Donald Harvey Marks MD PhD
Emeritus Fellow, American College of Physicians
September 2026
"All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident." — Arthur Schopenhauer
Why do almost all doctors generally give the same answers to the same questions? The medical profession places a high premium on standardization, driven heavily by board certification examinations, national clinical guidelines, and institutional protocols. These standardized systems are designed to ensure baseline competency, patient safety, and predictable quality of care across healthcare systems. Still, it could be interpreted that this is really Groupthink and a Conformity Constraint. I hope in this discussion to address the issue of medical knowledge Consensus, medical Board Exams, and Independent clinical thought. In some cases, systemic demand i.e. professional medical board opinions for consensus creates a profound professional tension. Board-certified physicians (i am certified by ABIM) can be penalized—both professionally and structurally—for straying from the officially sanctioned "correct" answer, even when they possess independent clinical insight, interpret emerging or novel rules differently, or recognize that a national consensus contradicts what they know to be true and factual based on direct observation, clinical experience or evolving evidence. Because standardized testing and institutional metrics reward conformity over critical inquiry, clinicians who push against established dogma risk failing board exams or facing administrative friction. This dynamic creates a paradox where the very standardization of medical knowledge which is meant to protect patients can inadvertently suppress the independent clinical reasoning required to challenge outdated practices and accelerate medical progress.
Clinical practice and board exam standards undergo "medical reversals" when randomized controlled trials overturn long-held pathophysiologic assumptions. Classic examples of medical board questions once scored as correct that are now known to be false include prescribing Class IC antiarrhythmics for asymptomatic post-MI PVCs, routine hormone replacement therapy (HRT) for primary cardiovascular prevention, and intensive tight glycemic control in the ICU. Conversely, practices once considered false or contraindicated—such as prescribing beta-blockers for systolic heart failure, treating peptic ulcer disease with antibiotics, or using low-tidal-volume ventilation in ARDS—are now core evidence-based standards.
Concepts Scored as "Correct" on board exams but Now Known to Be False or Harmful
Class IC Antiarrhythmics for Post-MI PVC Suppression
The Classic Question: A 62-year-old post-myocardial infarction patient demonstrates frequent, asymptomatic premature ventricular contractions (PVCs) on telemetry. What is the next best step in management?
I do not recall this question being asked on my internal medicine board certification exam, but that it has come during certification for CME courses I have taken
Historical "Correct" Answer: Initiate an antiarrhythmic such as flecainide or encainide to suppress ventricular ectopy and prevent sudden cardiac death.
Current Standard: The landmark CAST (Cardiac Arrhythmia Suppression Trial, 1989) demonstrated that suppressing asymptomatic PVCs with Class IC antiarrhythmics more than doubled all-cause and arrhythmic mortality. Routine antiarrhythmic suppression, which was once accepted practice, is now strictly contraindicated.
Hormone Replacement Therapy (HRT) for Primary Prevention of Coronary Disease
The Classic Question: A healthy 55-year-old postmenopausal woman with mild vasomotor symptoms inquires about long-term cardiovascular health. Which pharmacologic intervention is indicated to reduce her risk of coronary artery disease?
Historical "Correct" Answer: Prescribe combination estrogen plus progestin therapy (or estrogen alone post-hysterectomy) for cardioprotection.
Current Standard: All internal medicine physicians, including those not practicing in the Ob-Gyn area, recognized this as a trick question. The Women's Health Initiative (WHI) trials in 2002 established that combined HRT does not provide primary cardioprotection and significantly increases the risks of coronary events, stroke, venous thromboembolism, and invasive breast cancer.
Intensive Glycemic Control in Critically Ill Patients
The Classic Question: A 68-year-old patient in the medical ICU following septic shock has blood glucose levels between 160–190 mg/dL. What is the optimal target for continuous intravenous insulin infusion? Although I do remember this question coming up during my medical training, almost all doctors I know would now recognize this as a trick question
Historical "Correct" Answer: Strict normoglycemia targeting blood glucose of 80–110 mg/dL to reduce bacteremia and multi-organ failure. This was the standard of care when I was an intern and resident in internal medicine.
Current Standard: The NICE-SUGAR trial (2009) showed that intensive insulin therapy aiming for 80–110 mg/dL significantly increased severe hypoglycemia and 90-day mortality compared to a moderate target of 140–180 mg/dL.
Routine High-Flow Supplemental Oxygen in Acute Normoxemic MI
The Classic Question: A 58-year-old man presents to the ED with crushing substernal chest pain, ST-segment elevations in leads II, III, and aVF, and room-air oxygen saturation of 98%. What immediate routine initial therapy should be administered?
Historical "Correct" Answer: Immediate supplemental oxygen via nasal cannula or mask (the "O" in the traditional MONA regimen). this was the protocol taught during my medical school years, and during my internship and residency. Everybody did it reflexively, nobody discussed its rationale or advisability, and if you didn't do it, you would not receive received passing grades during internship and residency
Current Standard: The AVOID (2015) and DETO2X-AMI (2017) trials demonstrated that routine oxygen supplementation in normoxemic patient provides no benefit, can cause coronary vasoconstriction, and may increase myocardial infarct size. Oxygen is now indicated only if SpO2 < 90%.
Strict Bed Rest for Acute Low Back Pain
The Classic Question: A 40-year-old male presents with acute, uncomplicated mechanical lumbosacral strain without neurologic deficits. What is the primary non-pharmacologic prescription?
Historical "Correct" Answer: Strict bed rest for 7 to 14 days on a firm mattress. This was accepted clinical practice during medical school and my internship and residency.
Current Standard: Extended bed rest leads to physical deconditioning, loss of bone density, increased DVT risk, and delayed functional recovery. Early mobilization and resumption of ordinary activity within pain tolerance are of course now standard of care.
Concepts Scored as "False / Incorrect" Then But Now Known to Be True
Beta-Blockers in Systolic Heart Failure (HFrEF)
The Classic Question: Which of the following medications is indicated to improve long-term survival in a patient with chronic NYHA Class II–III heart failure and a left ventricular ejection fraction of 25%?
Historical Scoring: Choosing a beta-blocker, while I was in medical school, internship and residency, was considered incorrect/contraindicated due to acute negative inotropy and the fear of precipitating cardiogenic collapse. Internal medicine , doctors now recognize us as a trick question.
Current Standard: Large multicenter RCTs (MERIT-HF, CIBIS-II, US Carvedilol) in the late 1990s proved that specific beta-blockers (carvedilol, metoprolol succinate, bisoprolol) blunt chronic neurohormonal catecholamine toxicity, reverse LV remodeling, and dramatically reduce mortality. Beta blockers are now a cornerstone of Guideline-Directed Medical Therapy (GDMT).
Antibiotic Therapy to Cure Peptic Ulcer Disease (PUD)
The Classic Question: What is the primary definitive therapeutic approach to prevent recurrence in a patient with chronic, recurrent duodenal ulcers?
Historical Scoring: The prevailing doctrine was "no acid, no ulcer." Attributing ulcers to an infectious bacterial pathogen and selecting an antibiotic regimen was marked false. When I was an intern / resident; this was never even considered. At one time, the "correct" answers were antacids, anticholinergics, H2 blockers, or even surgical vagotomy/antrectomy.
Current Standard: Barry Marshall and Robin Warren's discovery of Helicobacter pylori proved that most peptic ulcers are infectious in etiology. Antimicrobial eradication therapy is curative and now within standard of care.
Low Tidal Volume ("Permissive Hypercapnia") in ARDS
The Classic Question: How should PaCO2 be managed during mechanical ventilation for a patient with severe Acute Respiratory Distress Syndrome (ARDS)?
Historical Scoring: Maintaining normal arterial PaCO2 using traditional high tidal volumes was at one time the correct response. Allowing PaCO2 to rise and using low tidal volumes was considered inappropriate.
Current Standard: The ARDSNet ARMA trial (2000) showed that lung-protective ventilation using low tidal volumes and plateau pressure actuaĺly reduces 180-day mortality, even if it results in respiratory acidosis. This is termed permissive hypercapnia.
Dietary Seed and Nut Intake in Diverticulosis
The Classic Question: Which dietary restriction is essential to counsel a 60-year-old patient found to have asymptomatic colonic diverticulosis on screening colonoscopy?
Historical Scoring: Strict avoidance of nuts, corn, popcorn, and seeds to prevent them from becoming trapped in diverticula and triggering diverticulitis. This was what I was taught during medical school, internship and residency. This trick question seen to have a mechanistic basis or logic.
Current Standard: The prospective Health Professionals Follow-up Study (2008) showed no association between nut, corn, or seed consumption and acute diverticulitis. Patients are instead advised to consume a high-fiber diet with no restriction on nuts or seeds.
"Every great truth begins as a blasphemy." — George Bernard Shaw (Annajanska, the Bolshevik Empress, 1919)
References
Top Medical Journals including JAMA and NEJM Challenged by Department Of Justice. Fraud vs clever and misleading deception. by Donald H. Marks
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