Wednesday, November 10, 2010

Advice from an Old Fart

One thing that I keep telling the trainees working under me is, take your time, develop your own style. I think it's important, because many of them get so confused why we all do things a bit differently. Picking this medication instead of that. Doing this. Not doing this.
Because truly, as much as the practice of medicine is a science, it's also a whole lot of art. And I think professional personalities can differ as much as our social personalities.
For example, as a physician, I consider myself a minimalist. I'm not a big fan of using the newest medications just because they're out there, because as we all know, new=expensive, and usually lacks the clinical outcomes data the olders meds have. And I've become very skeptical of Big Pharma, and what their hot-rep-in-a-miniskirt tells me about their new wonderdrug.
Also, I tend to be a realist. Yes, I do try to get the hemoglobin A1c down to less than 7%. But the truth is for some patients it really doesn't matter anymore that they're slightly above goal. The very old, those with multiple comorbidities and who are likely more at risk of hypoglycemia. Those who won't have the life expectancy to see any possible benefits in microvascular risk reduction of lowering the A1c. So, sometimes rather than starting an 80 year old on insulin, we agree to just 'chill' and watch things conservatively (now this might come back to haunt me in a pay-for-performance scheme where the doctors are reimbursed purely based on numerical goals, without considering the individual patient. Methinks this will force providers to be too aggressive, with resultant hypoglycemia complications in many patients).
Likewise, if I see a 78 year old with a thyroid nodule, I'm likely to not suggest a biopsy, because I really don't wanna know what's in there. Even if that 1.2 cm nodule harbored some papillary cancer, it's highly unlikely surgery will prolong his life since he will almost definitely die of other causes like a heart attack. Conversely, a patient that age will likely have a higher surgical risk. So, if I think I'm unlikely to suggest surgery anyway, I ask the patient, Do you really want to know?
This is in contrast to some of my colleagues. Biopsy every patient with a nodule. A1c MUST be under 7% (or 6.5%, depending on your beliefs).
So I give my students and residents this advice. I think it's important when they're at that malleable stage of their careers: "Don't do what I do". Or what Dr. X or Y does, for that matter. Don't blindly follow without understanding.
Instead, read the literature. Review the guidelines, and the studies that support them in the first place. And then, based on your take of things, make your own treatment decisions. Because at the end of the day, you'll have to justify your decisions. And saying I'm picking this insulin because that's what Dr. V likes isn't going to inspire a lot of confidence.
So, to you students and residents and fellows out there, take your time, do your reading, to figure out just what kind of doctor you'd wanna be.


Blogger pilocarpine said...

good advice.. thanks..

11:03 PM  
Anonymous Anonymous said...


6:00 AM  
Blogger huajern said...

Good advice.

6:02 AM  
Anonymous Dunlop said...

good advice

6:27 AM  

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