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  • Originally posted by wideopenspaces View Post

    I guess I don't know why you'd assume the doc is otherwise unobjectionable if he's willing to prescribe a medication with no benefit at this stage of the game. Also, it takes 60-90 days to credential someone. Why does the quack get to jump the line? I don't think this is a precedent we want to set.
    This is a slippery slope. Society sets norms by making "laws". That means a standard is set and violations are subject to some type of "inconvenience", "prohibition", or "punishment". All well and good. But the mechanism is making a law, not the entities or individuals "deciding there was a violation and the appropriate action". Unless something is illegal under a law, a minority of one is perfectly legal and should have the right without having normal privileges taken away.

    Should someone have the right to a trial by jury of their peers? (Is an example)
    We now have crossed into that no-vaccination automatically disqualifies a person from jury duty. Suitable jurors are defined as "must be vaccinated".
    https://www.yahoo.com/news/judge-rul...112400273.html

    There are huge issues. Should a law be federal? Constitutional problems. Should a law be state or local and what is there is a difference between state and local? Huge differences by each state and local authorities. Should a law be left up to public and private entities? Obviously, an individual can't make a law, but they are subject to a huge potential loss of individual choice with some serious erosion or suffering consequences for which there is zero agreement or even written policies or guidelines.

    They don't have a vaccine. Is that a crime? There ought to be a law. Unfortunately our political process had not reached a conclusion. Anyone in a position of authority can make a rule and decide the punishment. At the same time, the individual is being found guilty, without a law and punished.

    The fact is "guilty" is by mandate for which there is no crime or damage, just it might happen (a future unintentional event) is defined as a violation of law, mandate or policy. Making a future result illegal is the question of law.

    Tobacco, alcohol and marijuana are other example that the principal involved is a slippery slope. We tried prohibition. It this the path that will fit our society?
    The current course is unequal interpretation and enforcement. Each situation is "this time is different" because of the authority making the rules and decisions.
    That is not "equal protection under the law".

    My concern is the political influence for political reasons, not for the health or protection of citizens. If nothing more, the two FDA resignations give me pause for concern that political power is on "recommendations" or mandates rather than creating laws through the legal process. We just are not there yet,






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    • CordMcNally, do you think willingness to "pick your battles" varies by clinical setting?

      Inpatient treatment and ER are pretty different from my perspective. I may be wrong but as an ER doc you can lay down the law and in less than 24 hours you're done with the patient regardless, but in other settings the physician may need to pick battles to retain the patient's buy-in for treatment such as when working on a suicide safety plan, engaging with PT/OT/SLP, not leaving AMA (which admin hates and leads to higher rates of readmission; it's not innocuous).
      Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, continues to be a common and vexing problem. This article reviews the prevalence, costs, predictors, and potential ...

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      • Originally posted by CordMcNally View Post

        Is this honestly a realistic scenario you see on a routine basis? I'm somewhat shocked at your reasoning for prescribing them unindicated medications. If they were on inappropriate psych medications (not prescribed by you) would you continue them as inpatient? As I tell many of my patients, I can't control what other physicians do but I can control what I do.
        It really depends on what the goal of the hospital stay is and if there’s a possibility of getting a buy in from the patient’s outside physician. I don’t as a matter of course try to taper someone off of benzodiazepines which they’ve taken for years unless I know their primary psychiatrist or PCP is on board. Obviously if someone is shooting heroin they’re not getting restarted on their Percocet. I know that technically my name is on the medicine and I’m “prescribing” the medicine, but I rationalize to myself that I’m just continuing something I don’t agree with for a few days rather than really making the decision to prescribe it myself.

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        • Originally posted by CordMcNally View Post

          I get what whoever put this graph out is trying to prove but this is likely a very deceiving graph for multiple reasons.
          Are there really counties that have 0-10% and 90-100% voting for one or the other? That alone makes the data suspect to me.

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          • Originally posted by Lordosis View Post

            Are there really counties that have 0-10% and 90-100% voting for one or the other? That alone makes the data suspect to me.
            There are many small rural counties that voted at least 90% for Trump but these counties typically only have a few thousand votes at most. It looks like there were a handful of counties that went the other way, too.

            An Extremely Detailed Map of the 2020 Election Results: Trump vs. Biden - The New York Times (nytimes.com)

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            • Originally posted by G View Post

              AR, I get what you are saying, but I'm weary of the "customer is always right" medicine. A) If they had gotten vaccinated, they probably wouldnt even be in hospital. B) If the doctor is such a superstar, he should at least be on the medical staff of a real hospital with other real doctors. C) Words (or in this instance, malpractice) matter.
              This isn't really customer is always right. I'm also not convinced that giving ivermectin in addition to standard therapy is "malpractice". I'm pretty sure zero docs have lost their licenses for prescribing Ivermectin for COVID and zero will.

              The prescribing doc in this case could point you some articles that show some questionable benefit. He could say that he has experience giving to X patients with good results. Sure, he could publish it but it will be too late for this patient by then. Also the drug is is really quite safe.

              So in this case we have a patient requesting a therapy that another fully licensed doc recommends and the patient is in a predicament where they can't just go see that doc somewhere else. Also the risk of harm is very, very low.

              Like I said, I'd still fight it myself. So we're definitely in agreement on that. I guess the only difference is that I wouldn't feel quite as bad about losing as you would.
              Last edited by AR; 09-03-2021, 09:41 AM.

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              • Originally posted by wideopenspaces View Post

                I guess I don't know why you'd assume the doc is otherwise unobjectionable if he's willing to prescribe a medication with no benefit at this stage of the game. Also, it takes 60-90 days to credential someone. Why does the quack get to jump the line? I don't think this is a precedent we want to set.
                To reiterate, I'm not in support of this at all, but I'll play devil's advocate.

                In reporting where the doc is mentioned, it's easy to look up to see if they have any complaints with their state medical board. I did that a couple of times and came up empty. Also there is pretty much no one is going to lose their license over prescribing ivermectin for COVID. It is not even close to meeting the threshold for license-losing malpractice. Docs do non-standard, unconventional stuff all the time. If docs lost their license for doing something with little to no literature support, we would have a lot fewer licensed docs.

                Also, there is some scant evidence of ivermectin doing a bit of good. It's not great evidence, imo. But it's published and it exists.

                The reason why the "quack jumps the line" is because you have a unique situation where the patient cannot wait and presumably the patient can't be moved elsewhere.

                I agree that it is a precedent we don't want to set. And that is one of the reasons I'd fight it. All I'm saying is that if I lost, I wouldn't feel terrible. I am very strongly in support of patients doing whatever they want (even stupid things) with their bodies as long as they are fully informed. In this case, the injury to the hospital (credentialing a doc who is willing to provide that care) is pretty minimal in a vacuum. So I can understand why a judge would rule the way they did. And I wouldn't like it, but I wouldn't feel that terrible about it.


                Once again, I'm not an ivermectin advocate. I just want to be clear on that.

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                • Originally posted by Jaqen Haghar MD View Post

                  Of course they are cherry picking the data out of political motivations. You could also invert the graph during previous waves when the Northeastern US had higher mortality than the south, but I doubt that came up from whoever created that graph. This country is honestly sick with politics from both sides. Extreme fringe elements on both ends drive the narratives.
                  Do you have some links handy to these inverted graphs? I would be very interested in them.

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                  • I guess ivermectin is less harmful than hydroxychloroquine? So maybe the trick is to spread misinformation about things that are possibly good for patients anyway. Hopefully after the ivermectin craze is over, someone will start hyping fish oil.

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                    • Originally posted by AR View Post

                      This isn't really customer is always right. I'm also not convinced that giving ivermectin in addition to standard therapy is "malpractice". I'm pretty sure zero docs have lost their licenses for prescribing Ivermectin for COVID and zero will.

                      The prescribing doc in this case could point you some articles that show some questionable benefit. He could say that he has experience giving to X patients with good results. Sure, he could publish it but it will be too late for this patient by then. Also the drug is is really quite safe.

                      So in this case we have a patient requesting a therapy that another fully licensed doc recommends and the patient is in a predicament where they can't just go see that doc somewhere else. Also the risk of harm is very, very low.

                      Like I said, I'd still fight it myself. So we're definitely in agreement on that.
                      Some may see this as a rather dramatic argument from myself and maybe it is but if you're not practicing good medicine then why are you a doctor? Seriously. This isn't directed at you, in particular, but the entire physician community. If you can't stand up for practicing good medicine against a minority of physicians and any administrators that want to question your practice (and for the patient's benefit) then I question what you're doing. Try going into the C-suite and telling them how they should be running the hospital as a business. See if they incorporate your ideas. I doubt they do. This is one of many reasons why we are proving ourselves to be replaceable by those lesser trained. You're (the collective you) a physician so stand up for yourself and start acting like it.

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                      • Originally posted by G View Post

                        Well, I no longer sit on C&P, but I guarantee you that I would not be strong-armed to credential a quack and I guarantee you that a judge will not strong-arm me to practice poor medicine. If this is non-fiction, it is yet another demonstration of the complete castration of the medical staff.
                        Or, more than a few quacks on staff which is much more likely.

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                        • Originally posted by CordMcNally View Post

                          Some may see this as a rather dramatic argument from myself and maybe it is but if you're not practicing good medicine then why are you a doctor? Seriously. This isn't directed at you, in particular, but the entire physician community. If you can't stand up for practicing good medicine against a minority of physicians and any administrators that want to question your practice (and for the patient's benefit) then I question what you're doing. Try going into the C-suite and telling them how they should be running the hospital as a business. See if they incorporate your ideas. I doubt they do. This is one of many reasons why we are proving ourselves to be replaceable by those lesser trained. You're (the collective you) a physician so stand up for yourself and start acting like it.
                          I'll start with the standard disclaimer that I'm not a supporter of ivermectin use in COVID.

                          I'm not sure any of above (which I agree with) has anything to do with the matter at hand.

                          Obviously these ivermectin prescribers think they're practicing good medicine. The thought process could very easily be something like "Well the risk of harm of Ivermectin is very close to zero, and based on this study I read the risk of benefit is also close to zero, but still an order of magnitude higher than the risk of harm, so giving it is probably a reasonable thing to try. Especially if the patient receives otherwise standard care."

                          To be honest, on occasion, I've had similar thought processes when recommending other treatments to patients. I'd be surprised if most docs haven't.

                          Once again, I'm not a supporter of ivermectin use in COVID.

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                          • Cant see the graph for what people are talking about but given context I think its actually very important and indicative. There is no way an area that had prior warning, testing, was locked down before spread should allow themselves to catch up to a place that was caught flat footed with zero tests, treatments, and one of the most densely populated heavy public transport etc...especially when they had a vaccine available for almost a years time.

                            Its just plain failure.

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                            • Originally posted by AR View Post

                              I'll start with the standard disclaimer that I'm not a supporter of ivermectin use in COVID.

                              I'm not sure any of above (which I agree with) has anything to do with the matter at hand.

                              Obviously these ivermectin prescribers think they're practicing good medicine. The thought process could very easily be something like "Well the risk of harm of Ivermectin is very close to zero, and based on this study I read the risk of benefit is also close to zero, but still an order of magnitude higher than the risk of harm, so giving it is probably a reasonable thing to try. Especially if the patient receives otherwise standard care."

                              To be honest, on occasion, I've had similar thought processes when recommending other treatments to patients. I'd be surprised if most docs haven't.

                              Once again, I'm not a supporter of ivermectin use in COVID.
                              The difference with other medicines we may use without significant risks and benefits is that we don't have multiple professional groups, government groups, and the manufacturers of those medications coming out and explicitly saying don't use that particular medicine like we have with ivermectin. With that said, if we get good data that shows clinically useful benefits then I'll be happy to change my stance.

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                              • Originally posted by CordMcNally View Post

                                The difference with other medicines we may use without significant risks and benefits is that we don't have multiple professional groups, government groups, and the manufacturers of those medications coming out and explicitly saying don't use that particular medicine like we have with ivermectin. With that said, if we get good data that shows clinically useful benefits then I'll be happy to change my stance.
                                I don't think that's really different at all. For many non-standard therapies, you will generally find mountains of evidence and practice guidelines recommending against them. Yet some docs will still prescribe them. The only difference is that there is more media coverage with ivermectin (for obvious reasons). I don't think the amount of media coverage something gets should inform us on how to practice at all.

                                To reiterate, I don't support the use of ivermectin in COVID.

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