A post-pandemic view on medicine

I wonder about the difference in perspectives on medicine having been a doc trained during the pandemic. I see a frame shift in my generation, a sense of humility. I inherit patients from older doctors and see a different practice style, and ideal of manipulating people’s physiology to control disease, to treat sensations.

I was trained during a time where we realized medicine is largely helpless. I began my residency during normal times, watched a global pandemic decimate the healthcare system, kill off a portion of the population while researchers desperately scrambled to find any viable treatments. Physicians made up medicine on the fly, nurses desperately proned and suctioned secretions from patient’s airways. None of it seemed to help. The patients would just die despite your best efforts. Then, even when we found amazing viable treatments, a large portion of the population, unfortunately listening to quacks like Alex Jones and Donald Trump, declined our best evidence based interventions.

Doctors of the prior generation often blanket checked labs on all patients, listened to every patient’s heart and lungs, palpated their abdomens. They did these intensely thorough physical exams to find hidden pathology, palpated every prostate that walked in the door, felt for every breast lump, did a hernia exam on every adolescent boy. What we have found based off that mentality, through extensive population level studies, is that sometimes patients who came and saw us, patients who were poked and prodded, actually died faster than the patients we left alone. Our interventions for prostate cancer often caused incontinence, erectile dysfunction, and even killed people who were never going to have any problems from their prostate cancer. We tested the thyroid of everyone who walked in the office, and we found that the younger population rarely if ever benefited from treatment when they didn’t have symptoms and the older population actually died faster because of our treatment.

I have watched a prescription opioid crisis create a whole population of patients whose pain is worse than had they never been started on the medications. I have watched patients come in emaciated, anxious and sleepless because they were prescribed amphetamines for their very normal, very not-pathologic difficulty concentrating in life. I have seen recovered alcoholics pride in their sobriety be decimated when they learn that the clonazepam their doctor put them on for anxiety is, in reality, just alcohol in pill form.

I believe we have created a population of patients who believe sensations need treatment, that existence alone is enough to need medications, that we can prevent every disease. The reality is that it is always an odds game, always weighing probabilities of risks and benefits. And after seeing a portion of the population die from a slight mutation in a common virus, I think I respect our limitations in medicine.

Avoid us. We will poke and prod you and test you and “treat” you until we have caused more harm than good. The most fundamental tenet to the hippocratic oath is “do no harm”. The reality is that there is no way to do no harm. I wish Hippocrates had gone with my high school economics teacher’s motto: “TANSTAAFL” an acronym for “They’re ain’t no such thing as a free lunch”. I tell my patients this all the time when I am trying to talk them out of unnecessary lab testing, unnecessary physical exam maneuvers. Anything I do comes with a cost. I listen to your heart and we lose a few seconds where I could be talking about tobacco cessation or healthy diet with you. Or worse, I hear a murmur that never would’ve caused you trouble and now I’m getting an ultrasound of your heart to evaluate that and I find a mildly dilated thoracic aorta and now I put you on beta blockers which slow your heart rate to a point where you lose your ability to hike up your favorite trail and I do annual monitoring of your aneurysm because that’s what the guidelines say to do and it costs you hundreds of dollars a year, money which you could be spending on a dietician, or a physical therapist, or going to a show with your family, or taking your partner out for a lovely date.

Don’t just avoid doctors. Avoid all of us. “Alternative medicine” practitioners are no better. Naturopaths, chiropractors, functional medicine, homeopaths, will poke and prod you, empty your pockets, convince you of pathology that has no basis in reality such as “being out of alignment” and bring you back in for repeat “treatments”. Avoid all of us unless you need us.

Nothing I do is benign. Nothing I do is without risk. Doctors are not gods. There is a 100% mortality rate to this existence. Don’t fix it if it’s not broken. TANSTAAFL.

Open access scheduling

I am working on implementing a different type of scheduling in primary care. I know that is probably the most un-exciting way to begin a blog post so bear with me for a second because I think it is kind of interesting. Every other primary doc I know of is booked out for weeks. They have different backlogs of patients with half a dozen queues for patients. They have different slots for different types of visits each day, for example: two annual exams a day, one procedure slot, two same-day appointments, two medicare wellness visit slots, six follow up slots. They may be booked out for months for medicare wellness visits but their same-day slots may not even get filled. Continue reading Open access scheduling

The harm of the over-attentive doctor and the incidentaloma

I was talking with one of my former co-residents tonight, reflecting on our practices with regards to lab and imaging investigations on various patients. In residency I was probably one of the most conservative providers. I ordered only a handful of MRIs my whole residency, rarely ordered X-rays, avoided routine laboratory blood work, and rarely follow up imaging or labs on various mild abnormalities. She is in line with me, one of the least investigative providers in our residency. As interns we classically order very little imaging and labs, and often they were inappropriate if we did order them. As we get further along we learn what really truly needs investigating and are asking more questions, balancing more diseases and patient concerns and our ordering goes up. Continue reading The harm of the over-attentive doctor and the incidentaloma

My three rules for placebo

Placebo or practices that are poorly or not based in evidence is an ethically questionable practice in medicine. Is it okay to prescribe medications for patients knowing that they will have limited or no benefit? Because of this I’ve established three rules for myself with regard to placebo. To some extent they are unattainable but I’ll keep trying. Continue reading My three rules for placebo

My style in primary care

I’ve been suffering an identity crisis as a new primary care physician. I’ve had guidance with nearly every decision up until this point but now I’m on my own. I reflect back a distinct interaction with one of my attendings in residency. He is an osteopath, manipulates people’s muscles, and fascia for the bulk of his work. I was precepting a patient with him one afternoon. The patient had terrible sleep habits, drank caffeine in the evening, took naps at 5pm, watched tv in his bed, had untreated anxiety and would contemplate the next day’s plans all night. He didn’t work, didn’t exercise, had nothing to exhaust him during the day. He wanted a medication to make him sleep and instead I counseled him on sleep hygiene, a strategy to fix the problem rather than masking it with meds. My attending, disagreed with me and said I should just give him the med. Continue reading My style in primary care

Intrinsic joy

When I was in high school and college, most of the activities I was doing were to obtain validation of others. I had quite an overpowering fear of death, or rather of being forgotten. I remember having this fear around my junior year of high school that one day I was going to die and no one would care. I quickly realized that theism was an easy way out of facing this angst and that was not going to be the solution for me. I needed something more tangible. For years that solution was to be greater, to have influence on the world, to be remembered. I pursued that through racing triathlons for a while. A few people noticed me and a couple people knew who I was. I was the first to cross the line at some little local races and I thought I was somebody. That was really hard. I tried so hard. Continue reading Intrinsic joy

What it’s like to die from covid

I had an odd interaction with a patient a few weeks ago. I was encouraging him to get the vaccine, telling him it was safe and effective. I dispelled all his fallacies claiming lack of research, rushed to the market, lack of long term data, and that as a late 40s guy he was at low risk for adverse effects or death from covid. I pointed out that he deferred to experts in his everyday life, trusted driving on a brand new bridge the day it was built (did not need any long term data there), and told him of several 40 year olds I had seen who had died or maybe wish they had died from covid. His response was that he was not scared to be dead. He said, if I am dead, I will be dead, so I won’t care. He has a young daughter. I told him his daughter would care. He said she would be alright without him. I told him it is not the being dead that is so scary, it is the dying part. He said he thought he would be sedated and unaware for that whole process. That is what baffled me the most. He had literally no idea how people die from covid. I want to dispel that. Continue reading What it’s like to die from covid

The strange ethics of vaccination, male contraception in comparison to cancer screening

We are facing a global crisis with an absurd amount of people refusing vaccination. I have nearly hourly conversations with patients about the importance of vaccination and largely my professional advice falls on deaf ears. To be honest, I’ve probably overly entertained the ethics and decision challenges regarding vaccination and find some similarities between that and male contraception in comparison to cancer screening.

Discussing specifically the medical ethics of immunization for rare diseases, it is kind of a strange practice. In the context of covid-19 vaccination this is moot given the absurd prevalence and declining the vaccine is really just an inability to make adult decisions. Nothing else. However, in the case of rare diseases, when we choose vaccination we choose to take a therapy that may potentially in even more rare circumstances cause us harm in order to protect those around us. It is an individually and medically absurd decision, but socially is absolutely vital. Continue reading The strange ethics of vaccination, male contraception in comparison to cancer screening

The sin of the rvu

I could never have fathomed how badly residency and medicine in the US could try to beat the compassion out of me. We all went into medical school with bright eyes, touting our love and desire to help people as our primary motivation for pursuing this career. It is likely what made us special, what marketed us as exceptional beyond the grades, MCAT scores, and extracurriculars. And yet a year and half into residency I am finding persistently berated by moral injury of a desire to help people in a system that seemingly strives to make it nearly impossible to do that.

A few months ago my residency transitioned all of our appointments to 30 minute slots, a subtle but heinously impactful change from a mix of 30-45 minutes appointments prior. Independent of new patient or established, routine or presenting with a dozen chronic diseases, we have 30 minutes to meet another human being, learn what makes them who they are and why they strive for health, and make recommendations to help influence their lives. The system is set up this way because of financial incentives to decrease duration of visits while maintaining revenue, a meaningless need to reach the arbitrary number of 1650 patient encounters before the end of residency, and a need to supply care for seemingly infinite demand with extremely limited supply. Continue reading The sin of the rvu

Adventures of a medical student