Wonderful column, thank you. I always wonder if there is too much over testing. I’m 46 and told that I should get a colonoscopy, not sure if I should. Prostate cancer is more frequent in my family. Yet when I hear friends that are my age and have caught cancer early due to a colonoscopy I think maybe I should have one.
John: thank you for this. I have seen such egregious abuse of these guidelines for screening over the years. In one recent example, an elderly patient of mine came in for follow up of her end stage liver disease. Her daughter was distraught. What was wrong I asked. Someone from her insurance company had called the daughter to chastise her for being a poor caregiver as she had not brought her mom for routine mammography.
Years ago when I was pregnant with my second daughter she was measuring quite small. My OB was fantastic and we were continueing to monitor the baby's development with weekly ultrasounds. At one point we met with a perinatologist who told me I needed an induction as it was uncertain why the baby was small. I asked what would happen if I wanted until term (6 weeks away) and he told me the baby could die. He seems taken off guard I was not immediately going for an induction and was insisting on gathering more information. I proceeded to meet with the head of the NICU and take a tour. Two weeks later I did opt for an induction. In hind sight if definitely would have been better to wait, but I am glad I stalled more. Throwing out death in such a cavalier way sticks with me to this day.
we physicians need to constantly remind ourselves of the value of doubt. Let's not subscribe to the rigid belief system that insists that all guidelines are infallible and that all RCTs are righteous & perfect.
In his 1996 book "The Lost Art of Healing", Dr. Bernard Lown (founder of International Physicians for Prevention of Nuclear War and world famous cardiologist) makes many of the same points about unnecessary and harmful medical promotion of fear. Some of his anecdotes are not only poignant but very funny.
Excellent article, Doctor. I think that your observations about hubris are central to all of the rest.
There is one factor that some of the medical reversals do not take into account; individual situations. Studies such as the ISCHEMIA trial, for instance, that include caveats about quality of life, have resulted in widespread refusal of revascularization for patients experiencing chronic degradation of physical stamina, episodic shortness of breath and other, multivariate, symptoms that are not perceived as anginal in origin by the diagnosing cardiologist.
Such suboptimal conclusions are to your point. When patients are considered no more than members of a statistical cohort, it becomes much easier to dismiss quality of life impediments.
When a patient cannot sustain the effort required to work at even sedentary occupations, a "wait and see" approach that depends entirely on lifestyle modifications and high-dosage statins may result in loss of income. Depending on socioeconomic status, that loss of income is hardly irrelevant to long-term outcomes. A patient with two 70% -plus restricted arteries, experiencing a typical degradation of function, may not have the leisure to spend their limited daily period of functionality on gentle exercise punctuated by rest periods. Any treatment with the possibility of incremental improvement in stamina should be considered.
Perhaps what I am trying to say, is that not all post-infarction patients should be considered to be part of the same cohort. Such consideration ignores the needs of the patient. Declaring a partially disabled patient fully functional with "no restrictions" eliminates their ability to obtain assistance within whatever social safety net is available to them.
A close examination of the ISCHEMIA trial reveals obvious flaws, or perhaps "distortions" might be a better term. Those distortions include, but are not limited to cohort inclusion and exclusion criteria. Those alone are sufficient reason to avoid reorienting treatment practices promiscuously. When we also consider that the small statistical advantage enjoyed by conservative treatment "flips" to revascularization four years post-event, it should give any diagnostician pause to reflect that the trial is informative and useful, but hardly definitive for all individuals.
An EF of 55% and lack of absence of resting angina symptoms should not be the sole criteria for denial of a revascularization procedure, but that is, as far as I have thus far been able to determine, one of the results of credulous adherence to a myopic reading of the ISCHEMIA trial results. There are, of course, no guarantees of the efficacy of any particular intervention, but there is a strong argument for giving the patient a "fighting chance " to avoid homelessness and the premature mortality associated with complete loss of income. One of the effects of hubris is to deny patients any agency in an admittedly uncertain calculus of treatment options.
Anyway, thanks very much for your thoughtful and well-written article.
Good article except that you forgot to add 1 component to the evaluation and treatment of the medical patient, and that is, plaintiff attorneys. Are we really giving our patients the best or is there another aspect that needs to be put in the equation. More and more physicians are doing bare minimum as that lowers their overall risk to litigation. Sad, but true.
I take an anticoagulents for PAF. In 5 plus years have had only 2 episodes of a sustained a fib, aborted within 2-3 hours with oral metaprolol . Now the anticoagulent is affecting my kidneys. So the anticoagulent is preventing a rare afib while killing my kidneys. Was told ablation does not have a high success rate so not advised by my HMO. So where does that leave me. ?
“The take-home is that while we should help people make the best probabilistic choice, no one should lose their mind if a patient declines to take the guideline-directed net-beneficial medicine.”
it applies primarily to “low incidence events” such as heart attack or stroke. For a patient with a higher incidence condition (e.g. the very common NIDDM/obesity/sleep apnea/metabolic syndrome), forgoing weight loss and other standard care would very likely be a disaster.
“the point is that while the average effect is beneficial, the vast majority of patients get the same outcome regardless of their choice, and some are harmed by the beneficial choice.”
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Thank you. I have enjoyed your podcast and look forward to the future writings for this substack.
Wonderful column, thank you. I always wonder if there is too much over testing. I’m 46 and told that I should get a colonoscopy, not sure if I should. Prostate cancer is more frequent in my family. Yet when I hear friends that are my age and have caught cancer early due to a colonoscopy I think maybe I should have one.
as always John.. spot on... keep it up!
John: thank you for this. I have seen such egregious abuse of these guidelines for screening over the years. In one recent example, an elderly patient of mine came in for follow up of her end stage liver disease. Her daughter was distraught. What was wrong I asked. Someone from her insurance company had called the daughter to chastise her for being a poor caregiver as she had not brought her mom for routine mammography.
An electrophysiologist!!! To me, that’s like a rockstar
Years ago when I was pregnant with my second daughter she was measuring quite small. My OB was fantastic and we were continueing to monitor the baby's development with weekly ultrasounds. At one point we met with a perinatologist who told me I needed an induction as it was uncertain why the baby was small. I asked what would happen if I wanted until term (6 weeks away) and he told me the baby could die. He seems taken off guard I was not immediately going for an induction and was insisting on gathering more information. I proceeded to meet with the head of the NICU and take a tour. Two weeks later I did opt for an induction. In hind sight if definitely would have been better to wait, but I am glad I stalled more. Throwing out death in such a cavalier way sticks with me to this day.
we physicians need to constantly remind ourselves of the value of doubt. Let's not subscribe to the rigid belief system that insists that all guidelines are infallible and that all RCTs are righteous & perfect.
Just ❤️
Love the humility you share Doctor!
In his 1996 book "The Lost Art of Healing", Dr. Bernard Lown (founder of International Physicians for Prevention of Nuclear War and world famous cardiologist) makes many of the same points about unnecessary and harmful medical promotion of fear. Some of his anecdotes are not only poignant but very funny.
Excellent article, Doctor. I think that your observations about hubris are central to all of the rest.
There is one factor that some of the medical reversals do not take into account; individual situations. Studies such as the ISCHEMIA trial, for instance, that include caveats about quality of life, have resulted in widespread refusal of revascularization for patients experiencing chronic degradation of physical stamina, episodic shortness of breath and other, multivariate, symptoms that are not perceived as anginal in origin by the diagnosing cardiologist.
Such suboptimal conclusions are to your point. When patients are considered no more than members of a statistical cohort, it becomes much easier to dismiss quality of life impediments.
When a patient cannot sustain the effort required to work at even sedentary occupations, a "wait and see" approach that depends entirely on lifestyle modifications and high-dosage statins may result in loss of income. Depending on socioeconomic status, that loss of income is hardly irrelevant to long-term outcomes. A patient with two 70% -plus restricted arteries, experiencing a typical degradation of function, may not have the leisure to spend their limited daily period of functionality on gentle exercise punctuated by rest periods. Any treatment with the possibility of incremental improvement in stamina should be considered.
Perhaps what I am trying to say, is that not all post-infarction patients should be considered to be part of the same cohort. Such consideration ignores the needs of the patient. Declaring a partially disabled patient fully functional with "no restrictions" eliminates their ability to obtain assistance within whatever social safety net is available to them.
A close examination of the ISCHEMIA trial reveals obvious flaws, or perhaps "distortions" might be a better term. Those distortions include, but are not limited to cohort inclusion and exclusion criteria. Those alone are sufficient reason to avoid reorienting treatment practices promiscuously. When we also consider that the small statistical advantage enjoyed by conservative treatment "flips" to revascularization four years post-event, it should give any diagnostician pause to reflect that the trial is informative and useful, but hardly definitive for all individuals.
An EF of 55% and lack of absence of resting angina symptoms should not be the sole criteria for denial of a revascularization procedure, but that is, as far as I have thus far been able to determine, one of the results of credulous adherence to a myopic reading of the ISCHEMIA trial results. There are, of course, no guarantees of the efficacy of any particular intervention, but there is a strong argument for giving the patient a "fighting chance " to avoid homelessness and the premature mortality associated with complete loss of income. One of the effects of hubris is to deny patients any agency in an admittedly uncertain calculus of treatment options.
Anyway, thanks very much for your thoughtful and well-written article.
Good article except that you forgot to add 1 component to the evaluation and treatment of the medical patient, and that is, plaintiff attorneys. Are we really giving our patients the best or is there another aspect that needs to be put in the equation. More and more physicians are doing bare minimum as that lowers their overall risk to litigation. Sad, but true.
I take an anticoagulents for PAF. In 5 plus years have had only 2 episodes of a sustained a fib, aborted within 2-3 hours with oral metaprolol . Now the anticoagulent is affecting my kidneys. So the anticoagulent is preventing a rare afib while killing my kidneys. Was told ablation does not have a high success rate so not advised by my HMO. So where does that leave me. ?
All true but regarding this:
“The take-home is that while we should help people make the best probabilistic choice, no one should lose their mind if a patient declines to take the guideline-directed net-beneficial medicine.”
it applies primarily to “low incidence events” such as heart attack or stroke. For a patient with a higher incidence condition (e.g. the very common NIDDM/obesity/sleep apnea/metabolic syndrome), forgoing weight loss and other standard care would very likely be a disaster.
Actually this was the relevant quote:
“the point is that while the average effect is beneficial, the vast majority of patients get the same outcome regardless of their choice, and some are harmed by the beneficial choice.”
We give options to the patient. Sometimes, they suck, but the patient has the right to choose.