How data pertains the Practice of medicine

[militarymd]

My online persona has been accused of many things while on this board....racist, chauvinist, backwards, politically incorrect...etc.....pretty much all the things that we do not want in our physicians.

While at the same time, in my non cyberspace life, I'm not perceived that way, so I figure I would bring up one of the aspects of my cyber personal traits and discuss it ....and see what responses you guys have.

I'm accused of making "generalizations" about all the topics that we discuss here......that there are always exceptions to the "generalizations" that I make.

I'm no idiot....I know there are always exceptions, but we don't practice medicine based on "exceptions".

Medical data is available in different forms...case reports, case series, retrospective studies....prospective studies...observational/interventional....and then there is the holy grail of data...prospective controlled double blind randomized trials.

From the data, we make generalizations that allow us to make daily medical interventions that will improve our patients life, quality of life, etc.

Here is my favorite example....treatment of hypertension. We know that hypertension, in GENERAL, leads to premature end organ dysfunction, so the recommendation is that we TREAT EVERY PERSON with hypertension.....However, what is the reality?

In reality, we all know many, many people who lived to their 90's with untreated hypertension without any sequala.

So why do we generalize? Because that is the nature of medicine...sure there are exceptions, but that is not the way to practice medicine....

How you do decide which hypertensive to treat? Even whey you know that the number needed to treat to prevent a premature MI in hypertensives is in the hundreds. You make your treatment decision based on the fact that, in general, treating hypertension prevents MIs....although not all the time.

Data is data....it is amusing to me how it is socially acceptable to generalize some data but not others.

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[GasEmDee]

My online persona has been accused of many things while on this board....racist, chauvinist, backwards, politically incorrect...etc.....pretty much all the things that we do not want in our physicians.

While at the same time, in my non cyberspace life, I'm not perceived that way, so I figure I would bring up one of the aspects of my cyber personal traits and discuss it ....and see what responses you guys have.

I'm accused of making "generalizations" about all the topics that we discuss here......that there are always exceptions to the "generalizations" that I make.

I'm no idiot....I know there are always exceptions, but we don't practice medicine based on "exceptions".

Medical data is available in different forms...case reports, case series, retrospective studies....prospective studies...observational/interventional....and then there is the holy grail of data...prospective controlled double blind randomized trials.

From the data, we make generalizations that allow us to make daily medical interventions that will improve our patients life, quality of life, etc.

Here is my favorite example....treatment of hypertension. We know that hypertension, in GENERAL, leads to premature end organ dysfunction, so the recommendation is that we TREAT EVERY PERSON with hypertension.....However, what is the reality?

In reality, we all know many, many people who lived to their 90's with untreated hypertension without any sequala.

So why do we generalize? Because that is the nature of medicine...sure there are exceptions, but that is not the way to practice medicine....

How you do decide which hypertensive to treat? Even whey you know that the number needed to treat to prevent a premature MI in hypertensives is in the hundreds. You make your treatment decision based on the fact that, in general, treating hypertension prevents MIs....although not all the time.

Data is data....it is amusing to me how it is socially acceptable to generalize some data but not others.

We practice medicine based on exceptions all the time. That is why much of our codified knowledge base is in the form of guidelines and recommendations, rather than absolute rules.

In medicine, we use the term "algorithm" a lot. Often, its an improper use of the term. An algorithm is a rigid set of steps that guarantees a particular solution. Rather, in medicine, we use typically use heuristics, which are rules of thumb that allow leeway for other considerations, i.e., clinical judgement. This is the catch phrase that means "allow for exceptions".

Yes, JNC7 says treat hypertension to prevent future cardiovascular sequela. However, we do not treat hypertension in patient who has just had an ischemic stroke. We allow permissive hypertension. Is that circumstance explicitly mentioned in JNC7? No. JNC7 is a *guideline* and there is room to consider circumstances that cannot be fully spelled out.

To return to the central issue: Yes data is data, but some generalizations are more harmful than others.
- It is not harmful to treat hypertension in a person who doesnt have any contraindications to treatment, even if that person would not have otherwise had a cardiovascular event
- It can be harmful to make generalizations about race, gender, and personal values.

We previously had a discussion on lifestyle as a reason for going into anesthesia, and you mentioned in absolute terms that anyone going into anesthesia with this perspective is "lazy." That word stuck in my mind, because you used it over and over, bolded it, and italicized it. I think that is as rigid a view as the perspective to "treat hypertension always".

I mentioned that the most successful person I know happen to choose his career for the "lifestyle". It lets him pursue other interests outside of clinical medicine. What he does outside of medicine is to publish papers, do business consulting, and run companies. He is wealther than the average physician by far, and he is more energetic and productive based on anyone i know. He is not lazy. However, you would have blacklisted him for his perspective on medicine.

Since you are a successful, practicing physician, and obviously much more knowledgeable in anesthesia/ccm than most of us here, I find it hard to believe you could be so black-and-white in person. (Or pherhaps you are, but just more diplomatic about it at work). However, I must admit that I think that is how you sometimes come across here. But hey, this is a message board and not an academic journal. People should feel free to speak their minds. And I do appreciate your perspectives and informative posts.

 

[militarymd]

It can be harmful to make generalizations about race, gender, and personal values.

why?

 

[GasEmDee]

why?

Because it can close your mind to good options for reasons that are too simplistic, and in the worse case, just plain wrong.

- Maybe that black person would have been an academic success despite being black and born in the inner city

- Maybe that woman, who you feared would be pregnant and required maternity leave, would have been an oustanding clinician and a great addition to your practice

- Maybe that man with "lifestyle" on the mind would actually be the hardest worker in your practice when he was actually on service. What does it matter to you what he does with his free time?

You just cannot tell these things based on the criteria that you have advocated in the past. Its can be dangerous to use such mind-numbingly simple heuristics to predict complicated behaviors.

In the case of generalizing for treatment of hypertension, you are erring on the side of safety for given individual.
- There is no known harm in treating hypertension, given the lack of standard contraindications.
- There may be harm in not treating a given individual.

In the case of using race and gender, generalizing errs on the side of harm.
- It doesnt hurt anyone to stay open minded to the potential of that black kid from the inner city.
- It can hurt a talented black person from the inner city, if you generalize that all such people are doomed to failure.

So you see, there is asymmetry here. Its like the ROC curve that trades sensitivity vs. specificity. In which direction you want to err will be based on the given circumstances.

And regarding personal values, they are just that. *Personal*. Lets say an individual found value in doing a PhD while in medical school. Can he then reasonably conclude that you are lazy, becase you didnt? That would be ridiculous.

What is your response to my posts?

 

[dogbone65]

There are certain generalizations about race, gender etc. that are correct. For example, many studies have shown that asian men have the smallest penises of all races....sorry mmd. Political correctness is a crutch of the weak and spineless and I for one will be glad when that crap is no longer "fashionable". PI....f*&&ing BS. MMD, I have found your posts to be informative, based on solid and extensive experience, and evidence as well as intuitive and usually on the money. Not to mention succinct...you don't bs around. Look forward to more...rock on!

 

[militarymd]

In the case of generalizing for treatment of hypertension, you are erring on the side of safety for given individual.
- There is no known harm in treating hypertension, given the lack of standard contraindications.
- There may be harm in not treating a given individual.

In the case of using race and gender, generalizing errs on the side of harm.
- It doesnt hurt anyone to stay open minded to the potential of that black kid from the inner city.
- It can hurt a talented black person from the inner city, if you generalize that all such people are doomed to failure.

Depends on who is being harmed.

In treating patients, one is concerned about not harming the patient.

In choosing an individual for an organization, one is concerned about not harming the organization.

 

[militarymd]

There are certain generalizations about race, gender etc. that are correct. For example, many studies have shown that asian men have the smallest penises of all races....sorry mmd. Political correctness is a crutch of the weak and spineless and I for one will be glad when that crap is no longer "fashionable". PI....f*&&ing BS. MMD, I have found your posts to be informative, based on solid and extensive experience, and evidence as well as intuitive and usually on the money. Not to mention succinct...you don't bs around. Look forward to more...rock on!

thank you for your support?

 

[GasEmDee]

There are certain generalizations about race, gender etc. that are correct. For example, many studies have shown that asian men have the smallest penises of all races....sorry mmd. Political correctness is a crutch of the weak and spineless and I for one will be glad when that crap is no longer "fashionable". PI....f*&&ing BS. MMD, I have found your posts to be informative, based on solid and extensive experience, and evidence as well as intuitive and usually on the money. Not to mention succinct...you don't bs around. Look forward to more...rock on!

This discussion has nothing to do with political correctness -- or penis size for that matter. It is about the advantages and pitfalls of generalization.

 

[GasEmDee]

Depends on who is being harmed.

In treating patients, one is concerned about not harming the patient.

In choosing an individual for an organization, one is concerned about not harming the organization.

I disagree with the simplistic filter that you use to find that individual.

 

[militarymd]

I disagree with the simplistic filter that you use to find that individual.

There is nothing simple about choosing an individual.

Countless variables are involved in choosing an individual for an orgainzation. Some of those variables are "generalizations" that one has to use based on available data.

 

[cloud9]

This discussion has nothing to do with political correctness -- or penis size for that matter. It is about the advantages and pitfalls of generalization.

Penis size in different races IS a generalization.

 

[GasEmDee]

There is nothing simple about choosing an individual.

Countless variables are involved in choosing an individual for an orgainzation. Some of those variables are "generalizations" that one has to use based on available data.

Agreed. However you said that you'd put any candidate who mentioned the word "lifestyle" right into the reject pile.

That is not "countless variables". That is *one* variable, and it's an oversimplistic one. That was my point in our previous discussion, and that is my point now.

 

[GasEmDee]

Penis size in different races IS a generalization.

Haha.

Ferraris are red.

That is generalization too. However, neither of these have any relevance to the debate.

 

[militarymd]

Agreed. However you said that you'd put any candidate who mentioned the word "lifestyle" right into the reject pile.

That is not "countless variables". That is *one* variable, and it's an oversimplistic one. That was my point in our previous discussion, and that is my point now.

Different selection process there, my friend.

One is for training....and I stand by that one....if you're already worried about "lifestyle" when you're just a trainee......you're going into the circular file....although I admit (in cyberspace) I say that with more emphasis than in real life.....but, in 5 years of residency selection, I've always put "lifestyle" candidates into the circular file.

On the other hand, selecting a partner is different.....many variables....all of them "generalized":

1) friendly personality.......generalized to more likely to get along with staff
2) good scores........gneeralized to knowledgabe
3) hobbies (see avatar).......generalzied to ability to bond with patients through common interests
4)...and other gneralzied traits....some of which are non PC

In my mind, selection processes for a residency and selection process for partners are different.......I'm sure there are many different views on this.

 

[GasEmDee]

You're Asian right Mil?

This immediately reminded of a funny situation situation my female asian friends have often complained about. It goes like this:

1. Girl in jr. high. Parents say "stay away from boys!!"
2. Girl in high school. Parents say "no dating! concentrate on school"
3. Girl in college/grad school. Parents say more of the same.
4. Girl graduates from school. Upon graduation, parents say "Ok its
time for you to settle down. Why arent you married yet??!!"



The point being, how do you expect someone to be so single-minded about hard work at the residency level, and then expect them to become well-balanced people immediately after finishing? Its an inconsistent expectation.

Different selection process there, my friend.

One is for training....and I stand by that one....if you're already worried about "lifestyle" when you're just a trainee......you're going into the circular file....although I admit (in cyberspace) I say that with more emphasis than in real life.....but, in 5 years of residency selection, I've always put "lifestyle" candidates into the circular file.

On the other hand, selecting a partner is different.....many variables....all of them "generalized":

1) friendly personality.......generalized to more likely to get along with staff
2) good scores........gneeralized to knowledgabe
3) hobbies (see avatar).......generalzied to ability to bond with patients through common interests
4)...and other gneralzied traits....some of which are non PC

In my mind, selection processes for a residency and selection process for partners are different.......I'm sure there are many different views on this.

 

[militarymd]

The point being, how do you expect someone to be so single-minded about hard work at the residency level, and then expect them to become well-balanced people immediately after finishing? Its an inconsistent expectation.

Maybe you can rank your priorities???? Sort of like ranking your list for residency???

People who come in ranking "lifestyle" first when training....gets the "general" circular file...."in general".

Geeks who can't speak English and have no interests beyond anesthesia..."generally" will be ranked lower than those who are well balanced.

 

[GasEmDee]

Where I went to medical school, the most hard working students were the ones that went into the "lifestyle" specialties. These were the students that had the best track record of success. They went to the finest undergraduate institutions, they had the best board scores, performed well on their clerkships, and had the most interesting and impressive extra-curricular records. These were the people with the most sheer intellectual horse power. That is how they were able to match into competitive "lifestyle" residencies at first-tier academic medical centers.

I had the pleasure of doing internship with many such individuals, and in our internship class composed of categoricals and one-year spots, the interns who were transitioning into the lifestyle specialties were the highest performing, most balanced, most fun-to-hang-out-with interns -- by far! That wasnt suprising -- they were just continuing on with a life-time track record of high performance.

The kid who went to Harvard, got an MD/PhD at Stanford, then went into Derm at UCSF is NOT a lazy person, no matter how many times he mentions "lifestyle".

I have no idea what kind of pool you are drawing your residents or your colleagues from, so maybe that explains why we have such polar perspectives. But, I see no correlation whatsoever between an interest in lifestyle and "laziness". It is the person's track record of hard work and academic success that predicts future success, not the fact that he or she metioned the word "lifestyle".

The bottom line is that you have your anecdotes and I have mine. Neither are sufficient to prove whose perspective is right. But I still have yet to hear you offer a logical and reasoned explanation for why "lifestyle" candidates get sent to the trash bin. All I have heard from you so far is that "they are lazy". Sorry bro, but that is not a real explanation.

Different selection process there, my friend.

One is for training....and I stand by that one....if you're already worried about "lifestyle" when you're just a trainee......you're going into the circular file....although I admit (in cyberspace) I say that with more emphasis than in real life.....but, in 5 years of residency selection, I've always put "lifestyle" candidates into the circular file.

On the other hand, selecting a partner is different.....many variables....all of them "generalized":

1) friendly personality.......generalized to more likely to get along with staff
2) good scores........gneeralized to knowledgabe
3) hobbies (see avatar).......generalzied to ability to bond with patients through common interests
4)...and other gneralzied traits....some of which are non PC

In my mind, selection processes for a residency and selection process for partners are different.......I'm sure there are many different views on this.

 

[SleepIsGood]

This immediately reminded of a funny situation situation my female asian friends have often complained about. It goes like this:

1. Girl in jr. high. Parents say "stay away from boys!!"
2. Girl in high school. Parents say "no dating! concentrate on school"
3. Girl in college/grad school. Parents say more of the same.
4. Girl graduates from school. Upon graduation, parents say "Ok its
time for you to settle down. Why arent you married yet??!!"


.

100% true

 

[TofuBalls]

You're Asian right Mil?

This immediately reminded of a funny situation situation my female asian friends have often complained about. It goes like this:

1. Girl in jr. high. Parents say "stay away from boys!!"
2. Girl in high school. Parents say "no dating! concentrate on school"
3. Girl in college/grad school. Parents say more of the same.
4. Girl graduates from school. Upon graduation, parents say "Ok its
time for you to settle down. Why arent you married yet??!!"

5. Me so horny... me love you long time!

 

[Faebinder]

My online persona has been accused of many things while on this board....racist, chauvinist, backwards, politically incorrect...etc.....pretty much all the things that we do not want in our physicians.

While at the same time, in my non cyberspace life, I'm not perceived that way, so I figure I would bring up one of the aspects of my cyber personal traits and discuss it ....and see what responses you guys have.

I'm accused of making "generalizations" about all the topics that we discuss here......that there are always exceptions to the "generalizations" that I make.

I'm no idiot....I know there are always exceptions, but we don't practice medicine based on "exceptions".

Medical data is available in different forms...case reports, case series, retrospective studies....prospective studies...observational/interventional....and then there is the holy grail of data...prospective controlled double blind randomized trials.

From the data, we make generalizations that allow us to make daily medical interventions that will improve our patients life, quality of life, etc.

Here is my favorite example....treatment of hypertension. We know that hypertension, in GENERAL, leads to premature end organ dysfunction, so the recommendation is that we TREAT EVERY PERSON with hypertension.....However, what is the reality?

In reality, we all know many, many people who lived to their 90's with untreated hypertension without any sequala.

So why do we generalize? Because that is the nature of medicine...sure there are exceptions, but that is not the way to practice medicine....

How you do decide which hypertensive to treat? Even whey you know that the number needed to treat to prevent a premature MI in hypertensives is in the hundreds. You make your treatment decision based on the fact that, in general, treating hypertension prevents MIs....although not all the time.

Data is data....it is amusing to me how it is socially acceptable to generalize some data but not others.

If you always generalize then you will never ever be fair.... You might say, life is unfair.... that's true but you are not life... and if you believe in any sort of karma of higher being then there will be some sort of accountability for the lack of fairness. A world where dog eats dog will quickly die.

Otherwise... there is absolutely nothing stopping you from trashing those candidates..... and nothing stopping the homeless outside your hospital from shooting you for the money in your wallet.

My 2 insignificant cents.

 

[militarymd]

If you always generalize then you will never ever be fair.... You might say, life is unfair.... that's true but you are not life... and if you believe in any sort of karma of higher being then there will be some sort of accountability for the lack of fairness. A world where dog eats dog will quickly die.

Otherwise... there is absolutely nothing stopping you from trashing those candidates..... and nothing stopping the homeless outside your hospital from shooting you for the money in your wallet.

My 2 insignificant cents.

I guess ultimately, some people will accept that we "generalize" things, while others will not accept it.

I don't differentiate between things that are PC vs Not PC.....just that there are trends in everything we deal with in life....we can either accept these trends or not.....

Not only do I accept the trends that exist, I embrace them, and use them to my advantage....in making decisions.....medical/clinical...or otherwise.

 

[GasEmDee]

I don't differentiate between things that are PC vs Not PC.....just that there are trends in everything we deal with in life....we can either accept these trends or not.....

Once again, this has nothing to do with political correctness.

Not only do I accept the trends that exist, I embrace them, and use them to my advantage....in making decisions.....medical/clinical...or otherwise.

You certainly believe you are using them to your advantage. Whether you actually are using them to you advantage is highly suspect, as you have yet to present any reasonable argument to support your opinions.

Let's bring this back full circle to your original post and your own example. Do you always treat hypertension? Or are there exceptions?

 

[militarymd]

Let's bring this back full circle to your original post and your own example. Do you always treat hypertension? Or are there exceptions?

Actually, I almost never treat hypertension in the perioperative period. JNC VII applies to hypertension that is present over the course of years.....and, yes, you should ALWAYS treat hypertension in the "patient population" described in JNC VII.

Although, the NNT, to prevent one premature event is in the hundreds.....but, in general, hypertensives, as described in the inclusion criteria, do better if you treat.

 

[militarymd]

Once again, this has nothing to do with political correctness.




You certainly believe you are using them to your advantage. Whether you actually are using them to you advantage is highly suspect, as you have yet to present any reasonable argument to support your opinions.

Let's bring this back full circle to your original post and your own example. Do you always treat hypertension? Or are there exceptions?

Same goes for you.

 

[dogbone65]

Yes, MMD, that was a show of support. Love the new avatar...bad lighting in the old one. Is that you? Please be gentle as I'm a newbie, but a transiet hypertensive episode in a patient without any signficant comorbities/risks in the perioperative period would not necessarily require treatment unless it occurs at a particularly critical part of the surgery...say a neuro case.? Is this what you are getting at? Also, somewhat along these same lines, can someone give me some insight. I know MD's, good ones, that do or don't do something because one untoward event happened to them in the past. No evidence, just happened so we can't do that. Is it a lack of balls or what? Can't figure out the rationale.

 

[militarymd]

Yes, MMD, that was a show of support. Love the new avatar...bad lighting in the old one. Is that you? Please be gentle as I'm a newbie, but a transiet hypertensive episode in a patient without any signficant comorbities/risks in the perioperative period would not necessarily require treatment unless it occurs at a particularly critical part of the surgery...say a neuro case.? Is this what you are getting at? Also, somewhat along these same lines, can someone give me some insight. I know MD's, good ones, that do or don't do something because one untoward event happened to them in the past. No evidence, just happened so we can't do that. Is it a lack of balls or what? Can't figure out the rationale.

A CRNA that I work with is an excellent amateur photographer, we got toether on saturday and took some shots of me, amateur racer, doing some corners.

I'm speaking of generalities in terms of perioperative hypertension....the patient who's hypertensive despite adequate anesthesia and where the increased bp is not affect the course of surgery....I don't treat those....although those patients should ultimately be evaluated by an outpatient physician for treatment of hypertension.

Practicing medicine based on "anecdotal" experience is, unfortunately, all too common, but it is human nature to remember the exceptions in your experience...whereas data should be the summation of experiences of many clinicians.

Practicing medicine based on anecdotal experience is not lack of balls, but rather lack of education.