3 ms·

Yup, you're an adult, you make up your own mind. If you're in my office and I recommend a medication that you decide not to accept I'm not going to twist your

Yup, you're an adult, you make up your own mind. If you're in my office and I recommend a medication that you decide not to accept I'm not going to twist your arm to take it. I might take calculated risks and do things myself, but when there are unknown risks due to utter lack of knowledge, you're right I wouldn't advise it for others. In my role trustworthiness is everything, it simply is wrong to do things that violate patients' trust. So true I won't take unnecessary chances with their health and well-being. Not my job to defend conduct of others of decades ago. I could argue with your comment about "overprescribing", but really I see no point debating non-issues. Discussion only means something when based on facts, IOW it always comes down to specifics, not squishy generalities.

recuter 5y ago
I don't know how one can reasonably weigh between a medicine with known risks (and plausibly unknown risks!) and the unknown risks of something like psychedelics, which are not yet understood at all but anecdotatlly appear to potentially have a very high reward/risk ratio. Shrooms is not cocaine, you can't OD on the stuff. That is not to say it can't cause other types of damage. Not prescribing anything at all might be the safest course of action. And here you also say that unlike the advice you give your patients you might decide differently when it comes to yourself. > Not my job to defend conduct of others of decades ago. I'm not saying this judgmentally, there doesn't seem to be an obvious way to reconcile all these things. Your predecessors clearly also meant the best and gave the most prudent advice they could at the time. This is something to factor into the risk profile. The most trust worthy thing to do is admit that there are limits to our knowledge. But I understand why you would hesitate to provide this asterisk with your advice as a lot of people will take it poorly and rush to webmd and homeopaths as a result.
- jrapdx3 5y ago
  Appreciate the thoughtful comment. > I don't know how one can reasonably weigh between a medicine with known risks (and plausibly unknown risks!) and the unknown risks of something like psychedelics, which are not yet understood at all but anecdotatlly appear to potentially have a very high reward/risk ratio. Yes, the key word in your statement is "anecdotally". Anecdotal evidence is not good enough. Need to have systematic, carefully vetted evidence documenting specific benefits and risks before it can be said the compound is understood well enough for general use. There's a process to work out drug dose/risks. A prospective treatment goes through phase 1/2/3 trials. Basically it's about discovering the characteristics of a drug, good, bad and ugly. Well, at least as much as can be discovered in the course of it. > That is not to say it can't cause other types of damage. Exactly so. Hallucinogens can be bad for people with predisposition to psychosis, mania, panic attacks, dissociation. That's maybe ~3% of the total population. People may not know or care if they're at risk, so it can be a problem. > And here you also say that unlike the advice you give your patients you might decide differently when it comes to yourself. What I mean is that I have an obligation, taken an oath, that I won't knowingly expose patients to unnecessary risks of harm. It's always about having evidence that benefits exceed risk. It's a judgement call to be sure. In any case everything is done under full disclosure and consent. I might be willing to take on a risk myself with less sure evidence of benefit than I could justify recommending to patients. There I have a higher burden of proof to meet. IOW I can experiment on myself but I won't experiment on others who might go along with it just because they trust me. > The most trust worthy thing to do is admit that there are limits to our knowledge. Fully agree and any trustworthy person would say "I don't know" when in fact one doesn't know something. When it comes to human knowledge it's always limited. For one thing we can't know what is unknowable, capabilities are constrained by our neurophysiological construction. I'm OK with saying so when I don't know. It happens a lot. One more point. It's true past practices in medicine are troubling to us now. I have qualms about certain things being done now. But cultures evolve, ideas of what's acceptable and not change. Applying today's ideas of standards to prior generations is likely to lead to a negative judgement, but is that a fair appraisal of our predecessors? If we take a hard, critical look at our own time, and think about how some contemporary practices (not just in medicine) will be viewed by people 100 years from now, really what will they think of us? Plenty of current things would qualify, but it's hard for us to see them that way. Culture is invisible to the people embedded it it.

recuter 5y ago

I don't know how one can reasonably weigh between a medicine with known risks (and plausibly unknown risks!) and the unknown risks of something like psychedelics, which are not yet understood at all but anecdotatlly appear to potentially have a very high reward/risk ratio. Shrooms is not cocaine, you can't OD on the stuff. That is not to say it can't cause other types of damage. Not prescribing anything at all might be the safest course of action. And here you also say that unlike the advice you give your patients you might decide differently when it comes to yourself. > Not my job to defend conduct of others of decades ago. I'm not saying this judgmentally, there doesn't seem to be an obvious way to reconcile all these things. Your predecessors clearly also meant the best and gave the most prudent advice they could at the time. This is something to factor into the risk profile. The most trust worthy thing to do is admit that there are limits to our knowledge. But I understand why you would hesitate to provide this asterisk with your advice as a lot of people will take it poorly and rush to webmd and homeopaths as a result.

jrapdx3 5y ago
Appreciate the thoughtful comment. > I don't know how one can reasonably weigh between a medicine with known risks (and plausibly unknown risks!) and the unknown risks of something like psychedelics, which are not yet understood at all but anecdotatlly appear to potentially have a very high reward/risk ratio. Yes, the key word in your statement is "anecdotally". Anecdotal evidence is not good enough. Need to have systematic, carefully vetted evidence documenting specific benefits and risks before it can be said the compound is understood well enough for general use. There's a process to work out drug dose/risks. A prospective treatment goes through phase 1/2/3 trials. Basically it's about discovering the characteristics of a drug, good, bad and ugly. Well, at least as much as can be discovered in the course of it. > That is not to say it can't cause other types of damage. Exactly so. Hallucinogens can be bad for people with predisposition to psychosis, mania, panic attacks, dissociation. That's maybe ~3% of the total population. People may not know or care if they're at risk, so it can be a problem. > And here you also say that unlike the advice you give your patients you might decide differently when it comes to yourself. What I mean is that I have an obligation, taken an oath, that I won't knowingly expose patients to unnecessary risks of harm. It's always about having evidence that benefits exceed risk. It's a judgement call to be sure. In any case everything is done under full disclosure and consent. I might be willing to take on a risk myself with less sure evidence of benefit than I could justify recommending to patients. There I have a higher burden of proof to meet. IOW I can experiment on myself but I won't experiment on others who might go along with it just because they trust me. > The most trust worthy thing to do is admit that there are limits to our knowledge. Fully agree and any trustworthy person would say "I don't know" when in fact one doesn't know something. When it comes to human knowledge it's always limited. For one thing we can't know what is unknowable, capabilities are constrained by our neurophysiological construction. I'm OK with saying so when I don't know. It happens a lot. One more point. It's true past practices in medicine are troubling to us now. I have qualms about certain things being done now. But cultures evolve, ideas of what's acceptable and not change. Applying today's ideas of standards to prior generations is likely to lead to a negative judgement, but is that a fair appraisal of our predecessors? If we take a hard, critical look at our own time, and think about how some contemporary practices (not just in medicine) will be viewed by people 100 years from now, really what will they think of us? Plenty of current things would qualify, but it's hard for us to see them that way. Culture is invisible to the people embedded it it.