Sensible Medicine

Professor Jeffrey Flier is a distinguished service professor and Higginson Professor of Physiology and Medicine at Harvard Medical School. He is the former dean of Harvard Medical School. We talked about the recent (and sudden) change in NIH funding. First a note on Professor Flier. He is not a normal medical school dean. He is active online. He speaks candidly, often critically. He and Vinay wrote together in STAT news during the pandemic. It was a great honor to talk with him for 47 minutes about the NIH news. Here is the Tweet that went crazy viral Friday afternoon. I had only a superficial understanding of grant funding. It turns out that every time a scientist earns an award, the institution receives extra funding known as indirect costs. The extra funds are given to support the infrastructure of the research center. Weirdly, as you will hear, some of the biggest research centers earn the highest percentages of indirect funds. The controversy stems from the sudden and massive cut in these indirect costs. It is an understatement to call the online reaction polarized. It was totally utterly hyper-polarized. Here is Elon Musk. Richard EbrightThere is absolutely no defensible basis for non-uniform indirect cost rates and absolutely no defensible basis for >=60% indirect costs. The previous system was a colossal fraud.Micheal Eisen It’s like saying you’re going to save money on a football team by cutting all the linemen.Anil Makam Whoa. Better accountability was needed where these expenses went, but this is draconian cut. Many institutions will struggle to support scientific infrastructure.C. Michael Gibson Woah…The government used to pay academic institutions 60% + on top of the costs of research grant to cover “Indirect costs.” That number just dropped to 15%. The viability of US academic medical centers & research is at risk.And of course Vinay Prasad, who also wrote Ten Things to Know about the NIH change. Good! This was the greatest slush fund ever created. It made researchers with NIH dollars invincible. Universities shielding them at all costs, even when research was fraudulent. This money was used to support initiatives, which Americans rejected, like DEI training & admin bloat.Sensible Medicine is a reader-supported publication. This is a free post but please consider becoming a paid subscriber as we aim to remain free of advertising support Here are some quotes I received via email from unnamed NIH funded researchers: A lot of the indirects go to admins who are increasingly important for grant submission process because it is unnecessarily cumbersome. I've been on 3 NIH funded grants. All from the same team. Each one was sillier than the prior.Another person—from the Southern US I submitted an R01 a few months ago and it’s difficult to navigate everything alone without admin support. The process for grant submission could be improved a lot And there should be more focus on important questions and more clinical trials.Another—from the MidwestUnless I wanted to study goofy BS, I realized my chances were hopeless. So the only other option was to stay and truly advance in the academy was to align with industry. And yet another from the MidwestThis overhead reduction is long overdue. Universities have been eating at the free buffet for a long time. They will, however, quickly figure out ways to take money away from researchers. I expect that lab space rent, personnel fees, and supply costs that the universities charge the investigators will become much higher in the coming year.Lastly, the US government wants to keep the additional indirect costs, I get that. Universities will find ways to bridge the gap by taking more money from investigators. The initial pain will be at the administrator level, but early investigators will bear the brunt of this in the coming 1-2 years. It's not a great time to be in academic medicine, esp as an investigator reliant on grants. Thank you for your support. Thank you Professor Flier. JMM 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 are back with a riveting discussion 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 recently recorded a conversation with Michael Easter from the TWO/PERCENT, a Substack and podcast. Michael offers “practical, accurate, and useful health, performance, and mindset information,” and in a space where there is a lot of drive, I find him remarkably thoughtful.Our conversation is on the podcast feed. Below are my notes for our conversation with links to many of the things we discussed.Adam Cifu, MDSensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber.I am skeptical of wellness celebrities and influencers. They annoy me because they tend to pick, choose and extrapolate data to fit their agenda. Because good medical advice is mostly personal and boring, many influencers cross over to data-free sensationalism to hold an audience.Michael Easter is a rare exception. On the TWO/PERCENT he somehow manages to be a sane, thoughtful – I might even say Sensible – health personality. I got to know Michael when he invited me to be on his podcast to talk about my article on the cult of the healthy lifestyle. Before talking to him, I dove into a bunch of Michael’s work and was impressed by its quality. I should have known that a person who would invite someone who had come out against the healthy lifestyle on his show dedicated to the healthy lifestyle was someone I’d like.My Questions:For people who don’t already follow you, tell me about the 2%. Where does that come from and how to you extrapolate its meaning?* Tell me a bit about yourself, how did you end up here?* In my intro, I mentioned that I think you are a rational “health influencer.” How have you managed this?* Is it a challenge to keep things fresh while telling people to stay active, eat less, and don’t do stupid things?* How do you see the balance of educating and inspiring?I wanted to talk to you about a couple of recent posts that I thought epitomized your approach.The benefits of silence was a post about introducing silence into your life. This is something that really doesn’t need data, but you went deep into the data, and then acknowledged how aware you are of the possible confounding. (People’s whose houses are on loud streets die earlier. That might be the noise but they are also poorer and are exposed to more particulate air pollution…).* What got you interested in that topic?The downsides of blood tests and full-body MRIsThis was a discussion with Dr. Bobby Dubois about the potential benefits and harms of screening tests. I’ve written a ton about this, but I was so impressed with the clarity of the conversation and, although you guys came out pretty negative on the topic, you were honest about the potential benefits and the reasons people find these attractive.* You seem to have a lot of respect for the audience. 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

Doctors often get credit (or blame) for having to make difficult, life-and-death decisions. But really, it is all of us, when we are patients, who make the bravest decisions that carry the highest stakes. 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 have long followed the work of Dr. Margaret McCartney. She is a general practitioner in Glasgow, Scotland, writer, public speaker, and now PhD. She is a fierce advocate for evidence-based medicine. She holds highly skeptical views of screening for disease—which, to my surprise is quite common in the UK. Her recently finished PhD sought empirical evidence regarding declaration of conflicts of interest in the UK. Here is a link to the document. Screening for atrial fibrillation is a focus of this work. Here is a link to her PubMed listing. We had a nice conversation about all things evidence and conflicts. I learned a lot about the health system in the UK. As an added bonus, Dr. M is also an avid cyclist. As always, thank you for your support of Sensible Medicine. This support allows us to bring medical content free of industry advertising. JMM Sensible Medicine is a reader-supported publication. To receive new posts and support 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

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 had the pleasure of being interviewed by Michael Easter. Michael is behind the TWO/PERCENT Substack where he offers “practical, accurate, and useful health, performance, and mindset information.” I’ve listened to, and read, a bunch of Michael’s content. Not only is it enjoyable but it seems, well, sensible. Our conversation was inspired by my Coming Out Against the Healthy Lifestyle post. I hope you enjoy our conversation and maybe find another substack to follow.Adam CifuSensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber.Our conversation covers:* Why Adam wrote the post and the rise of the cult of the healthy lifestyle.* The benefits, realities, and limits of adopting healthy lifestyle changes.* How the belief that all health can be improved with better diet and exercise can lead patients to wrongly believe they are responsible for all of their health issues.* Why criticism of modern medicine is on the rise.* How “medical reversal” highlights the need for evidence-based practices.* The rise of longevity and why many longevity practices often lack robust evidence.* Why personalized healthcare is essential for effective treatment.* Problems with over-medicalization.* How finding the right doctor can be a challenging process. 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

What does our philosophy have to do with RFK Jr and MAHA? 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

4 mistakes people make in systematic reviews 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

The woman with palpitations.The man with whom you used to joke and trade barbs who now sits silently, absent, while you talk to his wife.The woman whose depression dominates every visit; her depression being the one problem she refuses to address.The man whose joy and charisma makes every visit an absolute pleasure, despite his painful disability about which you can really do nothing.The man who never complains. Well, not never. The two times he did complain he ended up with emergent bypass surgery and a diagnosis of acute myeloid leukemia.The woman whose concerns are always uninterpretable. You wonder if the problem is your lack of cultural competence, that her language skills prevent her from articulating her problem, or maybe that her ineloquence keeps her from even knowing what she is experiencing.The woman who asks how you are doing because she recognizes that caring for her, with her dreadful prognosis, is hard.The man who, forever unsatisfied with his health, never accepts your advice, dismisses consultants, yet never misses a visit, praises you as the greatest doctor, and brags about you to his friends.The man whose world is spinning.The healthy 27 year old who is sure that her tension headaches are from a brain tumor.The man who berates the front desk staff, makes inappropriate remarks to the medical assistant, and has made racist comments to your nurse, but in the exam room – alone with you -- is the perfect gentleman.The man who laughs when you pull down his sock to examine his edema and a wad of cash and a dime bag of cocaine fall on the floor.The 75-year-old daughter who accompanies her 95-year-old mother to visits. You know that the older woman’s death will liberate and devastate the younger woman.The man who always exaggerates his symptoms because he is terrified by his own mortality and worries that he won’t be taken seriously.The woman who seemed impossible when you first met her but now brings you joy when the urgent care doctor calls and asks, “How have you taken care of this lady for 15 years?”The woman who doesn’t seem to like you and never seems to trust your opinion but, after 20 years, refers her daughter to you.The woman with six years of dyspnea and no diagnosis.The man you agree to see after he was “fired” by a colleague. His care, and your relationship with him, become an inspiring, and even rewarding challenge. He fires you after a year.The woman whose relapses, lies, and prescription forgeries angered and exhausted you for a decade now sits in a wheelchair, caregiver by her side, vacant.The woman who comes to see you for a new patient visit because her husband, your former patient, insisted that she start seeing you after he died.The man who hanged himself three weeks after he saw you. He had complained of fatigue.The man who apologizes because he sees it has been difficult for you to give him the news about his recent scan.The woman with painless jaundice.The patient who fires you, deservedly, because you made a rookie mistake.The man who brightens your day when you see him on the schedule but honestly, if you didn’t know him, you would probably move to the next train car if he got on.The patient you secretly hoped would change doctors and then, when she does, you feel bad that you failed her.The man who steps off the scale, places a thick wallet, two rings of keys, and a Glock on the exam table before getting back on the scale.The man who wrote a thank you note that he had his wife mail to you after his death.The man who fought you until the end, always wanting more treatment, even after every doctor told him we had nothing left to offer.The woman whose diagnosis you could never make, until you got a pretty good idea of it ten years after she died.The man who just has a cold. 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

This podcast is one of three we will be posting to answer the questions that came to us in response to this post. We had a nice set of questions so we will certainly be doing it again. 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 learned a lot from Elizabeth Fama’s multipart series on the back-to-sleep recommendation for infants. She agreed to put the entire series into an audio file. Here you go. JMM Sensible Medicine is a reader-supported publication. To receive new posts and support 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

Ask general internists what they love about their field, and they are likely to talk about long-term relationships with patients and the pleasure of solving clinical puzzles.  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

My lecture to the cancer care staff at a county hospital. 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

Even when a decision is clear, and things turn out badly, the lack of a counterfactual allows endless second guessing. 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 discuss how medical students are selected, and perhaps how they should be selected. 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

Remarks about a model clinician. 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