.

And frankly, that's overall a good thing. Yes, it does make conducting healthcare somewhat more challenging - but overall, more effective. For every doctor who's incorrectly challenged/wrongly mistrusted...there is a doctor who is corrected or whose diagnosis is improved. The downside of challenge is greatly outweighed by the cases where the diagnosis/treatment are improved or possibly even corrected.

[WisconsinWildcard]

My original thought was that there should be a more broadbased approach to healthcare than what sometimes occurs - heart surgery and other serious internal medicine conditions/procedures should always recommend a broadbased, detailed, personalized lifestyle consultation (diet, water, exercise, stress evaluation based on bloods, etc). It doesn't matter what the strategic framework is or how its executed that gets the system there.

Can everyone afford that? No. But that doesn't mean that you just leave a patient with out the means to actually solve the underlying causes long term.

The ones that have a good evidence base like heart failure this does occur at most health institutions.

But for the most part that is not realistic. Evidence is very poor in most nutrition fields (not their fault entirely, just very difficult to study in a clinically meaningful sense). I know you like Mayo and a year or two ago they had a good series of articles describing the state of crisis the field was in. If there is no evidence, insurance sure as hell not going to cover it. And for the most part, people are not going to want/be able to pay out of pocket for these things so in the end...they are on their own. The system needs to be fixed but it will have to start at a much higher lever. I am not optimistic as politicians do not get it or don't give a ****.

And frankly, that's overall a good thing. Yes, it does make conducting healthcare somewhat more challenging - but overall, more effective. For every doctor who's incorrectly challenged/wrongly mistrusted...there is a doctor who is corrected or whose diagnosis is improved. The downside of challenge is greatly outweighed by the cases where the diagnosis/treatment are improved or possibly even corrected.

People asking good questions is the best part of my job. I love an engaged patient. But you overestimate the average medical education of a patient. The vast majority of my time answering questions are things like explaining over and over again to a family why they cannot feed someone who is recently paralyzed on half their body. People with argue about how medications work, have no idea how to pronounce it or its mechanism of action, yet still with 100% confidence disagree. I spend much, much more time and effort on the Dunning-Kruger side of patient interaction than on the side of engaged, thoughtful questions.

[5mn_Major]

The ones that have a good evidence base like heart failure this does occur at most health institutions.

But for the most part that is not realistic.

If there is no evidence, insurance sure as hell not going to cover it. And for the most part, people are not going to want/be able to pay out of pocket for these things so in the end...they are on their own. The system needs to be fixed but it will have to start at a much higher lever. I am not optimistic as politicians do not get it or don't give a ****.

There are many other conditions (i.e., kidneys, etc) where lifestyle consultation is not the norm.

Not blaming you...but the fact that its considered not 'realistic' is part of the problem. Too often people just assume 'we can't fix it' perfectly and so do absolutely nothing to improve it. Also the fact that patients are sometimes not willing to pay out of pocket...does not mean that the physicians shouldn't have a full custom lifestyle as a recommendation and option available. Afterall, lifestyle changes are in fact recommended practice in these health outcomes...there's just no follow through to help keep the patient from coming back into the hospital a year later.

People asking good questions is the best part of my job. I love an engaged patient. But you overestimate the average medical education of a patient.

So again this is not directed at you...and I know you know this but...

What matters here is not the doctor...rather its the patient outcome. The patients health we're talking about...and ultimately they are the customer and they foot the bill. Patients are often wrong - but the resulting outcome is anywhere between patient feedback that improves the diagnosis...to at minimum doctors that are continually challenged to stay on top of their game. Not ultimately wonderful for doctors...but better overall for quality of healthcare.

[WisconsinWildcard]

What matters here is not the doctor...rather its the patient outcome. The patients health we're talking about...and ultimately they are the customer and they foot the bill. Patients are often wrong - but the resulting outcome is anywhere between patient feedback that improves the diagnosis...to at minimum doctors that are continually challenged to stay on top of their game. Not ultimately wonderful for doctors...but better overall for quality of healthcare.

Patient outcome is what matters. Unfortunately, we are reimbursed based on quantity not quality. I am not a surgeon, therefore my RVUs are much harder to come by and people in my field need to see many more patients just to keep their job.

Doctors are challenged all of the time by other doctors. These are probably the most useful interactions in improving quality. Academic centers are challenging in a very good way. You want to order a test? The first question will be how does it change management. The docs I worry most about are those on their own or in small groups where they can slowly drift away from best practice. But then again, that is why we have robust continuing education requirements, reboarding etc.

Here are a few things:
Happy (satisfied) patients, for the most part, have worst outcomes
VIPs, for the most part, have worst outcomes

There is a customer element to healthcare but the trends in the literature have been showing that when the customer is right, outcomes are worse.

[5mn_Major]

Patient outcome is what matters. Unfortunately, we are reimbursed based on quantity not quality. I am not a surgeon, therefore my RVUs are much harder to come by and people in my field need to see many more patients just to keep their job.

Doctors are challenged all of the time by other doctors. These are probably the most useful interactions in improving quality. Academic centers are challenging in a very good way. You want to order a test? The first question will be how does it change management. The docs I worry most about are those on their own or in small groups where they can slowly drift away from best practice. But then again, that is why we have robust continuing education requirements, reboarding etc.

Here are a few things:
Happy (satisfied) patients, for the most part, have worst outcomes
VIPs, for the most part, have worst outcomes

There is a customer element to healthcare but the trends in the literature have been showing that when the customer is right, outcomes are worse.

I might also believe that the outcome of 'when the customer is right, outcomes are worse' comes from doctors caving. What a doctor should do is rather stick to their guns when they are confident they are correct...there's no question that a patient can be wrong.

And again, while I can believe everything you say above as correct...it doesn't mean an educated patient is not a good thing for the overall quality of healthcare.

[unofan]

I might also believe that the outcome of 'when the customer is right, outcomes are worse' comes from doctors caving. What a doctor should do is rather stick to their guns when they are confident they are correct...there's no question that a patient can be wrong.

And again, while I can believe everything you say above as correct...it doesn't mean an educated patient is not a good thing for the overall quality of healthcare.

The problem is the Dunning Krueger effect, the patients/clients/whatever who think they're the most educated tend to actually be the least.

[5mn_Major]

The problem is the Dunning Krueger effect, the patients/clients/whatever who think they're the most educated tend to actually be the least.

Sure...but does the costs of that outweigh the benefits of a knowledgeable patient. I would argue no.

A knowledgeable consumer pushes a product/service provider to produce better offerings and do it with better service/support. This is the case whether you're ordering food at a restaurant, buying a dishwasher, booking a hotel or receiving healthcare. If you're the provider getting pushed, it makes your life more difficult...but the resulting improved offering makes for a better marketplace overall and improves quality of life for all.

[WisconsinWildcard]

I might also believe that the outcome of 'when the customer is right, outcomes are worse' comes from doctors caving. What a doctor should do is rather stick to their guns when they are confident they are correct...there's no question that a patient can be wrong.

What a great way to tank the Press-Ganey score and cause your hospital to lose money. You do that frequently enough and you will have 2 or 3 administrators so far up your ***...

The system is broken. Doctors and patients have poor advocacy for themselves. Politicians do not give a **** or listen to the profit makers in medicine over patients and health care professionals.