LawsOfMedicine

The Laws Of Medicine

Field Notes from an Uncertain Science

Siddhartha Mukherjee 2015 . Cedar Mill . 610.1 MUCKERJEE

• p04 Attending Dr. Castle: "It's easy to make perfect decisions with perfect information. Medicine asks you to make perfect decisions with imperfect information."

• p10 2000, SM first year of medical residency
• p12 no time to spend pocket money, spare cash by donating blood, $25/pint 2 to 3 times per month
• p12 before 1930s, no modern medicine besides some surgeries; internal medicine was placebo, palliation, and plumbing

• p12 Lewis ThomasThe Youngest Science: Notes of a Medicine-Watcher, 1983

• p13 William Osler at Johns Hopkins

• p14 Osler's students measured, not meddled or medicate

• p15 Pathophysiology platform for modern medicine

• p19 Samuel ShemThe House of God 1978 novel

  • thirteen laws of medicine: Law 12: "if the radiology resident and the intern both see a lesion on an X-ray, then the lesion cannot be there."
• p19 SM search for "laws", guiding principles, led toserious thinking about basic tenets

• p23 cachexia

• p25 "Beacon Hill scion" with scarred veins was IV drug addict with HIV
• p26 priors and perceptual biases: interpret a test in the context of prior probabilities.

• p28 prior "knowledge" (intuition!) can overcome weakness of a test

• p29 physician has patient walk, says wrong date and patient corrects. Last outing with friends? Handwriting changes? Extra socks?

  • screening for depression, anxiety, sleeplessness, sexual disfunction, neuropath, and other sequelae of her illness

• p33 Bayesian reasoning modifies input probability, without that most tests are useless or harmful

• p33 without priors, "screening" PSA tests do more harm than good
• p35 without infinite resources and perfect tests, no "screen for everything" without history and inference
• p41 Kepler tried 40 models attempting to explain Mars retrograde motion, inspired to consider ellipses. Mars "exception" crucial to the discovery of Kepler's eponymous Laws
• p45 outliers refine our understanding

  • David Solit researches cancer therapy "exceptional responses", studied single patient anecdotes, connected them to genetic variance, generated new data

• p49 response variations help discover "hidden inner logic"
• p51 (height/cm-100)/1.1 = average weight/kg ... me 67 in ⇒ 170 cm ⇒ 70/1.1 ⇒ 63.6 kg ⇒ 140 lb
• p51 "If medicine is to become a bona fide science, then we will have to take up every opportunity to falsify it's models, so that they can be replaced by new ones"

• p59 Breast cancer mastectomies, William Halsted blamed recurrence on "unclean operation", scraps left behind, led to radical mastectomy; actually presurgical metastasis to entire body

• p60 Geoffrey Keynes challenged this unsucessfully

• p60 randomized trial (radical vs conservative) led by Bernard Fisher ("In God we trust. All others must bring data") showed no difference in outcome. It took two more trials to convince oncologists that radical mastectomy WORSE THAN USELESS, and is no longer performed, after mutilating hundreds of thousands of women.