Sensible Medicine

Epizode

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  This Fortnight in Medicine XXXI 29.07.2026 41min

  Tamsulosin Deprescribing for Lower Urinary Tract Symptoms in Older Men A Randomized Clinical Trial* Side Effect Patterns in a Crossover Trial of Statin, Placebo, and No TreatmentCost-Effectiveness of Fecal Immunochemical Testing Alone vs Co-Testing With Helicobacter pylori Stool Antigen 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
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  This Fortnight in Medicine XXX 15.07.2026 44min

  Polypill for heart failure with reduced ejection fraction: the POLY-HF randomized trialJohn Mandrola: I am torn on the PolyPill concept 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
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  This Fortnight in Medicine XXIX 01.07.2026 37min

  Cefazolin for Methicillin-Susceptible Staphylococcus aureus Bacteremia* Stopping randomized trials early for benefit and estimation of treatment effects: systematic review and meta-regression analysisThe Impact of Midodrine on Guideline-Directed Medical Therapy in Patients Admitted With Systolic Heart Failure 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
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  Friday Reflection 62: The Ethics of Telling Patients We Have Nothing Left to Offer 26.06.2026 4min

  TR is an 88-year-old man who is disabled and in chronic pain from spinal stenosis and knee osteoarthritis. He has multiple other medical issues, including coronary artery disease and COPD.He has been through years of treatment for his knees and back, including physical therapy, multiple joint injections, and an in-office procedure for spinal stenosis. He has been on multiple regimens of oral pain medications. He is not interested in surgery (and probably would not be considered a reasonable candidate if he were).He comes to a visit and asks what can be done.Sensible Medicine is a reader-supported Substack. If you appreciate our work, consider becoming a free or paid subscriber.We are taught never to say, “There is nothing I can do for you.” We may be out of surgical or medical options, but we can always continue to care for and support our patients. This is not part of the Hippocratic Oath, but it is so integral to our training that one might think it belongs there.There are good reasons to caution doctors from saying some version of, “I am sorry, I don’t think there is anything more I can do for you.” It is true that in 21st-century medicine, the act of caring for patients has been so trivialized that we need to remind ourselves that caring is not just a last resort but our first responsibility.Hope in the face of illness is exceedingly valuable. Robbing this hope is not only cruel, but probably bad for the health of patients.Then there is the truth that when one doctor has nothing left to offer, medicine often still has more to offer. I am still haunted by at least one case when I mistook my lack of knowledge for a shortcoming in the field.A doctor saying he has nothing left to offer may be taking the easy way out. Further research or a considered referral often suggests effective treatments, if not cures. There is always a risk that when we say, “We can’t help,” we are wrong.All this being true, I don’t think we admit that there is nothing left to be done often enough. The Modern Hippocratic Oath does include the line:I will not be ashamed to say “I know not”, nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.Is it that much of a stretch to imagine the oath saying:I will not be ashamed to say “I have nothing left to offer beyond my ongoing care and commitment”, nor will I call in my colleagues, knowing they have nothing to offer beyond protecting me from admitting medicine’s limitations.We no longer conceal bad diagnoses from patients; we consider this unethical. It is time that we consider it unethical to conceal that we have nothing to offer beyond palliation.It is hard to tell patients that the best we can do is control pain, especially when we have been trained not to. It takes work to be sure that neither you nor your colleagues have something to offer beyond a hamster wheel of care to provide hope but nothing more. It also takes some guts; we can never be 100% sure that nobody has anything to offer.Yet there are downsides to never saying we are done. Many patients accept that further care is futile, not after an honest conversation, but after being worn down by my endless visits, treatments, and promises that lead nowhere. All the while, time and money are wasted; time and money that could be better spent on life. The useless medical care leaves patients and their families increasingly frustrated by a medical system that refuses to be honest and caring.There are patients who welcome an honest assessment of their options and shift their focus to living with their disease and disability. There are also patients who do not. I’ve had patients fire me for saying there was nothing to do. They left me to get on that hamster wheel of care. This decision did not make them better, but maybe it made them happier and more ready to accept the inevitable. Eventually.TR calls now and then and comes to see me every three or four months. He tells me about his symptoms and the things he wishes he could do. I tell him there are things he could try and people he could see, but I let him know I don’t think any of these options would be productive. He tells me he’s not interested. I advise him to push up on his pain medications and to pretreat his symptoms; I know he will not take this advice. I know we will repeat this visit in the future; I actually hope we will, for years. 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
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  This Fortnight in Medicine XXVIII 17.06.2026 32min

  Amoxicillin-Clavulanate vs Amoxicillin for Acute Sinusitis in Adults* Prespecified Falsification End Points: Can They Validate True Observational Associations?* Ultrasonography versus Computed Tomography for Suspected NephrolithiasisGLP-1 receptor agonist use and cancer risk in obese nondiabetic adults* Risk for Cancer With Glucagon-Like Peptide-1 Receptor Agonists and Dual Agonists: A Systematic Review and Meta-analysis 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
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  This Fortnight in Medicine XXVII 03.06.2026 33min

  Reduced Melanoma After Regular Sunscreen Use: Randomized Trial Follow-UpGLP-1 Receptor Agonists or SGLT2 Inhibitors and Nonarteritic Anterior Ischemic Optic Neuropathy* Previously discussed on Fornight XXII: Glucagon-like peptide-1 receptor agonists and risk of substance use disorders among US veterans with type 2 diabetes: cohort study 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
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  This Fortnight in Medicine XXVI 20.05.2026 54min

  Left Atrial Appendage Closure or Anticoagulation for Atrial Fibrillation 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
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  This Fortnight in Medicine XXV 06.05.2026 30min

  Oral Nirmatrelvir–Ritonavir for Covid-19 in Higher-Risk Outpatients* Real-World Effectiveness of Nirmatrelvir–Ritonavir Against Severe Outcomes of COVID-19 in Taiwan: A Nationwide Population-Based Cohort StudyThree Low-Dose Antihypertensive Agents in a Single Pill after Intracerebral Hemorrhage* Effect of Combination Therapy on Adherence Among US Patients Initiating Therapy for Hypertension: a Cohort Study 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
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  This Fortnight in Medicine XXIV 22.04.2026 46min

  RSV Prefusion F Vaccine for Prevention of Hospitalization in Older AdultsUltrasound-Facilitated, Catheter-Directed Fibrinolysis for Acute Pulmonary Embolism* Endovascular management of intermediate-risk pulmonary embolism: evidence, outstanding questions, drivers of utilization, and the horizon 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
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  This Fortnight in Medicine XXIII 08.04.2026 33min

  Dengue Suppression by Male Wolbachia-Infected Mosquitoes* World Mosquito ProgramAntibiotic Therapy for Uncomplicated Acute Appendicitis 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
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  This Fortnight in Medicine XXII 24.03.2026 39min

  * Glucagon-like peptide-1 receptor agonists and risk of substance use disorders among US veterans with type 2 diabetes: cohort study* Immediate or Deferred Nonculprit-Lesion PCI in Myocardial Infarction* Andrew’s previous SM post on the subject: How a Meta-Analysis can Mislead—The Story of Complete vs Culprit-only PCI in STEMIAnd, a bunch of the other studies we discussed.* Complete Revascularization with Multivessel PCI for Myocardial Infarction* FFR-Guided Complete or Culprit-Only PCI in Patients with Myocardial Infarction* Initial Invasive or Conservative Strategy for Stable Coronary Disease 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
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  This Fortnight in Medicine XXI 11.03.2026 35min

  Sodium Correction Rates and Associated Outcomes Among Patients With Severe Hyponatremia: A Retrospective Cohort Study* A Randomized Trial of Targeted Hyponatremia Correction in Hospitalized PatientsEffect of Neuromuscular Warm-up on Injuries in Female Soccer and Basketball Athletes in Urban Public High Schools* Why Are So Many Teen Girls Still Tearing Their A.C.L.s?* Injury prevention programs that include plyometric exercises reduce the incidence of anterior cruciate ligament injury: a systematic review of cluster randomised 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
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  Going Beyond "AI in Medicine" 04.03.2026 24min

  Most conversations about “AI in Medicine” bore me. I think this is because either we lack the imagination to consider how AI will change medicine in the next decade, or we are not being specific enough about how small parts of medicine could be productively affected.Dr. Shantanu Nundy, MD, MBA, is a practicing physician whom I like to think of as a serial innovator. He is currently an advisor on artificial intelligence to the FDA in the Commissioner’s Office. He has spent a great deal of time and energy thinking deeply about what AI can bring us today and in the future. I hope you enjoy this conversation. 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
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  This Fortnight in Medicine XX 25.02.2026 39min

  High-Dose Influenza Vaccine Effectiveness against Hospitalization in Older Adults* High-Dose Influenza Vaccine to Reduce Hospitalizations* Efficacy of high-dose versus standard-dose influenza vaccine in older adultsBeta-blockers after myocardial infarction: effects according to sex in the REBOOT 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
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  Alternative Modalities for Breast Cancer Screening 18.02.2026 36min

  Today on the podcast, I am joined by Dr. Jennifer Rusiecki. Dr. Rusiecki is an Associate Professor of Medicine at the University of Chicago. She is the Director of Women’s Health and Gender-Based Care in the internal medicine residency program and the assistant clinic director overseeing gender-based care.Dr. Rusiecki and I discussed the article appraised in the other post today, and also discussed the issues of screening for breast cancer in women with dense breasts and breast cancer screening more generally. Dr. Rusieki and I don’t agree on everything, and you might leave more confused than you came, but I still think it is worth a listen.Some further reading:The infographic on mammography we discussed.A recent article on mammogram quandaries. 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
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  This Fortnight in Medicine XIX 11.02.2026 44min

  A Conservative Dialysis Strategy and Kidney Function Recovery in Dialysis-Requiring Acute Kidney Injury: The Liberation From Acute Dialysis (LIBERATE-D) Randomized Clinical TrialBeta-Blockers after Myocardial Infarction with Normal Ejection Fraction* Should Evidence Come with an Expiration Date? 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
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  This Fortnight in Medicine XVIII 28.01.2026 45min

  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 sensiblemedicine2022@gmail.com.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
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  Friday Reflection 56: Comments that Stuck 23.01.2026 7min

  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
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  When to treat (or not treat) a high cholesterol 18.01.2026 39min

  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
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  This Fortnight in Medicine XVII 14.01.2026 45min

  Medical Management and Revascularization for Asymptomatic Carotid StenosisVagus nerve-mediated neuroimmune modulation for rheumatoid arthritis: a pivotal randomized controlled trialWe 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