Sensible Medicine

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

NT is a 55-year-old man admitted to the general medicine service with cellulitis of his left leg. When the attending sees him the morning after admission, he notices the patient’s “Medical Center Trustee” hospital ID on his bedside table. After gathering a history and examining the leg, the attending leaves the room. In the hallway, he crosses paths with the hospital president, who is there to make a “social call”. She smiles and says to the attending, “Don’t let anything bad happen.”Sensible Medicine is reader-supported. If you appreciate our work, consider becoming a free or paid subscriber.Every clinician is familiar with the Very Important Patient, the VIP. Defining the VIP is challenging. In the most general sense, the VIP is a patient whose care imposes an additional burden on the clinician. The VIP is perceived to have an elevated social status, typically due to fame, wealth, connections, or power.The VIP may come to his or her status in several ways. The VIP might claim that status herself. The status might be granted by a third party, such as the source of the referral, or outside realities (fame, fortune, power). Sometimes, VIP status is granted by the physician alone.The physician recognizes that an untoward outcome in the care of the VIP — clinical or otherwise, expected or unexpected — will be acknowledged by a wider community and might be particularly unpleasant for the treating physician.VIP patients are a threat to healthcare. They need to be eradicated from hospitals and clinics as ruthlessly as we would eradicate E. coli from a well, Pseudomonas from a hot tub, or Legionella from a hotel HVAC system.Why should we eliminate the VIP? Because a patient’s wealth, station, or connections should have no bearing on the tests that are done, the treatments that are offered, or the haste with which care is provided.I have heard people argue about whether basic healthcare is a human right. I have heard people who agree that basic healthcare is a human right argue about what makes up basic healthcare and who should decide what qualifies. I have never heard people argue about whether people deserve different care based on their identity.The most obvious threat the VIP poses is to himself. We recognize that when people are treated as special, they are at risk of getting worse healthcare. This fact underlies the guidance that physicians avoid caring for close friends and relatives. The AMA Code of Medical Ethics states:When the patient is an immediate family member, the physician’s personal feelings may unduly influence his or her professional medical judgment. Or the physician may fail to probe sensitive areas when taking the medical history or to perform intimate parts of the physical examination. Physicians may feel obligated to provide care for family members despite feeling uncomfortable doing so. They may also be inclined to treat problems that are beyond their expertise or training.You could easily replace family member with VIP. While we can all avoid treating family members and close friends, VIPs are a reality in every physician’s life. Transferring their care to another physician usually does not change the circumstances.Ben Kean, an exceptionally colorful character and my parasitology teacher in medical school, shared a story about the risks VIP healthcare poses to the VIP. He once suggested that a patient with pneumonia — a patient who was also famous, wealthy, and important — be transferred from a private hospital to a public one, and treated under a pseudonym."But why a public hospital, when I have a good private clinic here with the best doctors and nurses?""There are two ingredients essential to your recovery," I explained, "that can't be found here and that you cannot buy. These are things found only at a large public institution, where hundreds of patients are seen each day, many of whom suffer from pneumonia. First, you need a large house staff -- bright, young people with new ideas and with daily experience in dealing with desperate situations. Second, you need a laboratory with specialized technicians available around the clock to monitor your breathing, to do special culture work for bacteria and parasites. This is a lovely private hospital, but the kind of help you need isn't available here."Then there is the reality that if you treat VIPs differently, and it becomes known, it is a bad look. Just ask the leadership of NYU Langone Health.But the threat of the VIP goes beyond personal risk. The overtesting, overtreatment, and early diagnosis that have been described not only threaten the VIP but are also bad for our healthcare system. Overspending and excess erode other people’s care. An unnecessary MRI ordered for the VIP’s week of sciatica may delay the diagnosis of cord compression in the non-VIP with back pain and prostate cancer.VIP treatment can lead to ill will among members of the healthcare team. Teams bond when they work together for the benefit of a patient. With VIPs, team members most under the patient’s sway may suggest management at odds with that proposed by team members less influenced by the patient’s status. It is not hard to imagine moral injury if a healthcare worker perceives they are acting because of who a patient is rather than because of what the patient needs.If a team bows to pressure, the ethics of medicine are compromised. Other patients will perceive a tiered system, and this will undermine their faith in medicine.Eradicating the VIP from healthcare is certainly more difficult than getting rid of E. coli, Pseudomonas, or Legionella. How do we ensure that the homeless man, with no wealth, power, or family, receives the same care as the woman for whom the hospital is named?It may be hard to eradicate the VIP when healthcare itself has played a significant role in creating the VIP. Hospital marketing and rankings promote the idea that doctors and hospitals are not equal. They do this to attract the “best payer mix” so they can build shiny new facilities. If patients, with their expensive, private insurance, are drawn to a medical center because of the rankings, should we be surprised if they expect something for their money and effort?I wish there were an easy answer. There is not. It is possible that Mick and Keith are our best guides here.As clinicians, we know that we need to provide the best care possible for our patients. We also recognize that different people want different things from their healthcare. Some people just want to be left alone at night, others want an extra cup of tea with breakfast, and others want a visit from the hospital president. If these allowances truly do not affect the care of patients, all patients, then there is no harm in providing the desired care in addition to the necessary care. Once management of the VIP threatens to affect care, hers or that of her fellow patients, then physicians need to recommit to their pledge to care for everyone equally, regardless of who they are. This is at the core of the practice of medicine. 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

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

Last week, John was at the European Society of Cardiology conference in Madrid, and Adam was at the Preventing Overdiagnosis 2025 International Conference in Oxford. A conversation about what we learned.Digitoxin in Patients with Heart Failure and Reduced Ejection FractionBeta-Blockers Post-MI: A Clear Clinical MessageAspirin in Patients with Chronic Coronary Syndrome Receiving Oral AnticoagulationHow does decontextualised risk information affect clinicians’ understanding of risk and uncertainty in primary care diagnosis? A qualitative study of clinical vignettesHow do we talk about overdiagnosis of mental health conditions without dismissing people’s suffering? 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

Metformin for Treatment of Knee Osteoarthritis in Patients With Overweight or ObesityOnce-Weekly Semaglutide in Persons with Obesity and Knee OsteoarthritisSemaglutide or Tirzepatide and Optic Nerve and Visual Pathway Disorders in Type 2 Diabetes 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

TR is a 72-year-old woman, a retired executive, who had been in excellent health until she began experiencing exertional dyspnea and palpitations. After waiting out the symptoms for about a month, she called and made an appointment to see her primary care doctor. The day before her appointment, she awoke unable to move her entire right side. With difficulty, she reached for her phone and called her daughter. Her daughter was unable to understand her and called 911.This Substack is reader-supported. If you appreciate our work, consider becoming a free or paid subscriber.Someday, I will close up my practice and be left with an enormous hole in my life. I will miss the 12-24 people I get to spend time with every day during their appointments. I will miss the sometimes-intense relationships with a fantastic diversity of people. I will miss working to make people’s lives better and longer. I will miss the diagnostic puzzles and the reward of seeing someone “get better” over days, or weeks, or months.I will also miss my colleagues, the clinicians who have chosen to dedicate their careers to helping people. I will miss meeting the next generation of doctors, nurses, psychologists, physical therapists, pharmacists, and the like.I will not miss The Look.I was well into my career when I first recognized The Look. I had just returned to our inpatient service after a leave to care for my mother, who had experienced a serious, life-altering illness.A few days after my return, my team admitted TR. She had been in excellent health until a few months before admission, when she began to lose weight and have some trouble sleeping. More recently, the symptoms had progressed to include exertional dyspnea and palpitations. Our evaluation revealed hyperthyroidism from a toxic multinodular goiter, leading to atrial fibrillation, leading to a large, embolic, left middle cerebral artery stroke.From a medical perspective, the case was classic and straightforward. My resident assigned TR to a medical student as she thought it was a perfect teaching case.On the second day of TR’s admission, I met her daughter and learned more about TR. She had grown up on Chicago’s South Side and had always been a star student. She excelled in the public school system and was eventually awarded a full scholarship to the University of Illinois. When she left for Urbana-Champaign, it marked the first time she had left Chicago.She graduated summa cum laude from U of I and began working in a corporate office back in Chicago. She excelled in this world as well, eventually managing a fifty-person team.She had one daughter, whom she adored, and two grandchildren. She retired just before her 70th birthday. She was thriving in retirement, traveling alone and with friends, and serving on two corporate boards. She loved her work on boards because it enabled her to meet a small group of African American women executives of her generation who shared similar experiences.The Look on her daughter’s face was familiar to me. I recognized it because I knew I had worn it a few weeks before, caring for my mother. The Look reflected the emotions TR’s daughter articulated to (and for) me. There was sadness and anger for what her mother had lost. There was anxiety about what was next for her mother. There was a realization that her mother’s situation would affect her. Their relationship had permanently changed. TR’s daughter spoke of how her mom had always been her foundation. Overnight, the daughter had become the middle of the sandwich. She now had to care for her kids and her mother. There was also a little bit of guilt. How can I worry about the impact this will have on my life when my mother is now disabled?Seeing The Look that I knew we shared, the empathy I felt for TR’s daughter made it difficult for me to play my usual role in counseling and planning. I told my resident and the case manager they would have to “do this one without me.”Since that day ten years ago, I recognize The Look not infrequently. I see it on the children who suddenly lose a parent, while gaining responsibility for that parent. I also see it on the faces of husbands and wives when their partners begin to fail. In these situations, my relationship tends to be different. While the adult child is, more often than not, a stranger to me, both members of the couple are often my patients. While I care for one partner with cognitive and/or physical decline, I care for the other living with the trauma of this decline.Filial love and romantic love (if this is the proper term for a decades-long relationship) are different; spouses experience something different than children. The spouse is not only mourning a relationship but also often dealing with direct caregiving. In addition, most couples evolve into productive codependency. Physical tasks are shared – who cooks, who cleans, who does the taxes, who fixes the sink – as well as cognitive ones. Who is better with names, keeps track of birthdays, maintains relationships with friends. While the sandwiched child must manage a new relationship, the spouse must manage losing a part of themselves.I am being overly writerly here. If you showed me 10 pictures of traumatized people, I would not be able to identify who had The Look. I only recognize it when I see the person and hear about the situation. As a clinical skill, though, recognizing this sign is useful. Like knowing what needs to be done when I smell the scent of alcoholic ketoacidosis, or hear the familiar ramblings of delirium tremens, I have come to understand the role I need to play when I see The Look.When I give up clinical practice, I will be happy to see The Look less. The human tragedies that lead to it are situations I’ll be happy to avoid.Photo Credit: Baptista Ime James 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

A “manel” reviewing trials and studies that explore the benefits and harms of hormone replacement therapy.The Women’s Health Initiative* Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial* The Women's Health Initiative Randomized Trials and Clinical Practice: A Review* The Women’s Health Initiative Hormone Therapy Trials: Update and Overview of Health Outcomes During the Intervention and Post-Stopping PhasesMeta-analysese* A systematic review and meta-regression analysis to examine the ‘timing hypothesis’ of hormone replacement therapy on mortality, coronary heart disease, and stroke* Mortality Associated with Hormone Replacement Therapy inYounger and Older WomenHistory: Observational HRT Data* Postmenopausal estrogen and progestin use and the risk of cardiovascular disease* Hormone therapy to prevent disease and prolong life in postmenopausal women 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

Primary Articles* As-Needed Albuterol–Budesonide in Mild Asthma* Early versus Later Anticoagulation for Stroke with Atrial FibrillationReferenced Articles * Albuterol–Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma* Stopping Randomized Trials Early for Benefit and Estimation of Treatment Effects: Systematic Review and Meta-regression Analysis 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

Primary articles discussed:* First myocardial infarction: risk factors, symptoms, and medical therapy* Oral vs Extended-Release Injectable Naltrexone for Hospitalized Patients With Alcohol Use DisorderA Randomized Clinical TrialArticles referenced:* Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis* General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis 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

A visit brings back the memories of patients and the lessons they taught. 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