Wil Ward retweetledi
A brief reply to @Wil_Ward_ 's recent @Sensible__Med article on the cardiac defibrillator by @drjohnm
open.substack.com/pub/sensibleme…
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Wil Ward
317 posts
@AppleHelix I think I understand your question & it is worth contemplating.
John Mandrola's post in Sensible Medicine today is a better response than anything I could come up with, myself.
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@Wil_Ward_ But also consider this
Let's say there's a drug. It works for 1/3 of pts. The other 2/3, no effect. MOA is confusing
If you run a RCT, most likely it'll be negative. Does it mean the drug doesnt' work for ALL patients?
Does it mean 1/3 of anecdotes are "fake"?
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As much as I criticize @Sensible__Med, I am actually a happy subscriber.
However, contributors often have double standards when it comes to level of evidence.
- On positions that they disagree with, they point out lack of RCT that meets their personal standards.
Jing Liang 🇺🇦@AppleHelix
I don't disagree.. But this is also from @Wil_Ward_ in Aug Anectdotes... sensible-med.com/p/how-jama-psy…
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Today in @Sensible__Med, @drjohnm responds to my article and adds important context about the Wearable Cardiac Defibrillator (WCD). His post is amazing. If you are a paid subscriber, please read. If not, I recommend you become one!
Should the WCD still be used, even though it failed a clinical trial? I think John's argument for limited use despite VEST makes a lot of sense.
It is an honor to write for @Sensible__Med. An even bigger honor to receive this response from @drjohnm, who I consider one of the most important thinkers and writers in medicine.
He improves my thinking every week on Sensible Medicine. And this week, he did it twice 🙏
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Wil Ward retweetledi
Wil Ward retweetledi
I was excited to read this submission to @Sensible__Med from @Wil_Ward_ on anecdote not being data.
Then I got even more excited because it used the wearable cardiac defibrillator and VEST trial as an example.
Superb. Superb. Please do read
sensible-med.com/p/i-see-it-wor…
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You raise an important point.
This is the distinction I see: LifeVest is defended using anecdotal evidence, even though we DO have clinical trial data suggesting it is less effective than is believed.
Regarding antidepressants, I agree that anecdotes aren't decisive evidence of withdrawal. My concern was that a meta-analysis of short duration trials (Kalfas et al) concluded withdrawal is always mild. But long term users are NOT well represented by available data. This, plus the fact that long term users anecdotally report debilitating symptoms, we should do more and better trials that actually include these people.
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- On positions they agree with, they're fine w/ anecdotes. And point out why trial data that disagrees with their position is flawed.
Not that there is anything wrong with this mental model. But lets drop the "holier-than-thou" attitude.
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Wil Ward retweetledi
Wow! Not one, 2 @JCO_ASCO articles in less than 2 months "defending" adjuvant CDK4/6 inhibitors in patients with early breast cancer!
Parlty in response of our works @vkprasadlab
Stakes are high, up to 40% of patients with newly diagnosed breast cancer could be eligible.
👉For an alternative perspective on the data, see The Oncology Shot !
(+ more on that topic soon, stay tuned)
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Wil Ward retweetledi
One of my best friends was a superb primary care physician. The stresses outlined in this excellent piece are why she elected to retire early. @adamcifu sensible-med.com/p/concierge-me…
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LAMP results are implausible. The effect size is larger than I would expect (RRR 44%). How could a medicine meant to affect metabolic health over months and years exclusively produce benefit in the first 30 days!?
We need a placebo-controlled trial before changing practice.
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Are GLP1s the next big thing in secondary stroke prevention? This RCT (LAMP) randomized participants with type 2 diabetes and recent stroke to either liraglutide or "control".
The trial design and supplemental materials leave me unconvinced.
jamanetwork.com/journals/jamai…
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Critical letter in JAMA Psychiatry responding to Kalfas et al.
The meta-analysis concluded no link between treatment duration and withdrawal severity, but relied almost entirely on 8-12 week trials. This overlooked the real issue: long-term use.
Glad to see this published.
Michael P. Hengartner, PhD@HengartnerMP
My letter with @ReadReadj and @PloederlM has now been published in JAMA Psychiatry. We comment on the meta-analysis by Kalfas et al, which concluded that withdrawal reactions from antidepressants are rare and transient and thus of no clinical relevance. jamanetwork.com/journals/jamap…
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Wil Ward retweetledi
fascinating trial from 18 public hospitals in Kenya!
Steroids work
safe to say its driven by severe CAP with hypoxia
Rare example where the subgroup analysis is very helpful
there is prior evidence of benefit if hypoxic & on oxygen vs not
Not flukish
NEJM@NEJM
Presented at #LIVES2025: In a pragmatic trial conducted in general medical wards with limited diagnostic and therapeutic resources in Kenya, glucocorticoids reduced mortality in patients with community-acquired pneumonia. Full trial results: nej.md/47glh02 Editorial: Glucocorticoids for Pneumonia in Africa — Old Therapy, New Context nej.md/4qgjdxH
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Just referring to John Mandrola's article, the evidence supporting left atrial appendage occlusion, screening colonoscopy, and sacubitril-valsartan is bad. But these interventions are heralded as standard of care.
Ultimately, the burden of proof is on the physicians making recs to patients to ensure an evidence-based approach.
This doesn't mean that guideline writers should serve no role in medicine. Rather, they should clearly delineate the limits of scientific knowledge and refrain from making recommendations where scant evidence exists.
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@aclong111 @drjohnm @Coronary4front @gbiondizoccai Which clinical guidelines are perfect Ann?
The CVS guidelines certainly aren't.
jamanetwork.com/journals/jama/… via @fanaroff et al @Wil_Ward_
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What @drjohnm sees is that doctors simply accept what guideline writers put into those colored boxes: Which would b fine if guidelines were written by neutral Martians free of dualities of interests. But that’s not the case
open.substack.com/pub/johnmandro… @Coronary4front @gbiondizoccai
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It is disturbing that when explaining an intervention, it is typical for physicians with decades of experience to defend it with mechanistic or guideline-centered thinking.
When pressed for evidence, few can provide it.
@drjohnm is right. We must do better as a profession.
Ash Paul@pash22
What @drjohnm sees is that doctors simply accept what guideline writers put into those colored boxes: Which would b fine if guidelines were written by neutral Martians free of dualities of interests. But that’s not the case open.substack.com/pub/johnmandro… @Coronary4front @gbiondizoccai
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