Medical “Reversals” and “Eminence based Medicine”

WOW. I just read an article that put together a bunch of things I’ve “sort of” known but didn’t have the references to support.  CoAuthored by Vinay Prasad and one of my favorite docs, John P. A. Ioannidis  it’s titled:

The reversal of cardiology practices: interventions that were tried in vain

They dig under the hood of a TON of cardiology practices that, despite some pretty effective debunking, continue to be used.   One of the now debunked things we used to do (give potent anti arrhythmic agents to people after heart attacks) is now estimated to have killed 50,000 patients during the years it was in vogue!

I got onto this mission looking into the “benefits” of cardiac stents as my own father has now fallen into a medical rabbit hole in Las Vegas and may end up having a stent recommended.  For those docs out there  please read this and tell me what you think.  I’ll be happy to communicate via private email if you’re not ready to come out of the closet with a public agreement quite yet.

Dr. Nick  –  2 months till I’m a pediatrician again 🙂

Prasad V. The reversal of cardiology practices: interventions that were tried in vain. Cardiovascular diagnosis and therapy. 2013-12;3:228-235.

P.S.  For those mathematicians in the crowd, check out Dr. Ioannidis seminal paper   “Why Most Published Research Findings Are False”. PLoS Medicine 2 (8): e124. doi:10.1371/journal.pmed.0020124. PMC 1182327. PMID 16060722

free pdf here:

Click to access DPV-Wiss-False-Research-Findings.pdf

Now for the Floor Mats!

Good article today about all the extra bills that get tagged on to a hospital stay that you have no idea you asked for.  In fact you often didn’t.

After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know   

The version I see is what I call “consultorama.”   A patient gets admitted for an orthopedic procedure – but instead of getting admitted to the orthopedic surgeon he gets admitted to my service; Internal Medicine.  The stated reason is “medical management.”  Often the patient really does need a lot of medical management that may be beyond the surgeon’s skill set, but often it’s a straightforward case and the surgeon just doesn’t want to do the “scut work.”  The surgeon is going to get paid the same whether he is a “consultant” or the “attending.”  The patient is now going to get 2 bills.  But wait… there’s more!  The patient had a dog who’s uncle had a pet parrot who had a heart attack.  We better get the patient’s heart checked out – consult the cardiologist!  But wait… there’s more!  The anesthesiologist demands some blood work before the surgery.  There is a slight elevation in the kidney test because the patient hasn’t had enough to drink because they are in pain from their broken hip.  Better consult the Nephrologist!  Wait the patient is in pain …. Consult Pain Managment.  Consult Physical Therapy, Occupational Therapy.  Pt is constipated Consult Gastroenterology!

In my job I often have to do the :”discharge summary” when a patient leaves the hospital.  Part of the dictation is to list all of the consultants.  It is not unusual to list 10!  Sometimes their might be 4 different nephrologists.  If they work for different groups the patient will get four different bills!    I have the lowest rate of consults in my group.  It’s not because I’m smarter, it’s just because I think that too many cooks in the kitchen make the soup worse.

Tell me your experiences as either a doctor or a patient.  I’m interested in what others have seen.

Dr. Nick

Panel Urges Overhauling Health Care at End of Life

Report pretty much states the obvious but I’m glad some “experts” are coming out with this information.  I’ve spent the last 4 years watching people die in hospitals. I would estimate less than 20% have their act together and make it home with hospice.  Granted I’m only seeing those who came to the hospital in the first place.  Leave me some comments on your experience with end of life issues.                              (NY Times article about topic)

Your Doctor is making you FAT

I’ve had this suspicion for awhile: antibiotics make you fat!  Nice article by Pagan Kennedy about the history of antibiotic use in livestock.  It’s been well known that feeding animals antibiotics makes them gain weight quickly.  How it works?  No one knows but here’s a newsflash:  HUMANS ARE ANIMALS.  And we doctors prescribe a ton of antibiotics.  Are we making your kids fat with all those amoxicillin prescriptions for ear infections?  The NNT (number needed to treat) for ear infections is at least 6 and probably higher.  Antibiotics for strep throat?  All day long we do this to prevent non-existent risk of Rheumatic Fever (in the US).  Check out the article and leave some comments.  Look forward to an upcoming post about the Rheumatic fever / Strep throat story.



Mammograms Revisited

Mammograms Revisited

This is the third rail in medicine.  Anyone who touches it fears getting emasculated by the Komen foundation.  More and more data, however, shows the risks of overdiagnosis.  I remember harassing women like Marie Myung-Ok Lee   into getting mammograms.  Now I am thoroughly embarrassed about my previous overconfidence.  Like many things in medicine, the benefits are oversold and the risks minimized.  It’s OK to question your doctor and common wisdom.  Good for you Marie!

Simpsons have it Wrong

Simpsons have it Wrong

I’m hoping I wasn’t the basis for the awesome Simpson’s Doctor!

The only problem is that it’s not true! Doctors are like plumbers: the more we screw up the MORE we get paid! It’s a wonderful system from my end. Some regulations are going into effect to try to stop the incentive to make you sicker so you stay in the hospital longer, but I’m dubious they will be terribly effective. And if you die? We still get paid by Medicare!

Creating disease out of Aging

Creating disease out of Aging

Nice op/ed about one of the many ways we try to turn aging into a disease.  As with most medical interventions, however, there are unintended consequences.  Notwithstanding the physical side effects, I’m really opposed to telling an otherwise healthy person that they have a medical “condition.”

I guess “lose weight, get more exercise and eat right” just doesn’t sell billions 😦

Patients’ Costs Skyrocket; Specialists’ Incomes Soar –

Patients’ Costs Skyrocket; Specialists’ Incomes Soar –


Great anecdote about one of the ROAD specialties (Radiology, Ophthalmology, Anesthesia and Dermatology).  These are the “lifestyle” specialties and are very competitive to get into.  Only the smartest medical students with the best scores.  They also turn out to be pretty good businessmen, generally making twice what your average pediatrician will get.  Read the story to see how they do it and let me know what you think.

Dr. Nick