Healthcare in the News

[ANESMCR]

24 minutes ago, sas5814 said:

1) Only because its mandated and 2) not without trying to talk the patient out of it. If it is the only choice I have then I'll order it.

Blindly following low value data is lazy. It took 25 years of poking our fingers into butts to feel prostates annually (low value data) before it was determined to not have changed prostate cancer morbidity or mortality at all and it fell out of popularity. I quit years earlier.

Like I said...we are (or should be) thinking clinicians and not robots.

My point is that I’m 99% sure you use low quality evidence on a daily basis. Nobody said anything about following blindly. These screenings and diagnostics are ordered by thinking clinicians and appropriate scenarios (in a perfect world). You have no basis to discount low quality evidence. 
 

Edit: In a broad sense, I’d argue the opposite. Blindly and broadly ignoring guidelines that are low quality evidence because you disagree with it is not only bad medicine, it could be argued as negligent. 

Edited October 21, 2022 by ANESMCR

[sas5814]

1 hour ago, ANESMCR said:

Edit: In a broad sense, I’d argue the opposite. Blindly and broadly ignoring guidelines that are low quality evidence because you disagree with it is not only bad medicine, it could be argued as negligent. 

You're going to have to show me where I suggested broadly and blindly ignoring anything. I said we are supposed to be thinking and reading and making value judgements. You can find conflicting guidelines on many many topics between large groups full of area experts. Even doing PSA tests remains contested by many area experts though it is a pretty standard thing that most of us do without a thought.

The famous finger wave is a great example. It often resulted painful and unnecessary procedures such as prostate biopsies and was, ultimately, determined to be of no real value. So with low value data and conflicting experts we should have the intellectual capacity to make a judgement..... unless you are very comfortably ensconced in being an assistant in which case you can just do what your SP says. It works for a lot of people.

[ANESMCR]

19 minutes ago, sas5814 said:

You're going to have to show me where I suggested broadly and blindly ignoring anything. I said we are supposed to be thinking and reading and making value judgements. You can find conflicting guidelines on many many topics between large groups full of area experts. Even doing PSA tests remains contested by many area experts though it is a pretty standard thing that most of us do without a thought.

The famous finger wave is a great example. It often resulted painful and unnecessary procedures such as prostate biopsies and was, ultimately, determined to be of no real value. So with low value data and conflicting experts we should have the intellectual capacity to make a judgement..... unless you are very comfortably ensconced in being an assistant in which case you can just do what your SP says. It works for a lot of people.

You’ll have to reference the context of this discussion, as to dismissing guidelines entirely based on low quality evidence. There are endless examples and anecdotes of guidelines that are no longer in practice or recommended, current guidelines recommend that are not in use, and numerous guidelines that are used frequently that have very low quality evidence. Invalidating on the basis of low quality evidence is not practical. We all use them. Doesn’t mean they’re all used competently. I’m simply countering your insinuation to invalidate or “talk patients out of”. It makes no sense other than to forward opinion in reference to the article. I’d encourage you to look at the guidelines you use in practice, guarantee many are of low quality. 

Edited October 21, 2022 by ANESMCR

[ANESMCR]

39 minutes ago, sas5814 said:

unless you are very comfortably ensconced in being an assistant in which case you can just do what your SP says. It works for a lot of people.

You’ll have to expand on this a bit. Not sure what you’re getting at. Sounds like you’re saying anyone that uses  standardized guidelines in their clinical practice is a slave to their MD? I find that more often than not, it’s the old guard MD’s that refuse to update themselves on newer guidelines, and the PAs that don’t stay UTD or are UTD and don’t use them…are the assistants. 

Edited October 21, 2022 by ANESMCR
Grammar

[sas5814]

I'm saying there are many PAs who prefer not to read and study and make educated decisions about data and are just fine doing whatever their SP says. Me? I have my own license and a brain. I have thoughtful discussions with my physician colleagues but I make my own decisions. If I wander astray I suspect the system will smack me down.

I suspect we are both speaking (or seeming to speak) in absolutes when the world is a grey place...and guidelines and recommendations are often very gray. 

If a patient wants a Cologuard instead of a colonoscopy I give them the data as I understand it and try to point them to what, in my experience, is the best choice. If they choose not to and want plan B I'm OK with it as long as it isn't actually harmful. When I was young in the profession I used to get really distressed when people didn't do what I said. Now I take a bit more libertarian view. I give them the information as I understand it. They get to make up their own mind.

[rev ronin]

So, specifically in the context of medical intervention for persons with gender dysphoria, I again ask, what if the guidelines are wrong?

Prostate exams, if they had no impact on prostate cancer mortality, killed people.

James LJ, Wong G, Craig JC, et al. Men’s perspectives of prostate cancer screening: A systematic review of qualitative studies. PLoS ONE. 2017;12(11):1-23. doi:10.1371/journal.pone.0188258

"Five themes were identified: Social prompting (trusting professional opinion, motivation from family and friends, proximity and prominence of cancer); gaining decisional confidence (overcoming fears, survival imperative, peace of mind, mental preparation, prioritising wellbeing); preserving masculinity (bodily invasion, losing sexuality, threatening manhood, medical avoidance); avoiding the unknown and uncertainties (taboo of cancer-related death, lacking tangible cause, physiological and symptomatic obscurity, ambiguity of the procedure, confusing controversies); and prohibitive costs.

"Conclusions: Men are willing to participate in prostate cancer screening to prevent cancer and gain reassurance about their health, particularly when supported or prompted by their social networks or healthcare providers."

We spent how many hours and dollars trying to get men to bend over and accept a gloved, lubricated, rectally-inserted finger for no statistical improvement in morbidity and mortality?  How many men forewent screening for other sorts of diseases just to avoid showing up to their PCP and being asked to submit to what they believed to be the bodily invasion and humiliation of a DRE?

I used to say "I hope the evidence shows that women who received Gardasil series as recommended as girls, prior to onset of sexual activity, will never need a pap." knowing how invasive and uncomfortable that exam is, even at the best of times.  Now, I'm pretty sure I'm not going to recommend a routine screening pap for women who got Gardasil as girls and have no specific high risk behaviors until and unless I see reasonable quality studies that show there is a benefit to doing so.

One of the things I've brought to medicine from IT Security is that every countermeasure has a cost, and we need to intelligently manage what we're going to spend our resources on. In this case, it's goodwill on cancer screening.

Now... that's all about inappropriate screening. Everything I've just critiqued about evidence-based medicine failures applies to potentially inappropriate irreversible interventions, surgery and cross-sex hormones, a thousandfold: the certainty evidence does not support the potential lifelong cost to the patient if we are wrong.

Edited October 21, 2022 by rev ronin
expand a bit, clarify

[TheFatMan]

Wanting independent practice while simultaneously choosing to ignore guidelines and expert/consensus opinion is not the hill I would choose to die on.

[rev ronin]

11 minutes ago, TheFatMan said:

Wanting independent practice while simultaneously choosing to ignore guidelines and expert/consensus opinion is not the hill I would choose to die on.

Whose guidelines? See above for a question I posted about abortion and breast cancer guidance.

Did they teach you to read guidelines in PA school, or evaluate and assess evidence? I may have gone to a weird PA program, but I was taught to evaluate the strength of studies at both my masters and doctoral level PA training.

Are you aware guidelines can be influenced by interest groups, and thus reflect what the interest groups want them to say rather than pure, unadulterated science? Anyone who's been following Covid-19 vaccination guidance or climate science or Alzheimer's drug research or... Basically, this should be a no brainer: organizations can be bought, and often are.

For example, the National Volunteer Fire Council, of all the relatively insignificant organizations, prominently features Anheuser-Busch as a partner. I quit, rather than continue to be affiliated with such blatant support of a company whose products kill Americans.

So no, I'm not in the least chastised by an appeal to authority. I'll stick to the actual science, thank you.

[ANESMCR]

Rev. You said you dismiss some guidelines because of low quality evidence. It’s that simple. Enough with the hypotheticals. Every anecdote you provide can be countered with life saving, often times strongly recommended, low quality evidence practice. You use them whether you want to admit it or not. If you only practiced medicine on moderate to high quality evidence, your practice would be severely limited. 

[CAAdmission]

Are we really trying to compare the consequences of a low evidence guideline about sticking a finger up someone's rump to low evidence guidelines about cutting pre-adolescent kids' genitals off?

As Pulp Fiction said, "Different ballgame? That ain't even the same damn sport!"

[rev ronin]

1 hour ago, CAAdmission said:

Are we really trying to compare the consequences of a low evidence guideline about sticking a finger up someone's rump to low evidence guidelines about cutting pre-adolescent kids' genitals off?

As Pulp Fiction said, "Different ballgame? That ain't even the same damn sport!"

I mean, guilty as charged, but I don't disagree with your final statement. The verbiage I used was "a thousandfold," but on reflection, that was more a qualitative statement than quantitative, and likely understated the actual impact of getting it wrong to the affected patients. These are real people's lives, and we need to get it right.

[rev ronin]

1 hour ago, ANESMCR said:

Rev. You said you dismiss some guidelines because of low quality evidence. It’s that simple. Enough with the hypotheticals. Every anecdote you provide can be countered with life saving, often times strongly recommended, low quality evidence practice. You use them whether you want to admit it or not. If you only practiced medicine on moderate to high quality evidence, your practice would be severely limited. 

If it's low quality, how do you know it's lifesaving? Sometimes, things we have thought for years to be lifesaving turn out to be minimally so at best.

Which guideline, based solely on very low certainty evidence, do I use on a regular basis?

[ANESMCR]

10 hours ago, rev ronin said:

If it's low quality, how do you know it's lifesaving? Sometimes, things we have thought for years to be lifesaving turn out to be minimally so at best.

Which guideline, based solely on very low certainty evidence, do I use on a regular basis?

Considering you’re in primary care, surely you treat GERD? Do you tell your patients to stop smoking that have severe reflux? Avoiding trigger foods? Raising the head of their bed? Avoiding food 2-3 hrs before bedtime? Do you ever Rx H2 blockers over PPI? Do you ever attempt to discontinue/taper pts on chronic PPIs w/o sxs or Barrett’s? All low evidence. Do you ever reference anything on UTD? 
 

You use them. Every day. You just don’t know it because you haven’t reviewed clinical guidelines. Broadly invalidating guidelines based on low evidence is pure nonsense material on a PA forum.

[rev ronin]

2 hours ago, ANESMCR said:

Considering you’re in primary care, surely you treat GERD? Do you tell your patients to stop smoking that have severe reflux? Avoiding trigger foods? Raising the head of their bed? Avoiding food 2-3 hrs before bedtime? Do you ever Rx H2 blockers over PPI? Do you ever attempt to discontinue/taper pts on chronic PPIs w/o sxs or Barrett’s? All low evidence. Do you ever reference anything on UTD? 
 

You use them. Every day. You just don’t know it because you haven’t reviewed clinical guidelines. Broadly invalidating guidelines based on low evidence is pure nonsense material on a PA forum.

Let's see: Not usually, yes but not for that reason, not usually, no, yes, yes depending on the totality of circumstances, and not in recent memory. And yes, I use UpToDate pretty regularly.

I know we're just listing things here, but I'd actually be curious for you to post the GRADE for each of those recommendations. Assuming for the sake of argument they are all "very low certainty" (rather than "low"), what is the impact of being wrong?

Smoking: You might reduce their cancer and COPD risk for the wrong reason
Trigger foods: You might waste their effort and reduce other more important dietary emphases.
Raising the head of the bed: Poorer sleep, waste of time, increased risk of falls, misuse of cinder blocks.
Avoiding food 2-3h qhs: inadvertently start them intermittent fasting
H2 vs PPI: less effective interventions with different ADRs and costs
d/c PPI: put pts through a possibly useless taper, dealing with upregulated acid production in the setting of long term PPI use.

To go back to the "That ain't even the same damn sport!" comment: Which of these involve intentionally applying chemicals designed to stop normal bodily functions? Which of these involve surgery to remove healthy and functional tissues?

Again, the point isn't "never use low quality evidence" but rather, make sure the evidence is sufficiently strong to justify the intervention. Low quality evidence is in the process of either being strengthened by additional experience, or refuted when the intended and actual outcomes prove inconsistent.

Low dose ASA is a great example of experience reversing evidence, and noting that even a relatively benign intervention did result in excess deaths. I'd argue that those deaths were unfortunate but not negligent because at the time the reduction in the risk of thrombotic events was believed to be higher than the increased risk of hemorrhagic events. Although again, what the new evidence really did is revise (narrow) the "P" to which the intervention actually successfully reduced morbidity and mortality.

[ANESMCR]

That is the GRADE. The useless taper prevents upregulated parietal activity. So you’d just continue low dose or high dose PPI indefinitely despite no symptoms? Or would you move on to more low quality evidence (apparently useless) testing? Like ambulatory PH  monitoring for atypical symptoms? Eating 2 hours before bedtime is intermittent fasting? Since when? At what point do you ever refer to a specialist? More nonsense renegade care. You disqualified guidelines for one reason, remember?

“why on earth would I want to consult guidelines based on low quality evidence?“ 

So I’ll say it again, this statement is utterly false and you know it. Just as admit you went overboard with that statement. That was the whole reason I even responded.

Edited October 22, 2022 by ANESMCR

[rev ronin]

50 minutes ago, ANESMCR said:

You disqualified guidelines for one reason, remember?

“why on earth would I want to consult guidelines based on low quality evidence?“ 

So I’ll say it again, this statement is utterly false and you know it. Just as admit you went overboard with that statement. That was the whole reason I even responded.

For context:

"Sorry, but WPATH guidelines are based on a "very low certainty" level of evidence at best. If I'm interested in caring for individuals with gender dysphoria, why on earth would I want to consult guidelines based on low quality evidence? My concern is doubled when we're talking about children, doubled again when we're talking about irrevocable hormonal or surgical interventions. "

I absolutely do not repudiate any part of the entire statement.  I am sorry that you thought that "low quality" meant something different than "very low certainty" as used in the first sentence, or that you felt that the middle of the three sentences was intended to stand alone without other two for context. I am satisfied that my expression of concern places my issue with quality squarely in the realm of impact (that is, potential harm) vs. certainty, and that my further posts have clarified it appropriately rather than walked anything back or moved any goalposts.

I'm unable to comment on the GI-specific parts of the evidence discussion, as I can't currently see your GRADE link (it's just showing up as underlined in the software), but no, I don't Rx ongoing PPIs or a regular basis. I will sometimes refill or start them for short term use by eating disorder patients, but I don't actually Rx them in primary care on a regular basis.

[Febrifuge]

A little while ago, I learned that what used to be called “the Ukraine” is actually Ukraine, which is its own country. Calling it THE Ukraine made it sound like it was just some region within Russia… which of course is the way Russia would prefer people think about it. I got new-to-me information, and was able to use that to question my own bias about how I assumed things worked, and change the way I talk about it.

I now understand, I was wrong to just accept what the Encyclopaedia Britannica or my teachers or the news stations of the 1990s had told me. There wasn’t any malice there, I definitely did not have a personal stake in the question, I’d never really given it any significant amount of thought, and the ignorance I had was innocent enough. But I decided that now I had new information, innocent ignorance was no longer good enough for me. I changed the way I think and talk about Ukraine. 

A different, more personal example: Years ago, I had a different last name. My not-actual family name is - let’s say - Febberton, and my wife’s not-actual family name is Centrifuge, and so when we got married we decided to be all modern and progressive, and I was only halfway done with PA school anyway, so we we both changed names, and she and I plus our kid are all the Febrifuge family. My license, my DEA, my credentialing all happened after I had my court documents and new name. Why? I had been married once before, as a dumb young 20-something, and I liked the idea of starting a whole new chapter in my life 10-15 years later. It’s not a common choice, but it happens. People in my life got used to it.

Sometimes there would be confusion, or questions. If anyone had hurt feelings, I never heard about it. Sometimes I would give a whole detailed spiel about my reasons, and sometimes I would just say “this is our name now,” depending on circumstances. People who wanted to respect and honor me made the switch, whether or not they really understood, and I appreciated it. People who met me after the change just accepted it as my name. Because it is. Anyone who felt like they need to argue with me about how my name is actually Febberton would be factually wrong, and I would get to decide if it’s worth my time and energy to engage with that dumbass argument and try to enlighten the poor misguided soul, or not. I can only imagine how annoying that would be, and how much I would hate those conversations, but I also know how strongly I would feel compelled to have them.

So here’s my point: If you can take in new information when someone explains something important to them, about something that doesn’t directly affect your daily life but is key to their own experience, and if you change the way you think and talk about it when it’s a question of politics and national identity overseas, or when it’s about a friend or relative or colleague’s legal name change, but you can’t take in new information and change the way you think and talk about someone else’s sexual orientation and/or gender identity, then I think it’s fair to ask why not, and what’s the difference. 

I’ve been pretty disappointed in some of the comments here. Turns out this might be an emotional subject for me. I have queer and trans friends and family. So, if I don’t engage or respond directly, please understand it’s because I value this group and community as colleagues, and don’t want to post out of anger. When others discuss parts of a person’s identity in a way that’s clearly hypothetical and abstract, it might be meant well, but sometimes it just feels personal. 

 

[rev ronin]

1 hour ago, Febrifuge said:

I have queer and trans friends and family.

I think it safe to assume pretty much everyone does at this point; the only question is, "first, second, or third degree relative?"

[Boatswain2PA]

Can I identify as someone born in 1960 so I can qualify for social security this year? Free money!!!

 

If you say no, can I call you ageist, sexist, racist, and Hitler?

 

Can I identify as American Indian?  (After all, I am typing this as I m deer hunting) so I can get free hunting license and tags, Free fishing licenses, and tribal healthcare?

 

If not, can I call you a racist, sexist, homophobe white supremacists? 

Edited October 22, 2022 by Boatswain2PA

[Febrifuge]

Those are disingenuous arguments, and the way they’re twisted around the collision between objective facts and the subjective internal experience of other people’s identity, they imply that anybody can be anything just because they say so. That’s not what this is about. 

[EMEDPA]

9 minutes ago, Boatswain2PA said:

Can I identify as someone born in 1960 so I can qualify for social security this year? Free money!!!

It isn't free...you paid into it your entire life. It isn't an entitlement, it's a safety net that is entirely self-supported. The reason that it is low is that various administrations over the years have "borrowed" (read stolen) from the fund to support other projects. 

[Febrifuge]

Quote

 

I think it safe to assume pretty much everyone does at this point; the only question is, "first, second, or third degree relative?"

A more pertinent and interesting question might be, “do your queer or trans relatives feel comfortable talking to you, or asking for advice?” If so, you’re probably okay on these topics. 

Edited October 22, 2022 by Febrifuge

[rev ronin]

16 minutes ago, Febrifuge said:

A more pertinent and interesting question might be, “do your queer or trans relatives feel comfortable talking to you, or asking for advice?” If so, you’re probably okay on these topics. 

I think there's a bit of subtle conflation here between people who are viewed as supportive and people who are knowledgeable: one can be either, both, or neither.

[Febrifuge]

That’s probably true, yes. All I mean is, people from marginalized communities often develop a pretty good sense of how to figure out whether someone is an ally. 

[EMEDPA]

5 minutes ago, Febrifuge said:

That’s probably true, yes. All I mean is, people from marginalized communities often develop a pretty good sense of how to figure out whether someone is an ally. 

Yup. Marginalized communities often includes PAs...