Sensible Medicine

FH is a 66-year-old woman who comes in for an urgent visit because she has been feeling woozy for two days. She is very anxious, almost distraught, because she thinks these symptoms are the same as the ones that her sister had before she died of a hemorrhagic stroke.Sensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber.A few years ago, a team building exercise was proposed at a meeting I was attending. To say I hate team building exercises is a gross understatement. I usually run for the door when these are suggested. On this day, I was too slow. For the exercise, I sat back-to-back with a partner who looked at a picture projected onto a screen. I could not see the picture. He described the image, and I had to draw what he described. After 5 minutes, I shared my drawing, and we discussed what worked and what didn’t.Recently, I was at the Art Institute of Chicago, one of my favorite places on Earth, preparing to help lead a group of medical students around the museum. Our guide described a similar exercise while looking at a painting of a woman in mourning. Because my mind was on medicine, it struck me how similar this exercise is to what I do in clinic.All diagnostic inquiries start with a patient experiencing a symptom. The symptom is a kind of platonic truth. What can make the search for an accurate diagnosis difficult is that a doctor seldom really has access to this truth. The doctor does not see or feel the symptom. Instead, the patient is asked to translate a sensation into language. Sometimes, the patient’s linguistic abilities are inadequate for describing the symptoms. Sometimes, our language itself is not up to the task.Often there are issues working against the patient accurately describing his or her symptoms. The patient is anxious, in pain, exaggerating or minimizing symptoms, being rushed, or distracted.No one can say if a patient is poorly describing his or her symptoms; that would be like telling someone that their description of red is incorrect.FH describes her symptoms as wooziness. The doctor seeing her, Dr. S, not having a differential diagnosis for wooziness, asks her, “What do you mean woozy. FH says, “I feel floaty, foggy, out of it, off kilter.” FH is already getting a little exasperated. She is worried she might be having a fatal stroke.To make a diagnosis, a doctor must characterize the concern, translating the patient’s words into a symptom with an established differential diagnosis and an associated diagnostic approach. This is where many diagnostic errors occur. This might happen if the doctor is not listening. But it also might happen if the doctor mischaracterizes what the patient is feeling because of how the patient reports the symptom. When that happens, the doctor begins evaluating a symptom that is not actually present.The approach to the dizzy patient should begin with the doctor asking, “What do you mean dizzy?” and then just sitting quietly while the patient describes the dizziness. This question is supposed to force the patient to characterize the dizziness as vertigo, orthostasis, disequilibrium, or non-specific dizziness. When Dr. S asked, “What do you mean by woozy?” she had decided that woozy meant dizzy and proceeded as if FH had complained of dizziness.The clinical interchange has just started and already the patient has translated her symptom into language and Dr. S has translated that into a medically useful symptom.After hearing wooziness described as “floaty, foggy, out of it, off kilter,” Dr. S. had had it with open ended questions. “When you feel woozy, does it feel like the room is spinning? Or does it feel like you are going to faint, you know like when your vision grays out? Or do you feel off balance, kind of drunk.”FH answered, “Yes.”At this point, we have a patient who is terribly worried about her condition and a doctor who is likely reconsidering her decision to come to work today.In my experience, this juncture is not uncommon. A patient is having symptoms that need to be addressed. The way these symptoms are being presented linguistically is not leading the doctor to a familiar, workable symptom. Dr. S has tried to shoehorn woozy into the diagnostic rubric for dizzy and, not surprisingly, has gotten nowhere.OK, tell me exactly what you were doing when you first got woozy?” asks Dr. S.“I had just woken up. I rolled from my left side to my right to grab my phone to check the time and then I just about lost it. I mean really lost it. I was woozy AND nauseated.”Dr. S. got really lucky. Although her interpretation of woozy as dizzy failed in her first two questions, she stuck with it with one more question. She hit on a suggestive answer, something that sounds like benign, paroxysmal, positional vertigo, BPPV. She performs the Dix Hallpike Maneuver and FH screams out. She has the most striking rotatory nystagmus Dr. S has ever seen.“Are you feeling the wooziness?”“Yes, this is exactly the sensation.”At this point, the symptom has become a visible, objective sign.What to take from all this? We always need to remember that reported symptoms are translations, one step removed from what is bringing a patient in. Unless you are lucky enough to be a dermatologist, when you can actually look at the problem, seeds for medical errors are sown as soon as a patient describes, translates, his or her symptom. The less specific the symptom, the more likely it is that the doctor will proceed down the wrong path. Acute onset pain at the base of the great toe might be reported as aching, burning, or searing, but you’re likely to end up thinking about gout.Fatigue, on the other hand, might be describing tired, or weak, or sleepy, or short of breath. The differential diagnoses for those four translations probably includes every known diagnosis. 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 Jeffrey Flier, a distinguished service professor and former dean at Harvard Medical School, dives into the recent upheaval in NIH funding. He breaks down the controversial cuts to indirect costs that support research infrastructures. The discussion highlights the stark disparities in funding rates among institutions and the polarized online reactions to these changes. Flier advocates for improved accountability and reforms within the peer review process, emphasizing the need for sustainable funding models to drive innovation in biomedical research.

Dive into a lively discussion about RFK Jr.'s recent hearings, blending humor and personal anecdotes. Explore the clash between eulogy and resume values in medicine, and rethink healthcare leadership qualifications. Learn about the 'Mom Index' as a critique of academic pressures and NIH funding issues. Discover how community notes can enhance transparency in research. Finally, the hosts argue for radical reforms in governance, stressing the importance of deep, meaningful changes over quick fixes in healthcare systems.

I recently recorded a conversation with Michael Easter from the TWO/PERCENT, a Substack and podcast. Michael offers “practical, accurate, and useful health, performance, and mindset information,” and in a space where there is a lot of drive, I find him remarkably thoughtful.Our conversation is on the podcast feed. Below are my notes for our conversation with links to many of the things we discussed.Adam Cifu, MDSensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber.I am skeptical of wellness celebrities and influencers. They annoy me because they tend to pick, choose and extrapolate data to fit their agenda. Because good medical advice is mostly personal and boring, many influencers cross over to data-free sensationalism to hold an audience.Michael Easter is a rare exception. On the TWO/PERCENT he somehow manages to be a sane, thoughtful – I might even say Sensible – health personality. I got to know Michael when he invited me to be on his podcast to talk about my article on the cult of the healthy lifestyle. Before talking to him, I dove into a bunch of Michael’s work and was impressed by its quality. I should have known that a person who would invite someone who had come out against the healthy lifestyle on his show dedicated to the healthy lifestyle was someone I’d like.My Questions:For people who don’t already follow you, tell me about the 2%. Where does that come from and how to you extrapolate its meaning?* Tell me a bit about yourself, how did you end up here?* In my intro, I mentioned that I think you are a rational “health influencer.” How have you managed this?* Is it a challenge to keep things fresh while telling people to stay active, eat less, and don’t do stupid things?* How do you see the balance of educating and inspiring?I wanted to talk to you about a couple of recent posts that I thought epitomized your approach.The benefits of silence was a post about introducing silence into your life. This is something that really doesn’t need data, but you went deep into the data, and then acknowledged how aware you are of the possible confounding. (People’s whose houses are on loud streets die earlier. That might be the noise but they are also poorer and are exposed to more particulate air pollution…).* What got you interested in that topic?The downsides of blood tests and full-body MRIsThis was a discussion with Dr. Bobby Dubois about the potential benefits and harms of screening tests. I’ve written a ton about this, but I was so impressed with the clarity of the conversation and, although you guys came out pretty negative on the topic, you were honest about the potential benefits and the reasons people find these attractive.* You seem to have a lot of respect for the audience. 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 podcast delves into the emotional weight of making tough medical decisions as a patient. It highlights how these choices often outweigh the pressures faced by physicians. Case studies showcase the complexities involved, emphasizing the need for patients to navigate this challenging terrain with the support of their doctors. The interplay between patient autonomy and physician guidance takes center stage, revealing the bravery required in these high-stakes situations.

Dr. Margaret McCartney, a Glasgow-based general practitioner and PhD holder, passionately advocates for evidence-based medicine while challenging the efficacy of disease screening. In this discussion, she critiques the misconceptions surrounding early medical testing and reveals how conflicts of interest can skew healthcare recommendations. McCartney underscores the importance of rigorous evaluation in medical practices, calling for better regulation and transparency in the UK healthcare system. Plus, her love for cycling adds a fun twist to her serious insights!

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

I had the pleasure of being interviewed by Michael Easter. Michael is behind the TWO/PERCENT Substack where he offers “practical, accurate, and useful health, performance, and mindset information.” I’ve listened to, and read, a bunch of Michael’s content. Not only is it enjoyable but it seems, well, sensible. Our conversation was inspired by my Coming Out Against the Healthy Lifestyle post. I hope you enjoy our conversation and maybe find another substack to follow.Adam CifuSensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber.Our conversation covers:* Why Adam wrote the post and the rise of the cult of the healthy lifestyle.* The benefits, realities, and limits of adopting healthy lifestyle changes.* How the belief that all health can be improved with better diet and exercise can lead patients to wrongly believe they are responsible for all of their health issues.* Why criticism of modern medicine is on the rise.* How “medical reversal” highlights the need for evidence-based practices.* The rise of longevity and why many longevity practices often lack robust evidence.* Why personalized healthcare is essential for effective treatment.* Problems with over-medicalization.* How finding the right doctor can be a challenging process. 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

Andrew Foy, a practicing cardiologist in Pennsylvania, dives into the implications of political events on healthcare and the principles of medical conservatism. He critiques the commercialization of health and addresses the complexities surrounding vaccine policies, urging a more evidence-based approach. The discussion touches on the societal factors contributing to chronic diseases like obesity, while advocating for improved drug safety systems. Foy also examines the financial conflicts within medicine and the need for transparency in public health decisions.