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

This is a poignant reminder about patient motivation. Even *a literal heart attack* is not enough to get most patients to care about their health, and these aren't particularly hard targets to reach! I bet if this chart added obesity, it would look even worse.

Great summary by ACC/AHA/Multisociety Dyslipidemia/Prevention GL ‘26

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.

It’s going to be very embarrassing to have to downgrade the recommendations after Corcal and ROBINSCA.

Positions filled and match rates for the 2025 NRMP Medicine and Pediatric Specialties Fellowship Match

If the physical exam were a lab or image test, we’d never order it. Not sensitive or specific enough. Yet there are those that hold onto these quaint ideas about the exam. And I do an exam. Focused. I won’t be counting moles or look at your pubic hair distribution. But. For the exam to improve sensitivity and specificity you need clinical experience and expertise. Variables we all know exist but people don’t want to talk much about here because it seriously changes the calculus on predictability and magnitude of effect. We like things neater and tidier. Medicine also generally abhors intuition or admitting that those with good intuition have a style that should be developed and nurtured. The best clinicians are either HIGHLY intuitive (rare) or they have all the details and data points memorized (uncommon). I don’t have any problems with the detail memorizers. I understand how and why they exist. But they seem to despise my style of intuitive approach because they can never understand it. I can tell a lot about you from the door when you show up in my ICU. And that’s totally fine. It’s not an argument against using an exam. And you often need an exam of some limited capacity. Sometimes more. The skin can tell you a lot. And it’s also probably the trickiest. I’ll never pretend to be Superman skin diagnostician. Maybe the most important reason to do an exam. Especially in clinic. Patients like it. Expect it. Think it means more than it does. Assign a value to it much higher than it deserves because they don’t understand the bigger contexts. And many are not sophisticated enough to understand the nuance discussed here. That just is. It’s not good or bad.