by Sensible Medicine Authors - Prasad/Cifu/Mandrola/Demania/Makary/Cristea/Alderighi & More
Common sense and original thinking in bio-medicine A platform for diverse views and debate <br/><br/><a href="https://www.sensible-med.com?utm_medium=podcast">www.sensible-med.com</a>
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April 30, 2025
<p>The most common question we get asked is: is there a course on how to become better at critically reading medical research. Well, now there is!</p><p>This is the first of 9 videos that we recorded as part of a course on clinical appraisal, and there will be many more to come. We call our class: How Not to Get Fooled by the Medical Literature. These are topics that each of us teaches separately, but, here, for the first time, we teach them together, and the whole is more than the sum of the parts.</p><p>The first lecture will be made freely available to everyone, and the next 8 parts will be shared with our subscribers as a thank you for your support.</p> <br/><br/>This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit <a href="https://www.sensible-med.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2">www.sensible-med.com/subscribe</a>
March 7, 2025
<p>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.</p><p><p>Sensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber.</p></p><p>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.</p><p>Recently, I was at the <a target="_blank" href="https://www.artic.edu/">Art Institute of Chicago</a>, 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 <a target="_blank" href="https://www.artic.edu/artworks/11390/portrait-of-a-noblewoman-dressed-in-mourning">painting of a woman in mourning</a>. Because my mind was on medicine, it struck me how similar this exercise is to what I do in clinic.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>The <a target="_blank" href="https://accessmedicine.mhmedical.com/content.aspx?bookid=1088&sectionid=61698199">approach to the dizzy patient</a> 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.</p><p>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.</p><p>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.”</p><p>FH answered, “Yes.”</p><p>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.</p><p>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.</p><p>OK, tell me exactly what you were doing when you first got woozy?” asks Dr. S.</p><p>“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.”</p><p>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 <a target="_blank" href="https://en.wikipedia.org/wiki/Dix%E2%80%93Hallpike_test">Dix Hallpike Maneuver</a> and FH screams out. She has the most striking <a target="_blank" href="https://www.medlink.com/media/rotary+%28torsional%29+nystagmus">rotatory nystagmus</a> Dr. S has ever seen.</p><p>“Are you feeling the wooziness?”</p><p>“Yes, this is exactly the sensation.”</p><p>At this point, the symptom has become a visible, objective sign.</p><p>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.</p><p>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.</p> <br/><br/>This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit <a href="https://www.sensible-med.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2">www.sensible-med.com/subscribe</a>
February 8, 2025
<p>Professor <a target="_blank" href="https://x.com/jflier">Jeffrey Flier </a>is a distinguished service professor and Higginson Professor of Physiology and Medicine at Harvard Medical School. He is the former dean of Harvard Medical School. </p><p></p><p>We talked about the recent (and sudden) change in NIH funding. First a note on Professor Flier. He is not a normal medical school dean. He is active online. He speaks candidly, often critically. He and Vinay <a target="_blank" href="https://www.statnews.com/2020/04/27/hear-scientists-different-views-covid-19-dont-attack-them/">wrote together in STAT</a> news during the pandemic. </p><p>It was a great honor to talk with him for 47 minutes about the NIH news. </p><p>Here is the Tweet that went crazy viral Friday afternoon. </p><p>I had only a superficial understanding of grant funding. It turns out that every time a scientist earns an award, the institution receives extra funding known as indirect costs. The extra funds are given to support the infrastructure of the research center. Weirdly, as you will hear, some of the biggest research centers earn the highest percentages of indirect funds. </p><p>The controversy stems from the sudden and massive cut in these indirect costs. </p><p>It is an understatement to call the online reaction polarized. It was totally utterly hyper-polarized. </p><p>Here is <a target="_blank" href="https://x.com/elonmusk/status/1888022189984858476">Elon Musk</a>. </p><p><a target="_blank" href="https://x.com/R_H_Ebright/status/1888080158676107535">Richard Ebright</a></p><p>There is absolutely no defensible basis for non-uniform indirect cost rates and absolutely no defensible basis for >=60% indirect costs. The previous system was a colossal fraud.</p><p><a target="_blank" href="https://x.com/mbeisen/status/1888245146871119963">Micheal Eisen</a> </p><p>It’s like saying you’re going to save money on a football team by cutting all the linemen.</p><p><a target="_blank" href="https://x.com/AnilMakam/status/1888029111416930822">Anil Makam</a> </p><p>Whoa. Better accountability was needed where these expenses went, but this is draconian cut. Many institutions will struggle to support scientific infrastructure.</p><p><a target="_blank" href="https://x.com/CMichaelGibson/status/1888014276100583643">C. Michael Gibson </a></p><p>Woah…The government used to pay academic institutions 60% + on top of the costs of research grant to cover “Indirect costs.” That number just dropped to 15%. The viability of US academic medical centers & research is at risk.</p><p>And of course <a target="_blank" href="https://x.com/VPrasadMDMPH/status/1888021645169934411">Vinay Prasad</a>, who also wrote <a target="_blank" href="https://www.drvinayprasad.com/p/nih-reduced-indirects-from-60-to">Ten Things to Know </a>about the NIH change. </p><p>Good! This was the greatest slush fund ever created. It made researchers with NIH dollars invincible. Universities shielding them at all costs, even when research was fraudulent. This money was used to support initiatives, which Americans rejected, like DEI training & admin bloat.</p><p><p>Sensible Medicine is a reader-supported publication. This is a free post but please consider becoming a paid subscriber as we aim to remain free of advertising support </p></p><p>Here are some quotes I received via email from unnamed NIH funded researchers: </p><p>A lot of the indirects go to admins who are increasingly important for grant submission process because it is unnecessarily cumbersome. I've been on 3 NIH funded grants. All from the same team. Each one was sillier than the prior.</p><p>Another person—from the Southern US </p><p>I submitted an R01 a few months ago and it’s difficult to navigate everything alone without admin support. The process for grant submission could be improved a lot And there should be more focus on important questions and more clinical trials.</p><p>Another—from the Midwest</p><p>Unless I wanted to study goofy BS, I realized my chances were hopeless. So the only other option was to stay and truly advance in the academy was to align with industry. </p><p>And yet another from the Midwest</p><p>This overhead reduction is long overdue. Universities have been eating at the free buffet for a long time. They will, however, quickly figure out ways to take money away from researchers. I expect that lab space rent, personnel fees, and supply costs that the universities charge the investigators will become much higher in the coming year.</p><p>Lastly, the US government wants to keep the additional indirect costs, I get that. Universities will find ways to bridge the gap by taking more money from investigators. The initial pain will be at the administrator level, but early investigators will bear the brunt of this in the coming 1-2 years. It's not a great time to be in academic medicine, esp as an investigator reliant on grants. </p><p>Thank you for your support. Thank you Professor Flier. JMM </p> <br/><br/>This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit <a href="https://www.sensible-med.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2">www.sensible-med.com/subscribe</a>
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