Andrew Foy rejoins the Sensible Medicine podcast. We talk first about coronary artery calcium. Andrew is an expert in this area. We have co-written our case against CAC scoring for any cause in the American Family Physician. It’s had little effect as CAC scoring is running rampant.
At 76 with higher than normal cholesterol and recent higher than normal blood pressure my endocrinologist was upset that I didn't want to take a statin. My PCP ordered a CAC screen which turned out to be zero.
Argumentation in medicine is tough because medicine is so hierarchical. A person one year ahead of you in training is your senior, and that’s a meaningful distinction. Very hard for some people to adopt a position that disagrees with someone above them in the hierarchy as a matter of personality; we’re selecting hard for personalities who don’t disagree. Also very hard when the person you’re arguing with controls your career advancement.
But if the people at the top of the food chain are humble, then debate is fantastic.
One thing you failed to mention was the comparison of cost of one statin vs the other. A patient will take a statin the first month it is prescribed but if it costs $400 a month they will stop taking it. Doctors need to be more cognizant of this problem.
re CCS: tests *are* an intervention. thats the mindset to teach from (& to pts.)
when dxth is on the line (at least before compliance follow up): its hard for any pt to refuse any Tx. when talking "percent of a percent RR redctn"; physicians must communicate what that means. _JC
John, I will continue to beg on behalf of the many of us who are hearing impaired, are visual learners, or who just do not have 100 hours per day to listen to all the podcasts we receive. Autotranscribers are free/cheap and, while not perfect, are no more error prone than mishearing a podcast/videocast. Many sites now post transcriptions when they post their casts. You will radically improve the impact of what you do if you do this. Please. Otherwise, many of us will miss this great content forever. Thanks.
Dr Mandorla: you helped an anxious 56 year old today with this exact tioical discussion on CAC. It was recently promoted to me by my PCP with serious scare tactics that I might "fall over dead" even though my NMR lipid panel is fantastic and I am normotensive and I have no symptoms (other than profound anxiety over it). He clearly stated that if my score was greater than zero we would do the barrage. Calmer heads prevailed in the form of a new PCP (before I listened here) who metaphorically said, "What that Mandola guy said".
In primary care another pressure is the metrics we must meet to satisfy our employers, systems, insurance companies, clients. In Direct Primary Care where I practice we must prove our worth by meeting these “secondary endpoints” like percentage of people getting mammos, colonoscopies, BP control etc. in order to keep job, get paid, keep insurance contracts we have to do things that preclude a lot of critical thinking.
Unless that "new" medical education includes herbs and supplements, it will lead to nothing more than another round of useless and often harmful big pharma heart related drugs. You guys are going in circles and I refuse to hop on your drug induced merry-go-round.
an easy position to hold, while healthy. but i just want to say, if afflicted, your faculties will not be at your disposal as they are now (even just from fear.) so keep an open mind, perhaps. & try to find a physician on your wavelength.
it is gr8 that you are hear listening to this, which puts you so far ahead of most. however, it is worthy of note that "herbs and supplements" - whatever that means - also make people billions of $ and *also* arent studied or replicated. (...and *are* drugs.) just w (somehow) even less regulation.
of the things ive seen: the horror and terror watching people go down w a hand clasping at thr chest - the look in thr eyes... i dont have advice beyond what your are already doing, & beyond that shared above. but herbs make money & are drugs. i guess that's all. & keep doing things like listening to conversations like this, if you can find them. =) _JC
I hate to say this but to rely on any studies, even RCTS, has become very difficult, as we have learned about the corruption I mentioned above. It makes us rely on observation alone, which is valuable , but obviously fallible.
I know that may leave many rudderless, as physicians have relied on studies like this as our guide, but recent investigations have shown many are manipulated ,unreliable, and not reproducible. This opens us up to doing harm to our patients. Health care outcomes and life expectancy is lower in the US than many other 1st world countries, so perhaps less algorithm treatment strategies and interventions, and more lifestyle coaching would be appropriate.
I definitely sense the hesitation to commit to statin use in Andrew, which is a breath of fresh air. With the recent revelations about statin ineffectiveness in many classes of patients, and the obvious corruption of drug makers and our regulatory bodies, I sense the shift back to less is more in his talk. I hope more of this common sense thinking takes hold.
My take was slightly different, because Foy did say that he would tell a patient if they wanted to do the most possible to prevent a CVE, he would recommend a statin, and Mandrola also seems to think statins are both safe and effective. What I'm hearing is that they respect patient autonomy/self-determination, and that after they go over risks/benefits of statins, they have no problem allowing the patient to decide, and won't pressure them to take a statin the way many other doctors will. While they are often skeptical of other interventions and about the bias in industry sponsored research, to me they do not appear to be skeptical about the efficacy or safety of statins. I hope they do an entire podcast on statins in the future. I would especially like to know how statins are shutting down atherosclerosis when research shows CAC scores go up after starting a statin. The rationale is that statins calcify soft plaque, making it more stable. Great. But you still have plaque! I'm not sure if statins actually reduce plaque, and the small ARR might be due to its anti-inflammatory effect, and there are other ways to lower inflammation. It seems to me there is still A LOT we still don't know, and as Andrew said, chronic disease in humans is complex and multifactorial.
At 76 with higher than normal cholesterol and recent higher than normal blood pressure my endocrinologist was upset that I didn't want to take a statin. My PCP ordered a CAC screen which turned out to be zero.
Argumentation in medicine is tough because medicine is so hierarchical. A person one year ahead of you in training is your senior, and that’s a meaningful distinction. Very hard for some people to adopt a position that disagrees with someone above them in the hierarchy as a matter of personality; we’re selecting hard for personalities who don’t disagree. Also very hard when the person you’re arguing with controls your career advancement.
But if the people at the top of the food chain are humble, then debate is fantastic.
One thing you failed to mention was the comparison of cost of one statin vs the other. A patient will take a statin the first month it is prescribed but if it costs $400 a month they will stop taking it. Doctors need to be more cognizant of this problem.
Always great to hear people actually discussing issues. Especially in a medical context.
Foy is great. Such a low key common sense approach. No BS
gr8 conversation. _JC
also, cookbook medicine can be done by an Ai vending machine in the lobby. tho that may help wait times, i think it has drawbacks.
(& industry has too much input on guidelines...& AMA, & pt groups, & journals, & research funding...etal) _JC
re CCS: tests *are* an intervention. thats the mindset to teach from (& to pts.)
when dxth is on the line (at least before compliance follow up): its hard for any pt to refuse any Tx. when talking "percent of a percent RR redctn"; physicians must communicate what that means. _JC
& i agree w john: do you want to *know* you have an AVM? deep brain aneurysm? pts get scans to be told they are *well*, not find 'disease' perse.
CA & cardiac comes for us all: best case. thats why we need our heads str8 *before* we are holding our own test results in hand. _JC
John, I will continue to beg on behalf of the many of us who are hearing impaired, are visual learners, or who just do not have 100 hours per day to listen to all the podcasts we receive. Autotranscribers are free/cheap and, while not perfect, are no more error prone than mishearing a podcast/videocast. Many sites now post transcriptions when they post their casts. You will radically improve the impact of what you do if you do this. Please. Otherwise, many of us will miss this great content forever. Thanks.
you do it! & what a service for your unique community! im sure you could get permission to re-post them as well. something to think about. _JC
Dr Mandorla: you helped an anxious 56 year old today with this exact tioical discussion on CAC. It was recently promoted to me by my PCP with serious scare tactics that I might "fall over dead" even though my NMR lipid panel is fantastic and I am normotensive and I have no symptoms (other than profound anxiety over it). He clearly stated that if my score was greater than zero we would do the barrage. Calmer heads prevailed in the form of a new PCP (before I listened here) who metaphorically said, "What that Mandola guy said".
In primary care another pressure is the metrics we must meet to satisfy our employers, systems, insurance companies, clients. In Direct Primary Care where I practice we must prove our worth by meeting these “secondary endpoints” like percentage of people getting mammos, colonoscopies, BP control etc. in order to keep job, get paid, keep insurance contracts we have to do things that preclude a lot of critical thinking.
gross. & such easy answers to these things. at least on paper. _JC
Gross is exactly the word.
Unless that "new" medical education includes herbs and supplements, it will lead to nothing more than another round of useless and often harmful big pharma heart related drugs. You guys are going in circles and I refuse to hop on your drug induced merry-go-round.
an easy position to hold, while healthy. but i just want to say, if afflicted, your faculties will not be at your disposal as they are now (even just from fear.) so keep an open mind, perhaps. & try to find a physician on your wavelength.
it is gr8 that you are hear listening to this, which puts you so far ahead of most. however, it is worthy of note that "herbs and supplements" - whatever that means - also make people billions of $ and *also* arent studied or replicated. (...and *are* drugs.) just w (somehow) even less regulation.
of the things ive seen: the horror and terror watching people go down w a hand clasping at thr chest - the look in thr eyes... i dont have advice beyond what your are already doing, & beyond that shared above. but herbs make money & are drugs. i guess that's all. & keep doing things like listening to conversations like this, if you can find them. =) _JC
I hate to say this but to rely on any studies, even RCTS, has become very difficult, as we have learned about the corruption I mentioned above. It makes us rely on observation alone, which is valuable , but obviously fallible.
I know that may leave many rudderless, as physicians have relied on studies like this as our guide, but recent investigations have shown many are manipulated ,unreliable, and not reproducible. This opens us up to doing harm to our patients. Health care outcomes and life expectancy is lower in the US than many other 1st world countries, so perhaps less algorithm treatment strategies and interventions, and more lifestyle coaching would be appropriate.
I definitely sense the hesitation to commit to statin use in Andrew, which is a breath of fresh air. With the recent revelations about statin ineffectiveness in many classes of patients, and the obvious corruption of drug makers and our regulatory bodies, I sense the shift back to less is more in his talk. I hope more of this common sense thinking takes hold.
My take was slightly different, because Foy did say that he would tell a patient if they wanted to do the most possible to prevent a CVE, he would recommend a statin, and Mandrola also seems to think statins are both safe and effective. What I'm hearing is that they respect patient autonomy/self-determination, and that after they go over risks/benefits of statins, they have no problem allowing the patient to decide, and won't pressure them to take a statin the way many other doctors will. While they are often skeptical of other interventions and about the bias in industry sponsored research, to me they do not appear to be skeptical about the efficacy or safety of statins. I hope they do an entire podcast on statins in the future. I would especially like to know how statins are shutting down atherosclerosis when research shows CAC scores go up after starting a statin. The rationale is that statins calcify soft plaque, making it more stable. Great. But you still have plaque! I'm not sure if statins actually reduce plaque, and the small ARR might be due to its anti-inflammatory effect, and there are other ways to lower inflammation. It seems to me there is still A LOT we still don't know, and as Andrew said, chronic disease in humans is complex and multifactorial.