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How Does The Kool-Aid Taste? Standard of Care Practice of Medicine

As physicians, we get a very one-dimensional exposure to the medical sciences. To the family medicine doctor, it’s all about medication management; to the psychiatrist, it’s all about personality disorders; the orthopedist wants to cut; the radiation oncologist wants to radiate; and the interventional cardiologist wants to roto-rooter.

But how significant or impactful are our interventions? Did the mammogram really find the curable breast cancer or did we just cut out, radiate, and chemotize a lesion that would have disappeared on its own?

We’ve all been offered the Kool-Aid, and we are proverbially employed by Kraft Heinz. But have you been drinking yours? It’s hard not to.

Interventions That Work

A rheumatologist who starts a patient on biologics for their resistant Rheumatoid Arthritis can potentially change the course of the patient’s life; more daily functionality, fewer joint replacement surgeries, and less pain.

But for however many patients are started on biologics many can’t afford it, can’t tolerate it, or simply won’t benefit. And just because you think you can identify those who may or may not benefit doesn’t mean your predictions will come true.

Some refer to this as the NNT but there are many other ways to refer to the efficacy of a certain intervention.

The football player who got clipped will drastically benefit from having the 3 torn ligaments repaired. But the occasional weekend warrior may have the same surgery done for a similar injury with many more complications and far worse outcomes.

All The Busy Work We Do

We hospitalize patients for complicate workups, dialyze patients, inject type 2 diabetic with insulin, perform ex lap, remove uteri, stent coronary arteries, prescribe cough medications, pain meds, anti-hypertensive, lipid lowering drugs, and steroids.

How many of these interventions actually work? How many of them don’t work and make the patient even more dependent on the medical system as a consequence of bad consequences?

We do all of this sometimes because we don’t know what else to do. And because we have 5 minutes to spend with the patient, not nearly enough to smell someone’s BO, much less develop a bond, a trust.

What’s Your Favorite Flavor?

I suspect that 90% of the antibiotics I prescribe are completely unnecessary. And I’m sure the C Diffs I cause are quite unwelcome. Unfortunately, there are complex factors at play that lead to these kind of medical interventions.

But I, myself, wouldn’t take an antibiotic after a vasectomy or take chronic opioids for pain, or have a partial colectomy for a Crohn’s flare.

I don’t take this conversation lightly because I’m constantly asking myself if I would want this intervention for myself. Would I want my small skin abscess drained or would I just take antibiotics? Do I need a 2 cm laceration repaired or can I just leave its approximated ass alone?

Screening For Disease

We screen for disease because we believe that we’ll save someone a lot of disease and suffering in the future. The problem with screening guidelines is that they take decades to develop. In that time, the disease itself decreases in the population, and other causes and prevention are identified. All of this makes the initial screening test far, far less effective.

How effective are screening colonoscopies? It turns out, they are quite ineffective. Though they are quite effective at decreasing surrogate markers, they don’t do much to decrease colorectal cancer deaths or all-cause mortality.

Of course, a population-based screening colonoscopy is very different from a screening colonoscopy in high-risk patient. The high-risk patient is incredibly likely to benefit from even a FOBT, much less a colo.

Should you not do the PSA, mammogram, or colonoscopy? That’s the wrong question. The right question is who would benefit from a particular screening test which is the exact kind of showdown we’ve been asking for but never got.

Standard of Care is Your Job as a Doctor

You did go to medical school and you did finish a residency and fellowship. But that gives you no right to anything. It’s still at the the discretion of a specialty board to give you a specialty designation.

Next, it’s up to a state medical board to give you a state medical license to practice. Then, it’s up to a hospital to credential you and an employer to employ you.

I am saying all of this because I believe it will liberate you.

Finally, when you are ready to put your finger up your first patient’s butt as an attending, it’s not you who gets to decide what to do with the data you capture; it’s the Medical Practice Act and the Standard of Care that dictate how you can practice medicine.

I am saying all of this because I believe it will liberate you. When a 45-year-old patient presents to you, it’s your responsibility to offer them a colonoscopy, and the colonoscopist’s job is to deliver Informed Consent along with any involved risks, such as perforation.

Just because you can analyze your own research papers, dig into the studies yourself, and have first-hand experience with potential side effects, your state medical board decides what you can and can’t do.

Finding Your Tribe of Patients

Walk into a mainstream gynecologist’s office, and they’ll tell you to best avoid hormone replacement therapy when in menopause. But is that what you’d do for yourself? Maybe you’d prefer to sit there with a tub of vaginal estrogen with your hands down your pants while watching Netflix.

If you don’t believe in insulin for type 2 diabetes then you can run the kind of clinic that focuses on T2DM reversal. It’s not mainstream and it’s not standard of care but you also aren’t forcing insurance-based patients into that care.

Those who are sent to you by the insurance company expect you to manage their customers using the SOC paradigm; metformin followed by GLP1s, followed by insulin, followed by dialysis.

Got a great ACL tear rehab protocol that you’ve perfected, then your own ACL clinic with cash paying patients may be the way to go.

Don’t believe in chemo and radiation for stage 4 metastatic pancreatic cancer? Certainly, there are other interventions you’ve found useful that can still help support a patient through their journey and offer relief and empowerment.

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