My career in cardiology can be separated into two decade-long blocks. The first decade I practiced like most other cardiologists. I went with the flow, followed the guidelines. I went to few meetings, read few studies and as a result had little (mental) tension.
Your invoking of Sowell’s great insight from “A Conflict of Visions” to the practice of medicine is perfect. My oldest brother was an internist (geriatrician) and one of the early adopters of EBM. Geriatricians see the inevitability of death more clearly than most and the good ones know the constraints of both medicine and the human condition.
I followed my brother’s advice to always look at the evidence and have rejected multiple medical and surgical recommendations as a result, particularly related to PSA testing and spine and shoulder surgeries.
From my access to insurance claims data during my business career, I knew the actual practice of EBM wasn’t particularly common. But it was during Covid that the stark differences between those who know the constrained vision is the only one with good evidence and those who don’t became so clear. Even more frighteningly clear is the reality that we are treated and governed by docs and pols who almost universally follow the evidence-free unconstrained view. We are mostly the worse for it. Your work and willingness to shine a light on the problem is much appreciated.
I hope the reference to Thomas Sowell inspires others to read his works. Reading his magnum opus, "Knowledge and Decisions", as a young man had a profound effect on how I viewed practically everything. One of the great thinkers and expositors of the past several generations.
Constrained thinking in my opinion aligns much closer to true scientific practice. Conclusions and interpretations must remain within the scope of results. Did the experiment actually show X without any spin on the question at hand. When there is money to be made, the “results” are whatever drives greater industry, not the true outcome which is to protect and aid patients.
Well the next thing I do after this will be to look up that paper.
This is great stuff. Somewhat heartening that xarelto and eliquis spending exceeded corevalve….and that all those other devices (which have rarely equal ie Sapien ….but mostly less evidence ie all the rest) … attracted less spending. At least there is more data for those meds than for all of those devices.
It is truly baffling and maddening to see the low bar for approval of devices relative to meds, at least in the cardiology space. I’ve never understood the logic or justification for that disparity.
I don’t think a median of $50 would have outsized influence on anyone. However, I’d be curious about the top 1% of payments….how much that represents for cardiologists….who those recipients were….then matched to what those folks have publicly said. I imagine such a compilation would be interesting… and perhaps more than a little nauseating. And I wouldn’t be opposed to some naming and shaming besides.
I’d be even MORE curious about those top 1% lists matched to guideline writers, to see how much influence peddling $ exerts at the very top. I say this not because cardiology guideline writers hold any sway over me….I try my darnedest to practice to the evidence, and not to the guidelines (discouragingly recognizing more and more that those 2 things are not one and the same, as I had once thought earlier in my career)…but because every so often I venture to guidelines outside my strike zone (eg. PE) and quickly realize I have no idea about their evidence basis and need to take the guidelines at their word…then realizing most practitioners are in that same boat when it comes to perusing cardiology guidelines.
All that said, your summary statement hits the nail on the head. If spending this money didn’t work, pharma wouldn’t be doing it. That should give all of us pause the next time we each go to a conference, or a rep walks through the door.
I'm always a fan of escrow for these sort of problems.
The patient pays into escrow and if they're alive in say 5 years the drug company get their medical fee. This would tend to suppress false claims for little cost. There would probably be a secondary market trading these payments. Which I have not thought of the implications
As you wisely pointed out in your article, Sowell maintains that there are no perfect solutions but there are optimal solutions. Over and over, Sowell points out that optimal solutions require elimination of interference in the free market for goods and services. This almost always means eliminating government regulation and regulatory institutions. It is really not a great idea to have politicians and their appointees populating these groups and formulating policy. For example, how is that war on drugs going? Many people think the problem is "regulatory capture" by industry and that just having the right people in charge will take care of it. But a thorough examination of history tells us otherwise. During the late 19th and early 20th centuries various industries tried repeatably to establish monopolies but always failed. As soon as they tried to limit production and raise prices, new competitors would enter the market and undercut them. They then turned to the government to establish institutions and laws that would hamper their free market competitors. A thorough analysis of this process can be found in Murray Rothbard's book, The Progressive Era. So the optimal solution here is to eliminate the FDA, Interstate Commerce Commission, and practically all other government regulatory bodies at all levels of government. Would there still be problems? Of course, but it would be far superior to the mess that has evolved over the past 130 years.
At a cath conference after a complicated case was reviewed the cardiac surgeon summed up the situation . It was an example of " technology triumphing over reason" .
I have a friend (after 15 years I can call him that ) who services hot tubs. Mine leaked and he told me he needed a new cardiologist as his retired . He had a bypass 25 years ago and explained he had symptoms that were very concerning for progressive angina . He underwent a cath this week and a 95% RCA was stented. His LAfD mammary was perfect ...
I have sent many people for bypass and fought back against the let's do multiple stents knowing the surgeons would put in mammary and other arterial grafts.
As time has gone on that was a harder battle to win.
Then my friends cath films show up and it appears that "reason can triumph over technology" but it takes a bit of effort
He was discharged yesterday and said the new pump is in this week.
Well, Dr. Mandrola, first, you are not old. I’m 87 and do not consider myself old. My wife, age 88, and I walk 5 miles a day minimum. My wife has to take a synthetic thyroid hormone; otherwise, neither of us take any medication. My total cholesterol is under 135. I work hard in our garden and go biking every day. We don’t have a cardiologist to thank for our good health. We looked at the research 40 years ago and decided to change our horrible Standard American Diet. We realized we already had CVD, and if we did not make some changes, we would follow our parents with strokes or heart attacks. We have been on low fat, low salt, whole food plant-based nutrition ever since.
So, how do you bring constrained thinking to younger doctors? And how do you limit industry influence? One way is to practice 21st-century medicine by emphasizing prevention. Yeah, sometimes you have to be a scold. I have read your review of a study purported to show that food had little effect on heart health. And you rightly got taken out behind the woodshed for a thrashing by your readers. But the evidence is overwhelming now that a whole food plant-based diet can prevent and even reverse CVD, hypertension, type 2 diabetes, and even some cancers. A few older doctors are taking this message to medical students and residents, including Dr. Michael Klaper, cardiologist Dr. Columbus Baptiste at Kaiser Permanente, and Dr. Neal Barnard of the Physicians Committee for Responsible Medicine.
If you can keep your patients healthy by helping them change their destructive lifestyles, then the pharma and device reps will have nothing to offer you. And you can do what I do when I visit a new doctor for a physical or a minor injury. My first question after introductions is, “How is your plant-based eating doing doc?” I ask this to find out if they are practicing 21st-century medicine. So the next time an industry rep shows up, ask them that and tell them if they want to bring food or wine and dine with you, it must be plant-based. That will scare most of them off immediately.
Your patients are going to need help adopting whole food plant-based nutrition. So you have to set an example. Plant-based nutrition allows you to go faster and longer on your bike rides. At every patient visit, you ask them how their plant-based eating is going. Fortunately, today, there are endless resources to which you can refer them. Facebook, YouTube, and other social media have plant-based, vegan, and vegetarian support groups that post recipes and ideas daily. Numerous services will deliver ready-to-eat plant-based meals. When money or fresh produce deserts are the problem, you can subscribe to boxes of perfect but slightly blemished boxes of produce for delivery to your door.
We will still need cardiologists. It’s often too late for prevention. And stuff happens. Cardiologists are supposed to be innovative. Lifestyle changes, especially plant-based nutrition, should be part of their toolkit.
How about an old concept that still works: medical ethics. Yes, there is a right and wrong. Telling the truth is better for medicine than turning it into another cash cow influenced by industry and payers, as in insurance and the Federal government. Back in the dark ages when I taught Paramedics and practiced as same, there were so many opportunities for good: to do good, to speak the truth in love, to care about the outcome for our patients. I know, those were the old days when we were just “cowboys” trying stuff to see if it worked…no protocols, we were writing the protocols that I missed out on practicing in due to a series of severe back injuries (full disclosure, I have an Abbott Spinal Cord Stimulator implanted in my back which enables me to continue working in retirement in my true vocation as a Lutheran Pastor. I loved medicine, I am trying to love medicine now that I am just an educated patient. God bless you all and thank you for your service to all of us.
The present generation is already corrupted and they are passing on their corrupt practices to the next generation. They call their beliefs “guidelines” but they fail to acknowledge these are really written by that dark money you’re writing about. I’ve met no more than a half dozen thoughtful students/residents in the past 10 years. Every thing is teach to the test. They vomit back what has been pushed on by their teachers. They’re better at guidelines than we were at anatomy. They do what they have been taught and even when you show the evidence doesn’t support these teachings they keep doing them and likely will until they retire.
Kinda surprised that psych are high on the marketing list. I was in chronic non cancer pain and addiction and turned away every single opiate seller during the bloom of opioid liberation. And then turned away every bupe salesperson (usually young, attractive women). Once the organizations saw the money, true patient care went out the window.
“The challenge is how to bring constrained thinking to younger doctors. One way is to limit industry influence.”
Yes absolutely this is one way. Might bring drug and device costs down a little too. Another way is for government regulators and journal reviewers to exercise constrained thinking too. Recent exposure has revealed unjustified enthusiasm for the new, acceptance of low-quality proofs of efficacy and benefit of the doubt to developers. We will all happily spend other people’s money on a hope and a prayer and pad our wallets in the bargain if no responsible party holds our feet to the fire, and none seem to be doing that right now.
God bless and happy Easter. Keep up the good fight.
Your invoking of Sowell’s great insight from “A Conflict of Visions” to the practice of medicine is perfect. My oldest brother was an internist (geriatrician) and one of the early adopters of EBM. Geriatricians see the inevitability of death more clearly than most and the good ones know the constraints of both medicine and the human condition.
I followed my brother’s advice to always look at the evidence and have rejected multiple medical and surgical recommendations as a result, particularly related to PSA testing and spine and shoulder surgeries.
From my access to insurance claims data during my business career, I knew the actual practice of EBM wasn’t particularly common. But it was during Covid that the stark differences between those who know the constrained vision is the only one with good evidence and those who don’t became so clear. Even more frighteningly clear is the reality that we are treated and governed by docs and pols who almost universally follow the evidence-free unconstrained view. We are mostly the worse for it. Your work and willingness to shine a light on the problem is much appreciated.
I hope the reference to Thomas Sowell inspires others to read his works. Reading his magnum opus, "Knowledge and Decisions", as a young man had a profound effect on how I viewed practically everything. One of the great thinkers and expositors of the past several generations.
Constrained thinking in my opinion aligns much closer to true scientific practice. Conclusions and interpretations must remain within the scope of results. Did the experiment actually show X without any spin on the question at hand. When there is money to be made, the “results” are whatever drives greater industry, not the true outcome which is to protect and aid patients.
Well the next thing I do after this will be to look up that paper.
This is great stuff. Somewhat heartening that xarelto and eliquis spending exceeded corevalve….and that all those other devices (which have rarely equal ie Sapien ….but mostly less evidence ie all the rest) … attracted less spending. At least there is more data for those meds than for all of those devices.
It is truly baffling and maddening to see the low bar for approval of devices relative to meds, at least in the cardiology space. I’ve never understood the logic or justification for that disparity.
I don’t think a median of $50 would have outsized influence on anyone. However, I’d be curious about the top 1% of payments….how much that represents for cardiologists….who those recipients were….then matched to what those folks have publicly said. I imagine such a compilation would be interesting… and perhaps more than a little nauseating. And I wouldn’t be opposed to some naming and shaming besides.
I’d be even MORE curious about those top 1% lists matched to guideline writers, to see how much influence peddling $ exerts at the very top. I say this not because cardiology guideline writers hold any sway over me….I try my darnedest to practice to the evidence, and not to the guidelines (discouragingly recognizing more and more that those 2 things are not one and the same, as I had once thought earlier in my career)…but because every so often I venture to guidelines outside my strike zone (eg. PE) and quickly realize I have no idea about their evidence basis and need to take the guidelines at their word…then realizing most practitioners are in that same boat when it comes to perusing cardiology guidelines.
All that said, your summary statement hits the nail on the head. If spending this money didn’t work, pharma wouldn’t be doing it. That should give all of us pause the next time we each go to a conference, or a rep walks through the door.
I'm always a fan of escrow for these sort of problems.
The patient pays into escrow and if they're alive in say 5 years the drug company get their medical fee. This would tend to suppress false claims for little cost. There would probably be a secondary market trading these payments. Which I have not thought of the implications
As you wisely pointed out in your article, Sowell maintains that there are no perfect solutions but there are optimal solutions. Over and over, Sowell points out that optimal solutions require elimination of interference in the free market for goods and services. This almost always means eliminating government regulation and regulatory institutions. It is really not a great idea to have politicians and their appointees populating these groups and formulating policy. For example, how is that war on drugs going? Many people think the problem is "regulatory capture" by industry and that just having the right people in charge will take care of it. But a thorough examination of history tells us otherwise. During the late 19th and early 20th centuries various industries tried repeatably to establish monopolies but always failed. As soon as they tried to limit production and raise prices, new competitors would enter the market and undercut them. They then turned to the government to establish institutions and laws that would hamper their free market competitors. A thorough analysis of this process can be found in Murray Rothbard's book, The Progressive Era. So the optimal solution here is to eliminate the FDA, Interstate Commerce Commission, and practically all other government regulatory bodies at all levels of government. Would there still be problems? Of course, but it would be far superior to the mess that has evolved over the past 130 years.
You could always start a tiktok to reach us younger folk. But that might generate even more tension for you.
At a cath conference after a complicated case was reviewed the cardiac surgeon summed up the situation . It was an example of " technology triumphing over reason" .
I have a friend (after 15 years I can call him that ) who services hot tubs. Mine leaked and he told me he needed a new cardiologist as his retired . He had a bypass 25 years ago and explained he had symptoms that were very concerning for progressive angina . He underwent a cath this week and a 95% RCA was stented. His LAfD mammary was perfect ...
I have sent many people for bypass and fought back against the let's do multiple stents knowing the surgeons would put in mammary and other arterial grafts.
As time has gone on that was a harder battle to win.
Then my friends cath films show up and it appears that "reason can triumph over technology" but it takes a bit of effort
He was discharged yesterday and said the new pump is in this week.
Well, Dr. Mandrola, first, you are not old. I’m 87 and do not consider myself old. My wife, age 88, and I walk 5 miles a day minimum. My wife has to take a synthetic thyroid hormone; otherwise, neither of us take any medication. My total cholesterol is under 135. I work hard in our garden and go biking every day. We don’t have a cardiologist to thank for our good health. We looked at the research 40 years ago and decided to change our horrible Standard American Diet. We realized we already had CVD, and if we did not make some changes, we would follow our parents with strokes or heart attacks. We have been on low fat, low salt, whole food plant-based nutrition ever since.
So, how do you bring constrained thinking to younger doctors? And how do you limit industry influence? One way is to practice 21st-century medicine by emphasizing prevention. Yeah, sometimes you have to be a scold. I have read your review of a study purported to show that food had little effect on heart health. And you rightly got taken out behind the woodshed for a thrashing by your readers. But the evidence is overwhelming now that a whole food plant-based diet can prevent and even reverse CVD, hypertension, type 2 diabetes, and even some cancers. A few older doctors are taking this message to medical students and residents, including Dr. Michael Klaper, cardiologist Dr. Columbus Baptiste at Kaiser Permanente, and Dr. Neal Barnard of the Physicians Committee for Responsible Medicine.
If you can keep your patients healthy by helping them change their destructive lifestyles, then the pharma and device reps will have nothing to offer you. And you can do what I do when I visit a new doctor for a physical or a minor injury. My first question after introductions is, “How is your plant-based eating doing doc?” I ask this to find out if they are practicing 21st-century medicine. So the next time an industry rep shows up, ask them that and tell them if they want to bring food or wine and dine with you, it must be plant-based. That will scare most of them off immediately.
Your patients are going to need help adopting whole food plant-based nutrition. So you have to set an example. Plant-based nutrition allows you to go faster and longer on your bike rides. At every patient visit, you ask them how their plant-based eating is going. Fortunately, today, there are endless resources to which you can refer them. Facebook, YouTube, and other social media have plant-based, vegan, and vegetarian support groups that post recipes and ideas daily. Numerous services will deliver ready-to-eat plant-based meals. When money or fresh produce deserts are the problem, you can subscribe to boxes of perfect but slightly blemished boxes of produce for delivery to your door.
We will still need cardiologists. It’s often too late for prevention. And stuff happens. Cardiologists are supposed to be innovative. Lifestyle changes, especially plant-based nutrition, should be part of their toolkit.
How about an old concept that still works: medical ethics. Yes, there is a right and wrong. Telling the truth is better for medicine than turning it into another cash cow influenced by industry and payers, as in insurance and the Federal government. Back in the dark ages when I taught Paramedics and practiced as same, there were so many opportunities for good: to do good, to speak the truth in love, to care about the outcome for our patients. I know, those were the old days when we were just “cowboys” trying stuff to see if it worked…no protocols, we were writing the protocols that I missed out on practicing in due to a series of severe back injuries (full disclosure, I have an Abbott Spinal Cord Stimulator implanted in my back which enables me to continue working in retirement in my true vocation as a Lutheran Pastor. I loved medicine, I am trying to love medicine now that I am just an educated patient. God bless you all and thank you for your service to all of us.
Excellent reflection. Hope it is widely read. We need more constrained thinking in medicine.
The present generation is already corrupted and they are passing on their corrupt practices to the next generation. They call their beliefs “guidelines” but they fail to acknowledge these are really written by that dark money you’re writing about. I’ve met no more than a half dozen thoughtful students/residents in the past 10 years. Every thing is teach to the test. They vomit back what has been pushed on by their teachers. They’re better at guidelines than we were at anatomy. They do what they have been taught and even when you show the evidence doesn’t support these teachings they keep doing them and likely will until they retire.
Kinda surprised that psych are high on the marketing list. I was in chronic non cancer pain and addiction and turned away every single opiate seller during the bloom of opioid liberation. And then turned away every bupe salesperson (usually young, attractive women). Once the organizations saw the money, true patient care went out the window.
What advice would you (or others) have for a current medical student then?
“The challenge is how to bring constrained thinking to younger doctors. One way is to limit industry influence.”
Yes absolutely this is one way. Might bring drug and device costs down a little too. Another way is for government regulators and journal reviewers to exercise constrained thinking too. Recent exposure has revealed unjustified enthusiasm for the new, acceptance of low-quality proofs of efficacy and benefit of the doubt to developers. We will all happily spend other people’s money on a hope and a prayer and pad our wallets in the bargain if no responsible party holds our feet to the fire, and none seem to be doing that right now.
God bless and happy Easter. Keep up the good fight.
I am a fan of Ben Goldacre, suggest reading his book, Bad Pharma.