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.

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. 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.

“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. …

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

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

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

Health is a by-product of America’s healthcare system.

The product is profits for private industry. He product is delivered without fail.

We hit and miss on the by-product.

Two weeks ago I was feeling a little burned out.

So I did what I always do. I worked more. 1/20 I’m serious. I did more work because I was hating work.

It’s always worker for me and it worked this time too.

I know you, Reader. You are either angry or disbelieving. Hopefully you know me too. Come along while I explain. 2/20

Like most doctors of my vintage, I was taught to be two doctors.

Doctor One was for innocent victims of their disease. Good, respectable people who took their medicine and had a ride home at discharge. 1/20 Doctor One was textbook perfect. He took everyone at their word. Two beers a week meant 2/wk. Complaints of pain were taken at face value and met with concern and treatment. Intentions were never questioned. Extra time was given. 2/20

You and I probably have a different definition for the word “care.”

For me, care is not an attitude.

It’s not an intention.

It’s not even measure in time of effort.

For me, care is a result, not a plan. I can tell what I care about ~only in review~. 1/10 The things I care about, I change. 2/10

When I hear about people who are not vaccinated against COVID, Personally, I reserve hatred for people I know.

It’s too much energy to expend on a stranger.

If you set your mind to it, and you really want to hate your job and the patients you care for, you can blame almost every patient who comes in the hospital for making your day worse by making you work hard to take care of them. 1/10 If you want to get burned out and quit in disgust, look hard for patients who
- don’t take their medicines
- make bad life choices
- engage in high risk behaviors
- don’t invest the time and effort to exercise
- take dangerous jobs
- run with dangerous crowds 2/

If you are burned out, tired, angry or exhausted I want to help you.

I’d like to help you suffer less.

Let me offer you a suggestion that works for me. 1/15 You need to match your sphere of concern to your sphere of influence. 2/15

This is what it looks like to me when people say “masks are good” or “kids need to wear masks at school.” 1/10

https://twitter.com/medicalaxioms/status/1438906190893772804

The answer to both questions depend on a lot of factors.

- What water/mask are we talking about?
- What’s the alternative?
- What else do you have to drink/what else can you do to mitigate your risks?
- How thirsty/immunocompromised are you? 2/10

Do N95s protect the wearer from COVID? Do paper surgical masks protect the wearer from COVID?

Let’s discuss 3 facts:
1. You and your parents before you have been managing and balancing RISK v. DOING STUFF your whole life.
2. Over time your risk of dying of COVID will shrink beneath other risks.
3. We’ve been happily killing each other with infectious diseases forever. 1/ Like it or not (and style notwithstanding), this is the debate people like @VPrasadMDMPH and @drjohnm are trying to have right now.

And all of us will have sooner or later. 2/

“If you don’t get your A1C under 8 you will die.”

“… don’t take this Lipitor you will die.”

“If you take lisinopril instead of Entresto you are dead.”

I’m not sure who teaches med students and residents this approach but it will fail more than it succeeds. 1/10 Hyperbole and threats somehow seem effective with less educated people.

They aren’t. Most patients have already tried your “deadly experiment” and lives to tell the tale. 2/10

In case you haven’t figured it out, Twitter is not real life. It’s a fictional place full of made up characters.

Many of the stories are made up. Many of the accounts are just flimsy cardboard cutouts of people. Like a CGI crowd in a movie. 1/ It’s not a documentary. It’s more like Disneyland. The Disney princesses are just people at work. Creating an illusion. Because it’s their job.

The “people” you “like” play heroic lovable characters. 2/

There are 5 realms you will master if you want to be a good doctor. 5 bodies of knowledge about which we teach 3 in medical school. 1/ 1. Diseases. You must learn their traits and character. Their prey and weaknesses. Their mimics and behavior. In some fields there are hundreds. In internal medicine we have tens of thousands. 2/

I spent lunch on Google Scholar reading ivermectin in COVID papers (of which there are a lot more than I thought).

Tons of bias. Zero RCTs. I wouldn’t be surprised if it helps a little. I also wouldn’t be surprised if it does absolutely nothing or causes harm. That being said, I wouldn’t take it if I got sick.

More “promising” meds end up failing than succeeding. Every year we kill some people trying to test and find new medicines that end up being harmful.

Unpopular opinion: rote memorization is the foundation of true understanding in many subjects. @efunkEM I agree with this. Without training your brain to organize and recall the facts, you will not be able to think on the fly or spot rare diseases when they are sitting right in front of you.

You are not a chip. You have to be the whole computer. Storage, display, everything.