Sensible Medicine

TR is an 88-year-old man who is disabled and in chronic pain from spinal stenosis and knee osteoarthritis. He has multiple other medical issues, including coronary artery disease and COPD.He has been through years of treatment for his knees and back, including physical therapy, multiple joint injections, and an in-office procedure for spinal stenosis. He has been on multiple regimens of oral pain medications. He is not interested in surgery (and probably would not be considered a reasonable candidate if he were).He comes to a visit and asks what can be done.Sensible Medicine is a reader-supported Substack. If you appreciate our work, consider becoming a free or paid subscriber.We are taught never to say, “There is nothing I can do for you.” We may be out of surgical or medical options, but we can always continue to care for and support our patients. This is not part of the Hippocratic Oath, but it is so integral to our training that one might think it belongs there.There are good reasons to caution doctors from saying some version of, “I am sorry, I don’t think there is anything more I can do for you.” It is true that in 21st-century medicine, the act of caring for patients has been so trivialized that we need to remind ourselves that caring is not just a last resort but our first responsibility.Hope in the face of illness is exceedingly valuable. Robbing this hope is not only cruel, but probably bad for the health of patients.Then there is the truth that when one doctor has nothing left to offer, medicine often still has more to offer. I am still haunted by at least one case when I mistook my lack of knowledge for a shortcoming in the field.A doctor saying he has nothing left to offer may be taking the easy way out. Further research or a considered referral often suggests effective treatments, if not cures. There is always a risk that when we say, “We can’t help,” we are wrong.All this being true, I don’t think we admit that there is nothing left to be done often enough. The Modern Hippocratic Oath does include the line:I will not be ashamed to say “I know not”, nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.Is it that much of a stretch to imagine the oath saying:I will not be ashamed to say “I have nothing left to offer beyond my ongoing care and commitment”, nor will I call in my colleagues, knowing they have nothing to offer beyond protecting me from admitting medicine’s limitations.We no longer conceal bad diagnoses from patients; we consider this unethical. It is time that we consider it unethical to conceal that we have nothing to offer beyond palliation.It is hard to tell patients that the best we can do is control pain, especially when we have been trained not to. It takes work to be sure that neither you nor your colleagues have something to offer beyond a hamster wheel of care to provide hope but nothing more. It also takes some guts; we can never be 100% sure that nobody has anything to offer.Yet there are downsides to never saying we are done. Many patients accept that further care is futile, not after an honest conversation, but after being worn down by my endless visits, treatments, and promises that lead nowhere. All the while, time and money are wasted; time and money that could be better spent on life. The useless medical care leaves patients and their families increasingly frustrated by a medical system that refuses to be honest and caring.There are patients who welcome an honest assessment of their options and shift their focus to living with their disease and disability. There are also patients who do not. I’ve had patients fire me for saying there was nothing to do. They left me to get on that hamster wheel of care. This decision did not make them better, but maybe it made them happier and more ready to accept the inevitable. Eventually.TR calls now and then and comes to see me every three or four months. He tells me about his symptoms and the things he wishes he could do. I tell him there are things he could try and people he could see, but I let him know I don’t think any of these options would be productive. He tells me he’s not interested. I advise him to push up on his pain medications and to pretreat his symptoms; I know he will not take this advice. I know we will repeat this visit in the future; I actually hope we will, for years. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Medical Management and Revascularization for Asymptomatic Carotid StenosisVagus nerve-mediated neuroimmune modulation for rheumatoid arthritis: a pivotal randomized controlled trialWe spent quite a bit of time talking about blinding. This is the table on the adequacy of blinding from the supplement. It does seem like blinding was less than perfect. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

We cover questions from Amy J, Benjamin Hourani, Diana Stiles Friou, Chris Costas, Errol Laurie, Jim Healthy, Elizabeth Fama, Never Dull, Rod Rodriguez, Ellison Burns, David Araujo, and George.We have more to come!One nice reference I found while looking into some of the topics:DMSO Is Not a Cure-All. But the FDA’s Panic Over It Birthed a Myth This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

European Study of Prostate Cancer Screening — 23-Year Follow-upAssociation Between Baseline Diastolic Blood Pressure and the Efficacy of Intensive vs Standard Blood Pressure–Lowering TherapyFurther Reading* Effects of intensive blood-pressure control in type 2 diabetes mellitus* A Randomized Trial of Intensive versus Standard Blood-Pressure ControlSensible Medicine is 100% reader-supported. If you appreciate our work, consider becoming a free or paid subscriber. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Total cholesterol and all-cause mortality by sex and age: a prospective cohort study among 12.8 million adults* The Ideal Cholesterol Level ... Depends...And Cannot Be Determined From Observational StudiesStructured vs Self-Guided Multidomain Lifestyle Interventions for Global Cognitive Function: The US POINTER Randomized Clinical Trial* Can We Please Stop Asking if Crossword Puzzles Prevent Dementia? This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

We go all observational this week. A look at data suggesting the safety of GLP-1s and a re-examination of data on patient/doctor race concordance/discordance (a topic Adam said we should not study, and then John forces him to).GLP-1 Receptor Agonists and Cancer Risk in Adults With ObesityPhysician–patient racial concordance and newborn mortalityOriginal, 2020 article: Physician–patient racial concordance and disparities in birthing mortality for newborns This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe