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No video this week — we had a bit of a computer meltdown — but two interesting articles. As always, thanks for listening. If you have articles you would like us to cover, please send us a suggestion at [email protected]. This Substack is reader-supported. If you appreciate our work, consider becoming a free or paid subscriber. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

In a lifetime of possible memories, only some are accessible. There are a few comments — made by mentors, co-residents, and patients — that have lingered and shaped my medical practice. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

I was shocked at the comments on this post. Many people, some of them I know to be smart, thought I was nuts for suggesting two middle-aged women who had isolated high LDL-C needn’t take meds because their calculated 10-year risk was less than 3% What shocked me is that our guidelines suggest treatment with statins when 10-year risk is ≥ 7.5%. You may not know this but clinicians are supposed to consider cholesterol (and BP) based on overall risk, which include things like age, blood pressure, smoking status as well as HDL. Here is a link to the PCE. It drives me bananas that clinicians don’t go over this with patients. They just look at LDL-c in isolation. Content like this comes free of industry support. Please consider becoming a free or paid subscriber. Experts chose this a 7.5% threshold because they felt it was the point where the absolute risk reduction from statins (about 20-25% relative risk reduction) for nonfatal cardiac events outweighed any potential downsides of statins. It is an arbitrary threshold. The thinking: We know from many RCTs that statins reduce future risk by about 20-25% over 5 years. So .25 x the estimated risk outputs the absolute risk reduction. Let’s say a person has a calculated risk of 10%. They can expect a 2.5% risk reduction (.25 x 10% = 2.5%) over 10 years. But .25 x 3% = .75, so a person with an estimated risk of 3% who takes a daily pill for 10 years goes to 2.25%. That’s not much. Here are some pics of the pushback I recieved: My colleagues rightly point out that atherosclerosis of the coronary arteries is a slow process and longer exposure to lower LDL-c is beneficial. They feel that the 10-year horizon is too short. They cite something called Mendelian randomization studies which find that people who were born with genetic profiles that cause low cholesterol also have low rates of heart attacks. I wrote a post about this. I actually think that statins and blood pressure drugs may have greater effects in younger people who are at lower risk. But come on. Both individuals who I helped calculate risk were below 3%. That’s too low to worry about. Further, if you think we treat people with elevated LDL levels who have this low of a risk, why do we need risk calculators? Or…why don’t we just treat everyone above a certain age, since age is the largest driver in the calculators? These are issues I spoke with Drs Foy and Murthy about. I learned a ton. I hope you will too. Topics include: * The value of risk calculators * The uncertainty of prediction * The best time window to consider (statin trials were for 5 years; can we assume effect sizes over 5 years are similar at 30 years?) * The causal role of LDL-c vs “metabolic health” * The value of coronary artery calcium testing * Lipoprotein (a) Academic people like to make fun of podcasts, but I can’t imagine a more educational 40 minutes. Andrew and Venk are two of the most thoughtful people in cardiology today. Enjoy and consider supporting Sensible Medicine This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Medical Management and Revascularization for Asymptomatic Carotid Stenosis Vagus nerve-mediated neuroimmune modulation for rheumatoid arthritis: a pivotal randomized controlled trial We spent quite a bit of time talking about blinding. This is the table on the adequacy of blinding from the supplement. It does seem like blinding was less than perfect. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

We try to answer the remainder of your AUA questions. We will be back in the new year with more article discussions! Here are a few of the things we referenced. GDMT Bugs Me: A bit of a rant against the standard of care A Plan to Refocus Primary Care Sacrificing patient care for prevention: distortion of the role of general practice The Great Colonoscopy Debate Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

We cover questions from Amy J, Benjamin Hourani, Diana Stiles Friou, Chris Costas, Errol Laurie, Jim Healthy, Elizabeth Fama, Never Dull, Rod Rodriguez, Ellison Burns, David Araujo, and George. We have more to come! One nice reference I found while looking into some of the topics: DMSO Is Not a Cure-All. But the FDA’s Panic Over It Birthed a Myth This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Vascular and inflammatory diseases after COVID-19 infection and vaccination in children and young people in England: a retrospective, population-based cohort study using linked electronic health records Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

European Study of Prostate Cancer Screening — 23-Year Follow-up Association Between Baseline Diastolic Blood Pressure and the Efficacy of Intensive vs Standard Blood Pressure–Lowering Therapy Further Reading * Effects of intensive blood-pressure control in type 2 diabetes mellitus * A Randomized Trial of Intensive versus Standard Blood-Pressure Control Sensible Medicine is 100% reader-supported. If you appreciate our work, consider becoming a free or paid subscriber. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Effects of Intensive Blood Pressure Control in Patients With Frailty: A Post Hoc Analysis From ESPRIT * Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial * Reduction of Antihypertensive Treatment in Nursing Home Residents Polysaccharide Conjugate Vaccine against Pneumococcal Pneumonia in Adults * A trial to evaluate the safety and immunogenicity of a 20-valent pneumococcal conjugate vaccine in populations of adults ≥65 years of age with different prior pneumococcal vaccination This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Total cholesterol and all-cause mortality by sex and age: a prospective cohort study among 12.8 million adults * The Ideal Cholesterol Level ... Depends...And Cannot Be Determined From Observational Studies Structured vs Self-Guided Multidomain Lifestyle Interventions for Global Cognitive Function: The US POINTER Randomized Clinical Trial * Can We Please Stop Asking if Crossword Puzzles Prevent Dementia? This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Two papers this week, with a bunch of articles that we referenced in the conversation. Also, the last Fortnight podcast was accidentally posted behind a paywall. It is now up and free to listen to. My apologies. Sensible Medicine is reader-supported. If you appreciate our work, consider becoming a free or paid subscriber. Folinic acid improves verbal communication in children with autism and language impairment: a randomized double-blind placebo-controlled trial * Folate Receptor Alpha Autoantibodies in Autism Spectrum Disorders: Diagnosis, Treatment and Prevention * Association Between Maternal Use of Folic Acid Supplements and Risk of Autism Spectrum Disorders in Children * Cerebral folate receptor autoantibodies in autism spectrum disorder * What Is Leucovorin, the Medicine Being Approved for Autism Treatment? * Clinicaltrial.gov search Effects of Glucagon-Like Peptide 1 Receptor Agonist Initiation in Patients With Heart Failure With Reduced Ejection Fraction and Implantable Cardiac Devices * Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes * Effects of Once-Weekly Exenatide on Cardiovascular Outcomes in Type 2 Diabetes * Effects of Liraglutide on Clinical Stability Among Patients With Advanced Heart Failure and Reduced Ejection Fraction * Increased Risk of Heart Failure Hospitalization With GLP-1 Receptor Agonists in Patients With Reduced Ejection Fraction: A Meta-Analysis of the EXSCEL and FIGHT Trials This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

We go all observational this week. A look at data suggesting the safety of GLP-1s and a re-examination of data on patient/doctor race concordance/discordance (a topic Adam said we should not study, and then John forces him to). GLP-1 Receptor Agonists and Cancer Risk in Adults With Obesity Physician–patient racial concordance and newborn mortality Original, 2020 article: Physician–patient racial concordance and disparities in birthing mortality for newborns This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

NT is a 55-year-old man admitted to the general medicine service with cellulitis of his left leg. When the attending sees him the morning after admission, he notices the patient’s “Medical Center Trustee” hospital ID on his bedside table. After gathering a history and examining the leg, the attending leaves the room. In the hallway, he crosses paths with the hospital president, who is there to make a “social call”. She smiles and says to the attending, “Don’t let anything bad happen.” Sensible Medicine is reader-supported. If you appreciate our work, consider becoming a free or paid subscriber. Every clinician is familiar with the Very Important Patient, the VIP. Defining the VIP is challenging. In the most general sense, the VIP is a patient whose care imposes an additional burden on the clinician. The VIP is perceived to have an elevated social status, typically due to fame, wealth, connections, or power. The VIP may come to his or her status in several ways. The VIP might claim that status herself. The status might be granted by a third party, such as the source of the referral, or outside realities (fame, fortune, power). Sometimes, VIP status is granted by the physician alone. The physician recognizes that an untoward outcome in the care of the VIP — clinical or otherwise, expected or unexpected — will be acknowledged by a wider community and might be particularly unpleasant for the treating physician. VIP patients are a threat to healthcare. They need to be eradicated from hospitals and clinics as ruthlessly as we would eradicate E. coli from a well, Pseudomonas from a hot tub, or Legionella from a hotel HVAC system. Why should we eliminate the VIP? Because a patient’s wealth, station, or connections should have no bearing on the tests that are done, the treatments that are offered, or the haste with which care is provided. I have heard people argue about whether basic healthcare is a human right. I have heard people who agree that basic healthcare is a human right argue about what makes up basic healthcare and who should decide what qualifies. I have never heard people argue about whether people deserve different care based on their identity. The most obvious threat the VIP poses is to himself. We recognize that when people are treated as special, they are at risk of getting worse healthcare. This fact underlies the guidance that physicians avoid caring for close friends and relatives. The AMA Code of Medical Ethics states: When the patient is an immediate family member, the physician’s personal feelings may unduly influence his or her professional medical judgment. Or the physician may fail to probe sensitive areas when taking the medical history or to perform intimate parts of the physical examination. Physicians may feel obligated to provide care for family members despite feeling uncomfortable doing so. They may also be inclined to treat problems that are beyond their expertise or training. You could easily replace family member with VIP. While we can all avoid treating family members and close friends, VIPs are a reality in every physician’s life. Transferring their care to another physician usually does not change the circumstances. Ben Kean, an exceptionally colorful character and my parasitology teacher in medical school, shared a story about the risks VIP healthcare poses to the VIP. He once suggested that a patient with pneumonia — a patient who was also famous, wealthy, and important — be transferred from a private hospital to a public one, and treated under a pseudonym. "But why a public hospital, when I have a good private clinic here with the best doctors and nurses?" "There are two ingredients essential to your recovery," I explained, "that can't be found here and that you cannot buy. These are things found only at a large public institution, where hundreds of patients are seen each day, many of whom suffer from pneumonia. First, you need a large house staff -- bright, young people with new ideas and with daily experience in dealing with desperate situations. Second, you need a laboratory with specialized technicians available around the clock to monitor your breathing, to do special culture work for bacteria and parasites. This is a lovely private hospital, but the kind of help you need isn't available here." Then there is the reality that if you treat VIPs differently, and it becomes known, it is a bad look. Just ask the leadership of NYU Langone Health. But the threat of the VIP goes beyond personal risk. The overtesting, overtreatment, and early diagnosis that have been described not only threaten the VIP but are also bad for our healthcare system. Overspending and excess erode other people’s care. An unnecessary MRI ordered for the VIP’s week of sciatica may delay the diagnosis of cord compression in the non-VIP with back pain and prostate cancer. VIP treatment can lead to ill will among members of the healthcare team. Teams bond when they work together for the benefit of a patient. With VIPs, team members most under the patient’s sway may suggest management at odds with that proposed by team members less influenced by the patient’s status. It is not hard to imagine moral injury if a healthcare worker perceives they are acting because of who a patient is rather than because of what the patient needs. If a team bows to pressure, the ethics of medicine are compromised. Other patients will perceive a tiered system, and this will undermine their faith in medicine. Eradicating the VIP from healthcare is certainly more difficult than getting rid of E. coli, Pseudomonas, or Legionella. How do we ensure that the homeless man, with no wealth, power, or family, receives the same care as the woman for whom the hospital is named? It may be hard to eradicate the VIP when healthcare itself has played a significant role in creating the VIP. Hospital marketing and rankings promote the idea that doctors and hospitals are not equal. They do this to attract the “best payer mix” so they can build shiny new facilities. If patients, with their expensive, private insurance, are drawn to a medical center because of the rankings, should we be surprised if they expect something for their money and effort? I wish there were an easy answer. There is not. It is possible that Mick and Keith are our best guides here. As clinicians, we know that we need to provide the best care possible for our patients. We also recognize that different people want different things from their healthcare. Some people just want to be left alone at night, others want an extra cup of tea with breakfast, and others want a visit from the hospital president. If these allowances truly do not affect the care of patients, all patients, then there is no harm in providing the desired care in addition to the necessary care. Once management of the VIP threatens to affect care, hers or that of her fellow patients, then physicians need to recommit to their pledge to care for everyone equally, regardless of who they are. This is at the core of the practice of medicine. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Last week, John was at the European Society of Cardiology conference in Madrid, and Adam was at the Preventing Overdiagnosis 2025 International Conference in Oxford. A conversation about what we learned. Digitoxin in Patients with Heart Failure and Reduced Ejection Fraction Beta-Blockers Post-MI: A Clear Clinical Message Aspirin in Patients with Chronic Coronary Syndrome Receiving Oral Anticoagulation How does decontextualised risk information affect clinicians’ understanding of risk and uncertainty in primary care diagnosis? A qualitative study of clinical vignettes How do we talk about overdiagnosis of mental health conditions without dismissing people’s suffering? This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe