Look to the medmal lawyers. Does anyone get sued for "you took my dad to the Cath lab and he died two months later. If you had given him optimal medical therapy, he would have been much more likely to be alive still!"? But I think people get sued for "why didn't you take him to the Cath lab?"
Sure, the amount of money that caths make has got to be a factor, but it seems likely fear of being sued for what might look like inaction is a piece of it, too.
Also, once Dr X has said, "You need a stent!" it is very difficult for Dr Y to say "Not so fast!"
Agree. It will take a paradigm shift to change this mindset. I was in my Family Medicine residency 2001-2004 & I recall one of the Cardiologists I rotated with pointed out that stents had not been proven to improve long term outcomes over medical care…he was the only physician I encountered in my training who pointed this out.
Your patients have a right to expect your treatment goal to be maximizing their good health and well being, not minimizing your risk of a malpractice claim.
It's tiresome to hear doctors blame plaintiff's attorneys for their over testing and over treatment. If fear of being sued keeps you from doing what you know is right, find something else to do.
I am a primary care internist. I never put stents in anyone and usually the stent is a fait accompli by the time I am informed of it.
I think the point of this article is that many cardiologists appear to be practicing contrary to the evidence. When the evidence seems to point in one direction and all of the practicing cardiologists near me appear to point in another, I have a difficult time deciding what The Right Thing to do is. Again, the words of Yeats which I quoted above seem to apply.
Doing something--a medical procedure--gets paid for. Hospital/clinic gets utilized, which means reimbursement. Doing nothing pays for nothing. So the incentive is to intervene. The structure of the system is oriented this way. To moderate or mitigate is difficult--except by closer examination of the "norms" and how they got that way, as suggested.
Much of life is "all about the money," so that observation doesn't really solve the dilemma.
The money is certainly a huge motivating factor but so is fear of risking loss of credibility. It is difficult for a surgeon or interventional cardiologist to admit that almost all of the procedures they have done over the years had little or no benefit. By the same token, the bulk of generalists and cardiologists who have spent their careers nagging people about their diets and lack of exercise are not about to throw up their hands and say "Sorry. I guess that was all a big waste of time."
I work in Canada. Here, Ischemia has seemed to change things. Although I don’t Cath, I am a referral doc. And I’ve noticed that, in stable angina patients, my local IC’s do stop as long as there is no LM. However, we have a much different payment system vs the US, there is no institutional incentive to do more PCI, and staff are not judged by revenue units.
And yes, the cardiology trials substack is a great resource. It will become a great reference as a compendium of trials new and old for broad cardiology categories.
Makes you wonder what incentives lie behind such spinning of the results. Tragic, because it diminishes the confidence in medicine and scientific journals.
I look forward to the Cardiology Trials in book form!!!
The interesting thing is the lack of incentives, actually.
Working with scientists who clearly lie or spin the truth in order to make e.g., a new drug and its shady effectiveness more palatable to regulators and customers (and to woo other scientists with their academic and personality theater), underlying it all is about near-psychotically pushing this notion of progress without fair consideration of counter-arguments.
In other words, people just want to win, underneath all the virtue signaling; and it's because people define winning not as uncovering the truth but rather persuading folks of a lie. When the lie is discovered, it's already too late, because the contracts are in place and the drugs are gonna expire -- gotta make those sales!
These days, the authors (aided and abetted by the device manufacturers) would come up with a trivial but statistically significant improvement in some bizarre, meaningless composite endpoint.
The problem with these things is that with or without evidence they become the standard of care. Once established, it’s hard to run another study comparing doing something to not doing something, because doing something is now the standard, and not doing something is unethical. Guidelines are published saying that these things must be done. Docs are sued for not following guidelines. All future interventions are seen as additions to the new standard. And so the evidentiary edifice sits on a bed of quicksand.
I firmly agree that trial after trial has demonstrated limited benefit of PCI vs. med therapy, mostly in improving symptoms in symptomatic patients. However, your analysis of RITA 2, which showed a doubling of the primary endpoint (death/MI) in the PCI (POBA, not stents) group should point out that most of the difference is due to “procedural MIs” (CPK elevations, post procedure). Minor CPK elevations post PCI, are usually clinically unimportant. If we remove these pts from the outcomes, the endpoint difference mostly goes away. But the conclusion remains that the only benefit of PCI ( POBA)was a short-lived improvement in symptoms.
Amusing that the interventionists have decided that the Troponin leaks that they cause are "clinically unimportant peri-procedural MIs." Next you'll be telling me that the new brain lesions on MRI that 45% of AF ablation patients suffer are clinically unimportant because we can't measure a cognitive decline ; ) !
Agree. There is an absence of benefit with PCI for hard endpoints. But I wouldn’t be too alarmed about any evidence of harm when it is driven primarily by peri-procedural bio marker rises. I would consider those akin to type 2 events….you inflate balloon for a certain period of time, it makes sense you will knock off a few myocytes.
Just one of many examples of modern medicine just ignoring the evidence and doing what they think is right because it suits them (not the patient). My conclusion from this is that medical personnel and institutions are to be avoided as much as feasibly possible. And if medical advice is unavoidable, then research and double/triple check every pronouncement from any medical source.
Thanks for the analysis; certainly there is a cultural inclination to do something felt to be definitive in western medicine. Vague, nebulous ongoing treatment with medication forever is not very viscerally satisfying in an action oriented system. So if stents improve symptoms, and do not have any greater mortality, why wait around with symptoms if there is a solution, even if temporary?
Always important to take the individual’s preference/goals in mind. “Shared decision making.”
Interesting that many studies comparing "optimal medical management" and invasive therapies show no significant differences in mortality or even the great majority of the softer end points. Optimal medical management usually means medication to lower cholesterol and/or blood pressure along with "lifestyle" changes----usually related to diet, exercise, and/or smoking cessation. The next step in the logical chain would be to compare outcomes with groups under optimal medical management to those with placebo or no "treatment". Actually, there are a number of studies that do this and they generally show no differences----this is especially true with the "lifestyle" factors but the results with statin drugs and aggressive blood pressure control are also quite underwhelming. The obvious conclusion is that there is no scientifically valid preventive therapy for coronary heart disease. There has been some evidence supporting intervention in acute myocardial infarction and unstable angina and doctors should confine their efforts to these clinical situations.
Yes, they keep changing recommendations regarding statin use and beta blockers. Someone who tends to negatively react to every medication ever given to me, i am on the verge of giving up and avoiding doctors because 90% of the bad things that have happened to me health-wise have been from medical iatrogenia! This is disturbing to me because i am a doctor.
I understand and agree with you completely. I was in practice for forty years and my advice always was, and still is, to minimize contact with the medical system. If you think something is wrong, see a doctor and get a diagnosis. Avoid routine checks and screening tests. Don't be taken in by the fiction of preventive medicine.
Another very timely article by J Mandrola, which shows that in the area of cardiology there is someone who STOPs AND THINK. And this helps maintain hope that others will do the same.
What J. Mandrola perhaps didn't want to mention is that coronary angioplasty is a very profitable field. And the disagreement between eminence-based medicine and evidence-based medicine should be the subject of analysis and correction.
But this "makes no difference" makes sense, no? If you don't tell people that exercising and eating healthy is the way to go...after "getting the treatment" people are more likely to eat worse. Thinking the problem has been addressed. So whatever gain there is with the procedure gets negated by continuing or living a more unhealthy lifestyle. Or so, it seems to me.
Look to the medmal lawyers. Does anyone get sued for "you took my dad to the Cath lab and he died two months later. If you had given him optimal medical therapy, he would have been much more likely to be alive still!"? But I think people get sued for "why didn't you take him to the Cath lab?"
Sure, the amount of money that caths make has got to be a factor, but it seems likely fear of being sued for what might look like inaction is a piece of it, too.
Also, once Dr X has said, "You need a stent!" it is very difficult for Dr Y to say "Not so fast!"
The words of Yeats come to mind here:
The best lack all conviction, while the worst
Are full of passionate intensity.
Agree. It will take a paradigm shift to change this mindset. I was in my Family Medicine residency 2001-2004 & I recall one of the Cardiologists I rotated with pointed out that stents had not been proven to improve long term outcomes over medical care…he was the only physician I encountered in my training who pointed this out.
I appreciate this series.
Your patients have a right to expect your treatment goal to be maximizing their good health and well being, not minimizing your risk of a malpractice claim.
It's tiresome to hear doctors blame plaintiff's attorneys for their over testing and over treatment. If fear of being sued keeps you from doing what you know is right, find something else to do.
I am a primary care internist. I never put stents in anyone and usually the stent is a fait accompli by the time I am informed of it.
I think the point of this article is that many cardiologists appear to be practicing contrary to the evidence. When the evidence seems to point in one direction and all of the practicing cardiologists near me appear to point in another, I have a difficult time deciding what The Right Thing to do is. Again, the words of Yeats which I quoted above seem to apply.
Again it is all about the money - for physicians and institutions
Job security > science
Why do you think the pandemic played out the way it did?
If the government and/or society actually cared about scientists or actual science, it would protect dialog -- not destroy it.
Doing something--a medical procedure--gets paid for. Hospital/clinic gets utilized, which means reimbursement. Doing nothing pays for nothing. So the incentive is to intervene. The structure of the system is oriented this way. To moderate or mitigate is difficult--except by closer examination of the "norms" and how they got that way, as suggested.
Much of life is "all about the money," so that observation doesn't really solve the dilemma.
The money is certainly a huge motivating factor but so is fear of risking loss of credibility. It is difficult for a surgeon or interventional cardiologist to admit that almost all of the procedures they have done over the years had little or no benefit. By the same token, the bulk of generalists and cardiologists who have spent their careers nagging people about their diets and lack of exercise are not about to throw up their hands and say "Sorry. I guess that was all a big waste of time."
I work in Canada. Here, Ischemia has seemed to change things. Although I don’t Cath, I am a referral doc. And I’ve noticed that, in stable angina patients, my local IC’s do stop as long as there is no LM. However, we have a much different payment system vs the US, there is no institutional incentive to do more PCI, and staff are not judged by revenue units.
And yes, the cardiology trials substack is a great resource. It will become a great reference as a compendium of trials new and old for broad cardiology categories.
Makes you wonder what incentives lie behind such spinning of the results. Tragic, because it diminishes the confidence in medicine and scientific journals.
I look forward to the Cardiology Trials in book form!!!
The interesting thing is the lack of incentives, actually.
Working with scientists who clearly lie or spin the truth in order to make e.g., a new drug and its shady effectiveness more palatable to regulators and customers (and to woo other scientists with their academic and personality theater), underlying it all is about near-psychotically pushing this notion of progress without fair consideration of counter-arguments.
In other words, people just want to win, underneath all the virtue signaling; and it's because people define winning not as uncovering the truth but rather persuading folks of a lie. When the lie is discovered, it's already too late, because the contracts are in place and the drugs are gonna expire -- gotta make those sales!
These days, the authors (aided and abetted by the device manufacturers) would come up with a trivial but statistically significant improvement in some bizarre, meaningless composite endpoint.
The problem with these things is that with or without evidence they become the standard of care. Once established, it’s hard to run another study comparing doing something to not doing something, because doing something is now the standard, and not doing something is unethical. Guidelines are published saying that these things must be done. Docs are sued for not following guidelines. All future interventions are seen as additions to the new standard. And so the evidentiary edifice sits on a bed of quicksand.
I firmly agree that trial after trial has demonstrated limited benefit of PCI vs. med therapy, mostly in improving symptoms in symptomatic patients. However, your analysis of RITA 2, which showed a doubling of the primary endpoint (death/MI) in the PCI (POBA, not stents) group should point out that most of the difference is due to “procedural MIs” (CPK elevations, post procedure). Minor CPK elevations post PCI, are usually clinically unimportant. If we remove these pts from the outcomes, the endpoint difference mostly goes away. But the conclusion remains that the only benefit of PCI ( POBA)was a short-lived improvement in symptoms.
Amusing that the interventionists have decided that the Troponin leaks that they cause are "clinically unimportant peri-procedural MIs." Next you'll be telling me that the new brain lesions on MRI that 45% of AF ablation patients suffer are clinically unimportant because we can't measure a cognitive decline ; ) !
Agree. There is an absence of benefit with PCI for hard endpoints. But I wouldn’t be too alarmed about any evidence of harm when it is driven primarily by peri-procedural bio marker rises. I would consider those akin to type 2 events….you inflate balloon for a certain period of time, it makes sense you will knock off a few myocytes.
It will take many generations of Interventional Cardiologists to convince them to moderation!
Just one of many examples of modern medicine just ignoring the evidence and doing what they think is right because it suits them (not the patient). My conclusion from this is that medical personnel and institutions are to be avoided as much as feasibly possible. And if medical advice is unavoidable, then research and double/triple check every pronouncement from any medical source.
Thanks for the analysis; certainly there is a cultural inclination to do something felt to be definitive in western medicine. Vague, nebulous ongoing treatment with medication forever is not very viscerally satisfying in an action oriented system. So if stents improve symptoms, and do not have any greater mortality, why wait around with symptoms if there is a solution, even if temporary?
Always important to take the individual’s preference/goals in mind. “Shared decision making.”
Interesting that many studies comparing "optimal medical management" and invasive therapies show no significant differences in mortality or even the great majority of the softer end points. Optimal medical management usually means medication to lower cholesterol and/or blood pressure along with "lifestyle" changes----usually related to diet, exercise, and/or smoking cessation. The next step in the logical chain would be to compare outcomes with groups under optimal medical management to those with placebo or no "treatment". Actually, there are a number of studies that do this and they generally show no differences----this is especially true with the "lifestyle" factors but the results with statin drugs and aggressive blood pressure control are also quite underwhelming. The obvious conclusion is that there is no scientifically valid preventive therapy for coronary heart disease. There has been some evidence supporting intervention in acute myocardial infarction and unstable angina and doctors should confine their efforts to these clinical situations.
Yes, they keep changing recommendations regarding statin use and beta blockers. Someone who tends to negatively react to every medication ever given to me, i am on the verge of giving up and avoiding doctors because 90% of the bad things that have happened to me health-wise have been from medical iatrogenia! This is disturbing to me because i am a doctor.
I understand and agree with you completely. I was in practice for forty years and my advice always was, and still is, to minimize contact with the medical system. If you think something is wrong, see a doctor and get a diagnosis. Avoid routine checks and screening tests. Don't be taken in by the fiction of preventive medicine.
Another very timely article by J Mandrola, which shows that in the area of cardiology there is someone who STOPs AND THINK. And this helps maintain hope that others will do the same.
What J. Mandrola perhaps didn't want to mention is that coronary angioplasty is a very profitable field. And the disagreement between eminence-based medicine and evidence-based medicine should be the subject of analysis and correction.
But this "makes no difference" makes sense, no? If you don't tell people that exercising and eating healthy is the way to go...after "getting the treatment" people are more likely to eat worse. Thinking the problem has been addressed. So whatever gain there is with the procedure gets negated by continuing or living a more unhealthy lifestyle. Or so, it seems to me.
Clearly "do no harm..." has lost its meaning
🙏