Watching poker on television the other night, Daniel Negreanu talked about the levels of thinking in poker. At level 1 one plays ones own cards. At level 2 one starts to imagine why opponents are betting by trying to figure out their cards. This goes on to level 4 or 5 , when you are trying to figure out what the other player thinks you have and match that up with what you think the other player has.
So what does this have to do with medicine and spironalactone? Perhaps nothing, but allow me a few paragraphs to outline my thoughts about the levels of thinking in medicine.
- Level 1 – spironalactone decreases mortality iCHF
- Level 2 – spironalactone is only indicated for patients who have had class IV CHF within the past 6 months and who are know class III or IV
- Level 3 – start spironalactone at 25 mg for CHF, only going to 50 mg if the patient remains symptomatic
- Level 4 – spironalactone has side effects – gynecomastisa, hirsutism, and hyperkalemia
- Level 5 – hyperkalemia or a serum creatinine > 2.5 are contraindications to using spironalactone
- Level 6 – patients on spironalactone should have routine (frequent on initiation) laboratory testing – especially to check potassium levels
- Level 7 – diabetic patients with early chronic kidney disease are particularly susceptible to hyperkalemia
Practicing excellent medicine requires time and thought. We need to reach level 7 in our thinking about using spironalactone for CHF. Getting to level 7 takes hard study, and time.
If we want excellent medicine, then we must give physicians time to think and learn the nuances of care. Almost every drug that we prescribe has a list like that one. I even left out the possibility of interactions from this list.
What kind of physician do you want? Do you want someone who functions at level 1 or level 7? What worth can we assign to level 7? When will everyone understand that level 7 requires appropriate compensation?
