Thank you for this informative article. I was unaware of AHA utilize tiered recommendations. They seem so logical, so sensibile. I'm a retired DVM with a modest modicum of CV disease knowledge and now a medical consumer. My wife has had some questionable to minor heart problems. Her cardiologist has recommended the "4 pillars heart failure therapy" for a person with no symptoms, clear arteries, and mild LVeF. I have questioned her cardio as those recommendations that seem like overkill to me. He didn't really appreciate that! Now I have a new question to ask: "Dr, can you tell me what AHA Tier that recommendation is from?".
Is there a way the average medical consumer can find those recommendations?
Thank you for this informative article. I was unaware of AHA utilize tiered recommendations. They seem so logical, so sensibile. I'm a retired DVM with a modest modicum of CV disease knowledge and now a medical consumer. My wife has had some questionable to minor heart problems. Her cardiologist has recommended the "4 pillars heart failure therapy" for a person with no symptoms, clear arteries, and mild LVeF. I have questioned her cardio as those recommendations that seem like overkill to me. He didn't really appreciate that! Now I have a new question to ask: "Dr, can you tell me what AHA Tier that recommendation is from?".
These recommendations are really important and the American medical establishment needs a commission to implement many of these points. One problem during the pandemic as pointed out by Scott Atlas in his important book, A Plague Upon Our House, is that many bright experts including Tony Fauci had essentially no training or expertise in public health. Beware experts who speak outside their field. Remember Linus Pauling and his hallowing of Vitamin C. American medicine needs a conscious and conscientious commitment to reform to try to recapture the trust of the American people. Thank you, Dr. Marine.
I respect the good intentions of those who wish to reform the public health system but have serious doubts about the likelihood that this will bring about meaningful change. In my opinion "public health" is a fictional concept and, possibly, even an oxymoron. Medical care is a highly individualistic discipline and the attempts to collectivize it have led to most of the problems that we see today. All medical decisions should be left to the individual patient based on informed consent from one or as many medical practitioners as they choose to consult. All public health agencies should be eliminated. Groups or associations, medical or otherwise , may issue opinions and recommendations but none should have the force of law or government coercion. Reforming the current system or changing the personnel in charge will not do any more good than is accomplished by electing one politician rather than another.
The worst thing we can do is to work towards restoring public trust in federal agencies.
They should be hogtied and completely contained in their powers. They have proven they will always be corruptible if given the chance. They should always be overseen by elected officials.
Thank you, Dr. Marine, for an article into which you clearly put much thought. I have sometimes characterized communications as "so brief as to be seriously misleading." I would like to believe that simplicity is a virtue, but Mother Nature apparently does not. Alas, I think often of the Carl Jung quote, “Thinking is difficult, that’s why most people judge.”
These are good suggestions by and large, but I don't think they address the gap between public health and the public. Even though it's in Atlanta, the CDC is very Ivory Tower, and there is clearly a gap between how the people who show up there (or sit on their laptops in the suburbs) perceive things and what the reality is on the ground for everyone else.
The CDC needed some organized mechanism to get input from what public health would call stakeholders. I would suggest a panel of non-professional citizens from around the country, and I would want to have that panel provide at least a non-binding vote on the sort of policy positions the CDC has been putting out.
Thank you for your time. Appreciate your time and thoughts. That being said however, none of us who live in a glass house should be throwing any stones. Cardiology is one of many glass houses, and to say that it does the right thing but fauci was wrong is the pot calling the kettle black. Examples-is anyone listening to Substack cardiology trials, has anyone heard Dr. Prasad rip entresto apart. How about giving everybody a watchman and then a tavr. Don’t forget CT score.
Thank you for your comment. I think the house of cardiology is doing a little better than the CDC but all of us in medicine need to be humble and responsive to the public. I follow all the editors of Sensible Medicine and the Clinical Trials substack closely and agree we need to hold our fields to high evidence standards. We should also be candid with patients about the strengths and weaknesses for evidence for medical recommendations.
I don't believe that Dr. Marine said anywhere that cardiology as a field is flawless. If you are going to wait for an author from a flawless field, you are going to have a very long wait. I would question if cardiology has anywhere near the power that Fauci wielded at his peak, therefor a greater burden on Fauci to be thoughtful. For one, cardiology has never had an influence on my life, and Fauci obviously did.
Given available evidence, what would be the author’s position on, say, a requirement to receive measles vaccine as a condition of being allowed to attend a public school. What would a nuanced policy look like?
The FDA has a “nuanced policy” currently regarding measles. Go to the FDA website and with little effort you will find the statement, by the FDA, that if you can show that you have already had the measles, the vaccine is not required. That was a recognition of natural immunity which was ignored with Covid the last 4 years. Read about the 1905 Supreme Court decision regarding the smallpox vaccine mandate (Jacobson v. Massachusetts). Their less than nuanced decision allowed not taking the vaccine if a $5.00 fine was paid (about $150 in today’s $). Unfortunately, the Jacobson case has been purposely misinterpreted in support of mandates that do not offer alternatives. https://jackcaskinsmd.substack.com/p/back-to-the-future-1905-mandates
Thanks for your comment. I am not a content expert on this subject. My goal was to suggest a framework that the CDC should use to communicate with the medical community and the public. I have been vaccinated for measles, as have my children.
Overall good article, but I must take issue with #7: “Develop a statement of ethical principles.” The medical profession is replete with statements of ethical principles going back 2,000 years to the Hippocratic Oath and going forward to the Nuremberg Code following WWII, the Helsinki Declaration in 1961, and innumerable state, county, and hospital requirements for medical licensure and credentialing. The problem is not a lack of ethical principle statements, the problem is they were all ignored. Along the way, our rights and privileges supposedly guaranteed in the U.S. Constitution were also violated. The problem is a lack of accountability. And that accountability must be of sufficient severity to dissuade others from disregarding all these statements of ethics and human rights in the future.
1. “The voluntary consent of the human subject is absolutely essential. This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, overreaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him (or her) to make an understanding and enlightened decision.”
Excellent points. We have many sources to draw upon for medical ethical principles, and public health leaders ignored many of them during the pandemic. The challenge for public health workers is that they see their job as taking care of a population ("the herd") while doctors have an ethical responsibility to the patient in front of us. This is an intrinsic tension in public health work that should be openly discussed. In my view, the rights and ethical responsibility to the individual should be paramount. I do think it would be helpful for the CDC and the US Public Health Service to rethink a mission statement and ethical framework for their operations, which should be based on time-tested medical ethical principles.
This seems exactly right, and I pray it happens. I'm late enough in my career to remember when everything you listed was a normal part of medicine. The ethical piece is the most important, all the rest can be reasoned from that.
Thank you, Dr Marine. I love all of these suggestions! Excellent summary.
Obviously, a pandemic situation is very different than typical, routine medicine. I can see that pandemics don't lend themselves to "nuanced" discussions of all the options. BUT, I don't see that having a clear, straightforward directive as to high risk groups is "nuanced"! There really seems to have been more to this - politics played an outsized role and likely other agendas that we're not fully aware of. It is not terribly complicated to have strong directives to protect the high risk group (in this case, the elderly).
I hope public health officials can look back on this and see just how detrimental it has been to let politics overshadow clear medical judgement and recommendations. This whole episode should stimulate some change in public health degree programs.
After retiring from my work as a Medical Director for a mid-sized PPO-TPA - in the spring of 2022 - I found retirement difficult. As I looked for a job that would not require an active medical license (I considered Home Depot or Cabela's), I happened upon a post about a job in my county's Health Department - Community Health Educator. I got the job, had a wonderful boss, and enjoyed working with the county's Seniors, creating public health graphics (e.g. wall posters, handouts, pocket cards), and writing special topic white papers as needed.
One thing that troubled me in this job was the common use of the term 'evidence based'. As we worked with state health staff on how to approach various issues (e.g. vaping & STI teaching in schools, suicide prevention education), we constantly heard 'do it this way because it is evidence based', 'don't take that approach because it's not evidence based'. But when I would push back (on some topic where the recommended approach seemed questionable - or nonsensical) by asking for the evidence, the response was typically 'we'll get back to you on that' - and rarely, when there was some evidence reference provided, it was invariably weak. Small studies with overwrought conclusions, biased premises by conflicted authors, etc.
So in the public health world, if someone tells you a recommendation is 'evidence based', be VERY skeptical...!
The great Alvan Feinstein wrote in the 1990s that EBM would merely transfer power from clinicians to those who had the power to determine what constituted “evidence”. Time has borne out the wisdom of that insight.
Sure. But in a properly functioning research publication system where transparency, reproducibility, and ethics are promoted and where people needing to make decisions based on evidence are properly trained to understand and apply it, EBM is the best approach to guiding therapeutic choices. The problems I lament and which frustrates those who rightly use it is not the principle, it is the contamination of the evidence by incompetent and/or unscrupulous builders and users that compromises EBM. Poor training of clinical practitioners and policy makers leaves them unable to see through to the problems.
I was able to challenge those claiming evidence support for their recommendations because 1) I was properly trained and 2) I was properly motivated...
There are now and always have been such systems - problematicly such systems have not and are not adequately codified and organized. Efforts to improve have been ongoing since my first training in the 70's, and perhaps no end is in sight. But try we must..
Excellent suggestions, Dr. Marine. This is the nuanced and informed information that health care consumers would love to see. Saying, as Dr. Offitt reports Dr. Fauci saying, that the American people cannot understand nuance is the antiquated paternalist view of medicine. People today are smarter and have more tools at their disposal (some high quality some not so high quality) to assist them in evaluating medication, medical procedures, and the like. Saying that we general folks (not MDs) cannot evaluate nuance is a huge slap in the face to the intelligence of the nation.
This also encourages people to speak to their healthcare team to seek further clarification: Which class of risk/benefit am I in? Why do you believe that to be the case? Etc. This way there's a better relationship between patient and provider.
Thank you again, Doctor. This is truly a sensible approach to medicine!
Thank you for this informative article. I was unaware of AHA utilize tiered recommendations. They seem so logical, so sensibile. I'm a retired DVM with a modest modicum of CV disease knowledge and now a medical consumer. My wife has had some questionable to minor heart problems. Her cardiologist has recommended the "4 pillars heart failure therapy" for a person with no symptoms, clear arteries, and mild LVeF. I have questioned her cardio as those recommendations that seem like overkill to me. He didn't really appreciate that! Now I have a new question to ask: "Dr, can you tell me what AHA Tier that recommendation is from?".
Is there a way the average medical consumer can find those recommendations?
Could be fun and a game changer!
Thank you for this informative article. I was unaware of AHA utilize tiered recommendations. They seem so logical, so sensibile. I'm a retired DVM with a modest modicum of CV disease knowledge and now a medical consumer. My wife has had some questionable to minor heart problems. Her cardiologist has recommended the "4 pillars heart failure therapy" for a person with no symptoms, clear arteries, and mild LVeF. I have questioned her cardio as those recommendations that seem like overkill to me. He didn't really appreciate that! Now I have a new question to ask: "Dr, can you tell me what AHA Tier that recommendation is from?".
Could be fun and a game changer!
These recommendations are really important and the American medical establishment needs a commission to implement many of these points. One problem during the pandemic as pointed out by Scott Atlas in his important book, A Plague Upon Our House, is that many bright experts including Tony Fauci had essentially no training or expertise in public health. Beware experts who speak outside their field. Remember Linus Pauling and his hallowing of Vitamin C. American medicine needs a conscious and conscientious commitment to reform to try to recapture the trust of the American people. Thank you, Dr. Marine.
I respect the good intentions of those who wish to reform the public health system but have serious doubts about the likelihood that this will bring about meaningful change. In my opinion "public health" is a fictional concept and, possibly, even an oxymoron. Medical care is a highly individualistic discipline and the attempts to collectivize it have led to most of the problems that we see today. All medical decisions should be left to the individual patient based on informed consent from one or as many medical practitioners as they choose to consult. All public health agencies should be eliminated. Groups or associations, medical or otherwise , may issue opinions and recommendations but none should have the force of law or government coercion. Reforming the current system or changing the personnel in charge will not do any more good than is accomplished by electing one politician rather than another.
Good plan.
The worst thing we can do is to work towards restoring public trust in federal agencies.
They should be hogtied and completely contained in their powers. They have proven they will always be corruptible if given the chance. They should always be overseen by elected officials.
Thank you! This IS sensible medicine!
Thank you, Dr. Marine, for an article into which you clearly put much thought. I have sometimes characterized communications as "so brief as to be seriously misleading." I would like to believe that simplicity is a virtue, but Mother Nature apparently does not. Alas, I think often of the Carl Jung quote, “Thinking is difficult, that’s why most people judge.”
This is fantastic, Dr. Marine. Comprehensive and reasonable. Would they take your recommendations to heart.
These are good suggestions by and large, but I don't think they address the gap between public health and the public. Even though it's in Atlanta, the CDC is very Ivory Tower, and there is clearly a gap between how the people who show up there (or sit on their laptops in the suburbs) perceive things and what the reality is on the ground for everyone else.
The CDC needed some organized mechanism to get input from what public health would call stakeholders. I would suggest a panel of non-professional citizens from around the country, and I would want to have that panel provide at least a non-binding vote on the sort of policy positions the CDC has been putting out.
I also think CDC needs an ombusman.
That is an excellent suggestion. A public Board of Advisors.
Thank you for your time. Appreciate your time and thoughts. That being said however, none of us who live in a glass house should be throwing any stones. Cardiology is one of many glass houses, and to say that it does the right thing but fauci was wrong is the pot calling the kettle black. Examples-is anyone listening to Substack cardiology trials, has anyone heard Dr. Prasad rip entresto apart. How about giving everybody a watchman and then a tavr. Don’t forget CT score.
Thank you for your comment. I think the house of cardiology is doing a little better than the CDC but all of us in medicine need to be humble and responsive to the public. I follow all the editors of Sensible Medicine and the Clinical Trials substack closely and agree we need to hold our fields to high evidence standards. We should also be candid with patients about the strengths and weaknesses for evidence for medical recommendations.
I don't believe that Dr. Marine said anywhere that cardiology as a field is flawless. If you are going to wait for an author from a flawless field, you are going to have a very long wait. I would question if cardiology has anywhere near the power that Fauci wielded at his peak, therefor a greater burden on Fauci to be thoughtful. For one, cardiology has never had an influence on my life, and Fauci obviously did.
Given available evidence, what would be the author’s position on, say, a requirement to receive measles vaccine as a condition of being allowed to attend a public school. What would a nuanced policy look like?
The FDA has a “nuanced policy” currently regarding measles. Go to the FDA website and with little effort you will find the statement, by the FDA, that if you can show that you have already had the measles, the vaccine is not required. That was a recognition of natural immunity which was ignored with Covid the last 4 years. Read about the 1905 Supreme Court decision regarding the smallpox vaccine mandate (Jacobson v. Massachusetts). Their less than nuanced decision allowed not taking the vaccine if a $5.00 fine was paid (about $150 in today’s $). Unfortunately, the Jacobson case has been purposely misinterpreted in support of mandates that do not offer alternatives. https://jackcaskinsmd.substack.com/p/back-to-the-future-1905-mandates
I mistakenly wrote “FDA” when it is actually the CDC who has the policy of natural immunity alternative to vaccination.
Thanks for your comment. I am not a content expert on this subject. My goal was to suggest a framework that the CDC should use to communicate with the medical community and the public. I have been vaccinated for measles, as have my children.
Overall good article, but I must take issue with #7: “Develop a statement of ethical principles.” The medical profession is replete with statements of ethical principles going back 2,000 years to the Hippocratic Oath and going forward to the Nuremberg Code following WWII, the Helsinki Declaration in 1961, and innumerable state, county, and hospital requirements for medical licensure and credentialing. The problem is not a lack of ethical principle statements, the problem is they were all ignored. Along the way, our rights and privileges supposedly guaranteed in the U.S. Constitution were also violated. The problem is a lack of accountability. And that accountability must be of sufficient severity to dissuade others from disregarding all these statements of ethics and human rights in the future.
I wrote a short piece on Substack 3 years ago this month regarding the current violations of the Nuremberg Code: https://jackcaskinsmd.substack.com/p/nuremberg-deja-vu. The first tenet in that Code is profound:
1. “The voluntary consent of the human subject is absolutely essential. This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, overreaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him (or her) to make an understanding and enlightened decision.”
Exactly correct and so well expressed. Thank you.
Excellent points. We have many sources to draw upon for medical ethical principles, and public health leaders ignored many of them during the pandemic. The challenge for public health workers is that they see their job as taking care of a population ("the herd") while doctors have an ethical responsibility to the patient in front of us. This is an intrinsic tension in public health work that should be openly discussed. In my view, the rights and ethical responsibility to the individual should be paramount. I do think it would be helpful for the CDC and the US Public Health Service to rethink a mission statement and ethical framework for their operations, which should be based on time-tested medical ethical principles.
This seems exactly right, and I pray it happens. I'm late enough in my career to remember when everything you listed was a normal part of medicine. The ethical piece is the most important, all the rest can be reasoned from that.
Thank you, Dr Marine. I love all of these suggestions! Excellent summary.
Obviously, a pandemic situation is very different than typical, routine medicine. I can see that pandemics don't lend themselves to "nuanced" discussions of all the options. BUT, I don't see that having a clear, straightforward directive as to high risk groups is "nuanced"! There really seems to have been more to this - politics played an outsized role and likely other agendas that we're not fully aware of. It is not terribly complicated to have strong directives to protect the high risk group (in this case, the elderly).
I hope public health officials can look back on this and see just how detrimental it has been to let politics overshadow clear medical judgement and recommendations. This whole episode should stimulate some change in public health degree programs.
After retiring from my work as a Medical Director for a mid-sized PPO-TPA - in the spring of 2022 - I found retirement difficult. As I looked for a job that would not require an active medical license (I considered Home Depot or Cabela's), I happened upon a post about a job in my county's Health Department - Community Health Educator. I got the job, had a wonderful boss, and enjoyed working with the county's Seniors, creating public health graphics (e.g. wall posters, handouts, pocket cards), and writing special topic white papers as needed.
One thing that troubled me in this job was the common use of the term 'evidence based'. As we worked with state health staff on how to approach various issues (e.g. vaping & STI teaching in schools, suicide prevention education), we constantly heard 'do it this way because it is evidence based', 'don't take that approach because it's not evidence based'. But when I would push back (on some topic where the recommended approach seemed questionable - or nonsensical) by asking for the evidence, the response was typically 'we'll get back to you on that' - and rarely, when there was some evidence reference provided, it was invariably weak. Small studies with overwrought conclusions, biased premises by conflicted authors, etc.
So in the public health world, if someone tells you a recommendation is 'evidence based', be VERY skeptical...!
The great Alvan Feinstein wrote in the 1990s that EBM would merely transfer power from clinicians to those who had the power to determine what constituted “evidence”. Time has borne out the wisdom of that insight.
Sure. But in a properly functioning research publication system where transparency, reproducibility, and ethics are promoted and where people needing to make decisions based on evidence are properly trained to understand and apply it, EBM is the best approach to guiding therapeutic choices. The problems I lament and which frustrates those who rightly use it is not the principle, it is the contamination of the evidence by incompetent and/or unscrupulous builders and users that compromises EBM. Poor training of clinical practitioners and policy makers leaves them unable to see through to the problems.
I was able to challenge those claiming evidence support for their recommendations because 1) I was properly trained and 2) I was properly motivated...
There is not and there never has been such a system.
There are now and always have been such systems - problematicly such systems have not and are not adequately codified and organized. Efforts to improve have been ongoing since my first training in the 70's, and perhaps no end is in sight. But try we must..
Excellent suggestions, Dr. Marine. This is the nuanced and informed information that health care consumers would love to see. Saying, as Dr. Offitt reports Dr. Fauci saying, that the American people cannot understand nuance is the antiquated paternalist view of medicine. People today are smarter and have more tools at their disposal (some high quality some not so high quality) to assist them in evaluating medication, medical procedures, and the like. Saying that we general folks (not MDs) cannot evaluate nuance is a huge slap in the face to the intelligence of the nation.
This also encourages people to speak to their healthcare team to seek further clarification: Which class of risk/benefit am I in? Why do you believe that to be the case? Etc. This way there's a better relationship between patient and provider.
Thank you again, Doctor. This is truly a sensible approach to medicine!