Individual Daily Risk Profile picture
Apr 14, 2021 20 tweets 3 min read Read on X
One thing we don’t teach you in med school or residency is how to call in sick. 1/20
I will tell you an embarrassing story. 2/20
Twenty years ago, my then wife’s dad committed suicide on a Tuesday. 3/20
She called me at work in the middle of the afternoon. It was a ridiculous day in clinic. Three exam rooms full and a waiting room filling up. 4/20
The call caught me by surprise. Her dad had not notified my that he was going to jump to his death that day. 5/20
On the phone, I asked her if she had someone there. Then I made my mistake. 6/20
I said, “I have all these patients to see. I’ll be home as soon as I can.” 7/20
In my defense, I had never once in my med school or residency put a personal event ahead of my professional responsibility. 8/20
Quite the contrary. I had watched a vascular surgery fellow get told his wife was divorcing him, hang up the phone, and continue rounds without a shred of emotion. 9/20
This was the culture of medicine I was raised in. Ruthless prioritization of word over family was part of “professionalism.” 10/20
My wife survived until I arrived home a few hours later. She had spent most of the time on the phone with her siblings.

You can imagine other circumstances where I would not be immediately available.

That’s not the point. 11/20
The point is, I did not know how to leave my professional life in the event of an emergency. I honestly had never seen anyone do it. I had no role model and never done a role play.

I had no equipment for this important moment. 12/20
Here’s the most important part: 13/20
You people can survive without you. Everyone in a doctor’s life has learned to adapt to their absence. We force this lesson on our loved ones repeatedly throughout our careers.

“I’ll be home at 6.”

“Make that 7.”

“Uh oh you can go to sleep things are going the wrong way. 14/20
There are 2 main points:

1) The fact that people tolerate being #2 to your career doesn’t mean you shouldn’t sometimes make them #1 and

2) I delivered sub-standard care to those patients I saw that afternoon 15/20
No matter if your father in law kills himself or any other of a hundred tragedies, this is the essential part.

You have to be able to recognize when you are sufficiently impaired by your emotions not to be able to practice medicine. 16/20
When a colleague comes to you and says “I have to leave I am facing a situation.” You have to be able to say, “I’ll cover you go do your thing.” 17/20
It has to become more part of our culture. We can’t expect people in the midst of a personal tragedy to continue to practice medicine like a computer healthcare kiosk. 18/20
I was fortunate. To the best of my knowledge, I didn’t make any serious mistakes that day.

If I had, I would have compounded grief with guilt. This is not a situation we should expect medical colleagues to tolerate. 19/20
That means on the other end you may have to pick up the slack when a colleague steps out in the midst of a personal crisis. 20/20

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More from @medicalaxioms

Dec 8, 2023
Here’s the K-M survival curve from the recent #semaglutide #ozempic paper in non diabetics from the NEJM.

I’m going to teach you how to read a KM curve in a few steps.

First, let’s discuss the deception presented here.

Lincoff AM, Brown-Frandsen K, Colhoun HM, Deanfield J, Emerson SS, Esbjerg S, Hardt-Lindberg S, Hovingh GK, Kahn SE, Kushner RF, Lingvay I, Oral TK, Michelsen MM, Plutzky J, Tornøe CW, Ryan DH; SELECT Trial Investigators. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. N Engl J Med. 2023 Nov 11. doi: 10.1056/NEJMoa2307563. Epub ahead of print. PMID: 37952131.
This is actually 2 KM curves superimposed on one another. The honest KM curve is shown here.

If you are reading this correctly, you should be unimpressed. Which is why the authors chose to add a magnified version on top of all that white space. Image
Here’s what they added. It’s like a photo of the other curve taken under a microscope.

It makes the effects look much bigger (and faster). Which is a fair goal if you are trying to impress… Image
Read 8 tweets
Sep 7, 2023
The container on the left has 3,820 balls in it. 3819 white and one green. On the right: 4525 white and one green.

The rules of the game are simple. Shake up the container and draw 1 ball a day. WHITE ball means you play again tomorrow. GREEN means you’re dead. Image
I assign 8,399 people into two groups:

Enalapril: 4212 people
Entresto 4187 people

and have them play for 1260 days.

Here are the survival curves of the two groups playing this game. Image
For comparison, here is the survival curve (death from any cause) from JJ McMurray and M Packer’s 2014 Paradigm HF trial in NEJM. PMID: 25176015 Image
Read 11 tweets
Jul 5, 2022
“Primum non nocere” is a necessary fantasy.

I take a call from the ER about Miguel McJohsonberg in room 13. While I’m on the phone I open up his chart and start reading his personal business. His labs. His meds. The DC summary of his last admission. …
All the while he has not given me expressed permission. It is a violation.

We all agree to this violation. He bought his ticket. He knew what he was getting in to. …
Twelve hours later he is unconscious and intubated and the surgeons get permission from his friend to disarticulate his left leg at the hip for a necrotizing skin and soft tissue infection. …
Read 14 tweets
Jun 19, 2022
A doctor must be selfish. 1/20
It goes against your nature.
It offends the good kid your parents raised.
It will make you feel guilty and upset the people you love.

Still you must be selfish. 2/20
You can’t give away what you haven’t got.
You can’t draw water from an empty well.
Read 20 tweets
Jun 17, 2022
If it’s hang on a rope or hang up the stethoscope, that choice is easy.

Quit medicine. 1/10
No job is worth dying for. 2/10
It’s not normal to be able to tolerate exposure to all these stories, all this pain, all this tragedy, death and dying.

It’s normal to have a limit. It’s normal to reach capacity. The people who can do it for a lifetime are the oddballs. 3/10
Read 10 tweets
Jun 10, 2022
Your employer wants to burn you out. 1/x

(For those who don’t know my schtick, I often start with a controversial statement like this. While it’s true, it’s not the point of this essay. You have to keep reading…)
Your employer is smart.

They know what they sell—completed, signed notes. They need lots of them. Big ones. Procedural ones. It doesn’t actually matter at all who is writing them as long as they are good enough to sell for revenue. 2/x
The one thing your employer does not want is a bunch of expensive grey haired doctors shuffling around caring about stuff. That business model stinks.

The work is slow. They cost of labor is high. Old doctors are finicky. What a disaster.

Read 23 tweets

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