Wisdom…

…the quality of having experience, knowledge, and good judgment.

I read today a collection of words that exude wisdom. I share it with you because the purpose of this blog is to do create value through education.

Peggy Girshman was an award-winning health journalist. When ill with a life-limiting illness, she wrote her own eulogy. NPR published it today after her death.

Must-read is an overused phrase, but it modifies perfectly her words. Here are a few excerpts, with my thoughts.

Work-Life Balance: Though Girshman wished she could have worked longer, “to convince someone I was right,” she also wished she had divided her life to spend more time with her family. That one is hard to see in real time, isn’t it?

Low-grade Cancers: To “folks” with Stage 0 or less cancers, especially DCIS (ductal carcinoma in situ), or prostate cancer, Girshman advised resisting the “get it out of me” temptation. Why? Because approximately half don’t go on to become invasive cancers, and “you shouldn’t do all kinds of bad things to your body unnecessarily.”

I’m no oncologist, but I know this: medical care comes with both benefit and harm. We are doing a better job these days of explaining both–but the best medical decision happens when fear and ignorance are removed. (Credit there goes to Harlan Krumholz.) Most of what I do in a heart rhythm clinic is fear extraction.

Burden of Care: To women, Girshman warned that “breast conserving” surgery does not conserve the breast. And radiation therapy was the “biggest mistake of her life.”

Here, hindsight is sharp, but doctors can surely do a better job of painting a more honest picture of the burden of healthcare. LifeVest, and AF ablation come to mind in cardiology. Daily pills, too, come with significant burden.

Evidence: Though John Oliver will get more press, Girshman speaks passionately about evidence. Beware of anecdote and trust the scientific method, she advises. “Belief is powerful The placebo effect exists.”

The older I get the more this resonates with me. Drs. Vinay Prasad and Adam Cifu have written a masterful book on evidence, one that has changed my approach to patient care and critical appraisal of science. Go read Ending Medical Reversals; you won’t be disappointed.

Lifestyle: Girshman says…”please stop with the lifestyle advice…Don’t knock people about what they’re eating, how much and when.” Of course, she argues, everyone knows eating real food, and less of it, will lower one’s chances of getting disease. But Girshman wisely suggests convincing yourself that “people get sick for so many reasons that we don’t know about. One little mutation in one little cell.”

She asks us to stop judging people about the healthiness of their lifestyle. For instance, never ask someone with lung cancer if they smoked. Don’t even think it, she advises. You might leave cyclists without helmets alone too.

Of all my changes in thinking in the last half decade, none has been more profound than giving lifestyle advice.

Girshman’s stance makes me want to stand and cheer. I remain a fierce advocate for good health through good choices, and I believe nutrition, exercise and sleep are the most potent medicine, especially for heart rhythm disorders like AF, but healthcare people overstep their bounds when they delve into population health. A society’s health comes from good education, social supports, safety, available healthy food and walkable neighborhoods–not preachy doctors, vascular screening, mobile mammography and the like.

When I see an obese patient with AF, I frame weight loss as a potent anti-arrhythmic treatment. When I see an obese patient with high blood pressure, I tell her exercise and calorie restriction will beat any pill. But when I see an obese person with no medical problems, I do my best to advise them about the benefits of lifestyle choices, but I’m not their mother. I’m a mere advisor, and a damn imperfect one at that. Ask my wife and kids, or the guy serving burgers at my hospital.

A short book changed my view of public health. You should think twice before reading Petr Skrabanek’s The Death of Humane Medicine. Unseeing will not be possible.

JMM

3 comments

  1. Dr. John: I keep thinking about the statement that ductal carcinoma in situ does not have to be removed… because I don’t understand that thinking. I don’t think this is a “duct half full” or “duct half empty” view on cancer. If you have cancer and there is a 50% chance it will spread, isn’t that worth treating with surgery? Removing it improves prognosis and lessens the chance for invasive cancer or metastatic cancer, right? Since my wife was diagnosed with breast cancer, I have decided my asymptomatic afib is a disease/condition for babies. I take my Pradaxa, Bystolic, and vitamins and exercise freely. I feel great and I got my weight down to my cross country team weight. I’m 67. Now my knees hurt a little… but then I’m a big baby. -Pete

  2. This resonates.

    Recently on Medscape, there was a lively discussion regarding allowing terminally ill patients in hospice to have wine with dinner. Some doctors were indignantly opposed, claiming the wine would lead to “addiction” and a myriad collection of other evils, completely disregarding the humanity and dignity that a terminally ill patient should experience. Unreal!

    On a related note, I watched a woman in her 90s at my mom’s assisted living facility sobbing because she was denied the holiday dinner the rest of her companions were enjoying because her doctor was “worried about her cholesterol”. The ham, dressing, mashed potatoes and pie were forbidden, and she was served a miserable tasteless naked piece of skinless chicken, and a horrid little iceberg lettuce salad instead. That experience formed a lasting impression on me regarding medicine and common sense.

  3. I am so sorry to hear the sad news of Peggy Girshman’s death. What a brave lady. I too regret having radiation therapy for my early stage breast cancer as I have serious side effects now, including AFIB.

    Thank you for posting this article.

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