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Living thread of lessons learned after attempting primary care academic medicine since 2013--🧵
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Caspian Kuma Folmsbee MD
1.2K posts
Caspian Kuma Folmsbee MD
@FolmsbeeMD
internist - primary care - assistant professor | - (Salary 233k + RVU bonus) - no other COI
เข้าร่วม Haziran 2009
375 กำลังติดตาม305 ผู้ติดตาม
“The best medicine is the one they will take”—a phrase that runs counter to shared decision making.
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”A jack of all trades is a master of none, but oftentimes better than a master of one."
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Living thread of lessons learned after attempting primary care academic medicine since 2013--🧵
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Caspian Kuma Folmsbee MD รีทวีตแล้ว
2018 vs 2026 Lipid guidelines compared.
The visually striking thing is the number of recommendations made in 2026 vs. 2018 : more than 4x as many recommendations, and observational-evidence recommendations replaced RCTs as the foundation.
The COI story is interesting🧵
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AI is making us worse. Repeated bullet points. CAC point talks about meds? Do we even care what we share anymore?
Roger Blumenthal@rblument1
Great summary by ACC/AHA/Multisociety Dyslipidemia/Prevention GL ‘26
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Randomized evidence that CAC leads to more downstream investigations
pubmed.ncbi.nlm.nih.gov/36342823/
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More nuanced and low value. Perfect for AI.
Chris V MD@ChrisVMDHealth
I genuinely disagree with this. More and more nuanced management flow charts mean that we are getting closer and closer to the ideals of precision medicine: matching the right patient to the right treatment. It means our understanding of disease and risk mitigation is getting more nuanced. (Caveats here about evidence tiers for some recommendations.) Is it a pain? Sure. But that's the job.
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Publishing Class I recommendations while studies are still incomplete threatens recruitment of those studies and seeds distrust
Less-Is-More Cardiologist@DavidLBrownMD
@neeche41 @pash22 @dmljmd @venkmurthy It’s going to be very embarrassing to have to downgrade the recommendations after Corcal and ROBINSCA.
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Why does everyone assume brainstorming with an LLM is helpful? Wouldn’t it just feed you other people’s ideas and limit your own creativity?
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Caspian Kuma Folmsbee MD รีทวีตแล้ว
The end caps of my local grocery store. We are cooked.
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How about restricting its use to primary care only…
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@AnilMakam @hswapnil @kidney_boy I'm all for a bigger trial, but I wonder how much the heterogeity of the disease will limit understanding, not to mention the fact that many nephrologists already wouldn't enroll patients. Equipoise feels messy in this space.
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@hswapnil @kidney_boy @FolmsbeeMD I like the trial, and I worry about the numerical differences in death
i don't think we should be so flippant about the possibility of a meaningful difference if done in a larger sample
that is the ultimate outcome
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Is #NEPHJC going to cover LIBERATE-D? Or do you think we already know the answer (less is more).
@kidney_boy @hswapnil
open.substack.com/pub/unrelentin…
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@hswapnil @kidney_boy Appreciate you taking the time to read my rant. The authors made a compelling case for superiority. @Proximal_Baxi tells me HD PRN is SoC here in humble Chicago.
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@kidney_boy @FolmsbeeMD To your Qs on the Substack
- the authors did believe in superiority - they wanted to demonstrate that the conservative arm would actually help recovery
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@kidney_boy @hswapnil Oh shoot, not sure how I missed it. Should have just read yours, its got it all. I love the bottom line point of how will this get translated into the real world
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Took a deeper dive into LIBERATE-D after listening to your episode. Less practice changing and more guideline nudging?
@adamcifu @drjohnm
open.substack.com/pub/unrelentin…
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Please share with me data that any screening negatively effects patients on the whole WITHOUT the perverse incentive to needlessly intervene
Unnecessary interventions harm patients
Not screening
Anil Makam@AnilMakam
Another reason why whole body MRIs will lead to net harm
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@drjohnm @Sensible__Med Looking forward to reading it. Choosing a primary outcome that includes # of HD sessions in a trial in which one arm gets less HD sessions? Feels just like dipping toe in the pool with the wide CI. Why not just jump in given much at stake?
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Call for experts in trial and evidence. This week on @Sensible__Med we discuss the LIBERATE D trial of conservative v conventional dialysis in AKI.
Super complicated results.
Post today. Podcast Wednesday
sensible-med.com/p/initial-impr…
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@drjohnm This study looked at aged 30-40 so incredibly low risk. 46% sounds scary but we are talking absolute risk <1%? Let’s not forget the podcast episode you just had about low risk of events.
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@RichardLehman1 @crblease Thanks. Really appreciate you taking the time. Sometimes I feel like I’m going crazy when I see what we discuss in academic circles and what actually happens in clinic.
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This truly nails it. Shared decision making is a mirage without shared understanding and a relational context.
I gave up believing it possible until the arrival of generative AI. The BMJ triadic care Analysis articles explain how it might be achievable. @crblease
Ash Paul@pash22
Shared Decision Making : Is it even possible? unrelentingebm.substack.com/p/shared-decis… via @FolmsbeeMD @RichardLehman1 @glynelwyn @CoryRohlfsen
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Caspian Kuma Folmsbee MD รีทวีตแล้ว
Shared Decision Making : Is it even possible?
unrelentingebm.substack.com/p/shared-decis… via @FolmsbeeMD @RichardLehman1 @glynelwyn @CoryRohlfsen
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