Sensible Medicine

MM is 94 years old. Her only active medical issues are hypertension and vitamin D deficiency. She takes only 20 mg of lisinopril and 1000 units of vitamin D3 each day. She has no cognitive decline and gardens every day if the Chicago weather allows. Her Friday afternoon appointment is the doctor’s last of the week.Sensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber.I’ve already written a reflection on four things patients have taught me. After MM’s visit, I realized how much more there is to write on the topic. So here is a follow up with the unoriginal claim that the most valuable things I have learned from my patients are not about the practice of medicine. Though not profound, the lessons are universal. The longer I practice, and the older my patients get, the more frequently these truths are spoken.Aging is PainfulAnybody who gets to middle age knows that things don’t work like they used to. Around my house we say that any day that nothing hurts is remarkable. My patients are full of pithy phrases to make the point that aging is physically difficult.“Getting old is hard, but it beats the alternative.”“Aging is not for wimps.”“Every time I look in the mirror, I ask myself, how the hell did that happen?”People respond to their progressive disability in all manners. Some fight at every turn. Every visit, irrespective of age, is spent discussing aches, pains, and things that can no longer be accomplished. There are demands for me to make things better. I find it challenging to address the concerns, rather than dismissing them with “it’s just age,” while also letting people know that some suffering is “part of the human condition.”Other people accept frighteningly steep and acute declines. My challenge at these visits is to balance, “She’s not asking me to address the problem, so who am I to pry” with “This actually seems like something I should explore, even if she is willing to accept it.”Where there is little diversity is our ability to adjust to disability. I was taught that people rate the quality of life with a disability higher when they are living with it than when they are watching other people live with it. Thirty years of clinical experience has made this real. We should add to the saying, “There but by the grace of God go I” the addendum “but, when I end up there, I’ll be OK.” Aging is SadWhen I was an intern, I admitted an elderly woman with pneumonia. Her biggest problem was not the pneumococcus but her depression. Her mood made her miserable and the associated psychomotor retardation was going to make her post-hospital rehabilitation impossible. She was already taking an SSRI and seeing a therapist. I called her primary care doctor, a geriatrician. Like a true intern, I expected he would have an answer to her misery. His response was, “Yup, it is a sad time of life.”There is a lot to be said for the golden years: retirement, family, friends, greater financial security – but as the years go on, the psychological costs mount. Besides the physical decline, there is the constant loss. I repeatedly hear, “Everyone around me is dying.” Siblings, cousins, friends. It sometimes seems like those who are most connected suffer the most – that big family that has always provided support now provides an unending procession of funerals.People mourn their losses as well as their own mortality. You cannot ignore what is to come when your peers are dying. Those who deal with this best seem to be the people who can be honest that their grief about the loss of a friend is partly the fear and sadness that they are next.Loss is Never EasyI never felt like I had enough time with MM. Not that she needed time for me to attend to her medical problems. She was blessed with enviable genes and an outlook that combined cheer and steel. I just wanted time to hear more about her life and her experiences. I wanted to learn from her.On one unpressured Friday afternoon we chatted. I did not have another patient to see, another note to write, or another meeting to run to. Her daughter would not pick her up until 6:00 PM. I told her that I still thought about her husband, also a patient of mine, who had died about a decade earlier.She paused and then remarked. “We lived together in the same old house for more than 60 years. Every time something stops working there, I curse the damn house and I curse Charles for leaving me alone in it. He was always puttering around, fixing things. Then, of course, I think of the wonderful years we had here. I cry because I still miss him, and then I thank the house for reminding me of him.”I can’t write anything original about loss and grief and mourning. We’ve been writing about it for as long as we’ve had written language. What strikes me, though, watching so many people experiencing loss, is that it is always hard. Losing a loved one is hard. It does not matter if your father is 50 or 90. It does not matter if your mother’s death is sudden or expected. It does not matter if you have come to terms with the complexity of your relationship with your sister or have not.Our losses become a part of us, they shape us. The tearing, searing grief might last days, or weeks, or months, or years, but it always ends. Nobody, however, ever “recovers.” Nobody “gets over it.” Having known, having loved, and having lost makes us who we are. 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

In this engaging discussion, Piotr Futima, a cardiac electrophysiologist from Poland, explores innovative approaches to ablate atrial fibrillation (AF). He reveals how pandemic constraints sparked groundbreaking techniques using a single catheter for right atrial ablation, targeting ganglionated plexi without anesthesia. They delve into vagally mediated AF, explaining its link to high vagal tone in younger patients. The conversation raises intriguing questions about the unknown mechanisms of pulmonary vein isolation and the importance of precise patient selection for effective treatment.

We discuss the state of medical education, Harvard music video, causal language at JAMA and more 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

Video will be available to paid subscribers 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

Gosh was this a great conversation about her recent paper on specification curve analysis of nutritional observational studies. Here is Dr. Zeraatkar’s bio:Dena Zeraatkar, PhD is an Assistant Professor in the Departments of Anesthesia and Health Research Methods, Evidence, and Impact (HEI) at McMaster University. She earned her doctoral degree at McMaster University in the Health Research Methodology graduate program. Following her doctoral training, she pursued postdoctoral training at Harvard Medical School, for which she was awarded a Banting scholarship.Her research centers on evidence synthesis and evaluation—identifying and appraising research to optimally inform healthcare and public health decisions. She often works in areas in which the evidence is complex or conflicting, examples of which include nutrition and COVID-19 therapeutics. For her research, in 2023, she was awarded a Gairdner Early Career Investigator Award.First, it would help to read my comments yesterday on the paper. Dr. Zeraatkar is well-spoken, clear and she explains a complicated topic in simple terms. Her work is exactly the type we love at Sensible Medicine. Stay for her final comment. It made me so happy. Sensible Medicine is a reader-supported publication. To receive new posts and support 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

The Thomas Sowell quote, “On closer scrutiny, it turns out that many of today's problems are a result of yesterday's solutions” has been ringing in my head a lot lately. 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

Professor Erik Van Zwet from Leiden University discusses P-values in randomized trials, trial power, and trial replication. They explore the significance of P-values in interpreting study outcomes, the challenges of sample size, and understanding effect size. The conversation clarifies the unexpectedness of results and emphasizes the importance of historical data for comprehensive analysis in clinical settings.

Why have I been committed to medical education? Some of the reasons are admirable but not terribly novel. Others are a bit hard to admit, but just as true. 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

Friday Reflection 35: Why Don’t Doctors Want to See Patients?I was asked “Why is it that doctors don’t want to see patients?” and I could not answer the question. Fourteen months later, here is my response. 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

Examining the bias in observational studies and the findings of a new Austrian study on the effectiveness of boosters in individuals who have recovered from COVID-19. Discussion on the Effectiveness of Booster Vaccinations and COVID-19 Death Rates: critique of a study from Austria that examines the impact of booster vaccinations on testing positive for COVID-19 and argues against boosters for temporary reduction in cases. Lack of Effectiveness of Booster Shots in Individuals with Previous COVID-19 Infection: study showing no reduction in COVID-19 deaths from booster shots in individuals with prior COVID-19 infection, highlighting durable natural immunity and critiquing US policy and FDA approval of boosters.