Finally got around to testing this, thanks for the perspective. I went back and read the CAC article in AAFP. As a family doc I appreciate the perspective even more. Much of what I do is explaining why I’m NOT recommending a medicine, test, or treatment. Patients often lose trust and confidence when you’re NOT doing a lot of doctoring.
And in the spirit of “don’t hate the player, hate the game,” I think the omnipresent threat of malpractice looms over our best intentions as doctors. We are faulted for “not doing” more than for “doing.” And malpractice is a traumatic, potentially ruinous claim.
If the rules of the game were changed, and we had specialized malpractice courts instead of layperson juries who want to “stick it to the man” (a recent quote from a juror in the Philadephia area after finding an orthopedic surgeon liable for $41 million dollars) - then maybe doctors would feel more free to “do less” as a beneficent act.
I have been reading and listening a lot of your pieces and podcast for about 3-4 years.
But this one is one of my favorites, if not my favorite. It should be on the front page of every journals, medical or not. So well written and thought.
Thank you. Even more for making me add "medical nemesis" to my (long) book wishing list.
I came to your blog because of my afib, but work in the OB part of the medical world. I think there might be a different perspective on the role of preventative medicine at the OB and Pediatric end of the life spectrum of healthcare than in adult cardiology. It is not as though the same pitfalls don't exist, but the payoffs for successful preventative interventions can be lifelong.
A thought provoking read! Thank you. Much prolonged suffering arises from the inability of patients, and doctors, to give a "value for dying". Mitch Albom in his book 'Tuesdays with Morrie', gives us hints on why we can truly live only when we can find meaning for dying.
It is a legitimate question as to where the responsibility for well care belongs. Even if medicine were the place the cost is not far to high to be achievable. The biggest issue to me is food. If we cannot teach better nutrition and convince people to put it into practice not much will change. Does that belong in the home, in the school, in the local government. In the past the access to food was more limited and sourced more naturally. Advances in food access are valuable but the consumption issue is massive as is the abuse of many unhealthy snacks due to sugar and salt intake. The food industry needs to be part of the solution. Where is the FDA. I am not a fan of more regulation and policing people is not the answer. But education is.
What are your thoughts on treatment of cardiac sarcoidosis and related heart failure and arrhythmias associated with cardiac sarcoid scarring? Have maintained a very active lifestyle since diagnosis and treatment in 2016 and ICD/PPM implant in 2017. However, last 6 months have been a real struggle. My treatment team blames Sarcoidosis Associated Fatigue. Thanks!
Also... as a nurse... I’ve heard that 200,000 to 400,000 are injured or killed per year by medical mistakes... and they don’t even really track it. Many times they don’t even make the patient aware of the mistake. So with that... we don’t really know how many are harmed or saved.
John -- Great post. This idea is contrarian especially in the public commons where platitudes rule. I might add that sick care and prevention are not necessarily mutually exclusive. I would suspect that with some of your patient encounters there are opportunities to instill new health habits. You are in a unique position to impact folks when they're most vulnerable. Thank you for a great post...
As a doctor who has come to many of the same conclusions as yourself, I find myself wondering if maybe this is slightly off the mark.
It's reasonable, in my mind, for medicine to be involved in prevention. Yet at the same time i agree with you that this may be causing more harm than good. The problem is not with 'medicine', but because unfortunately the training and practice of doctors is so poor they cannot restrain themselves from doing an unnecessary test or intervention. The training and ethos of medicine today lacks so much awareness of the harm it is capable of that we have to prevent a doctor from touching a "well patient" because he will more likely than not turn a well patient into a sick patient. This doesn't mean that medicine should not have a major role in prevention. It is instead an indictment of the level of basic medical competence in our world today.
Excellent article. As a medical student, it is very useful to consider these thoughtful critiques of ways of thinking that are very in vogue. You said “don’t even get me started on digital health”, but I would love to hear from you on what your thoughts and hesitancies are on that particular subject.
Reading the paper about coronary artery calcium scans, I guess you would never prescribe a calcium scan for an individual who has had two nuclear imaging scans in 7 years (with similar results) and has been on statins for 20 years. Aren't calcium artery scans more difficult to interpret for individuals that have been on statins ??
Interesting piece. I would merge the concepts here with the high value vs low value care concept you have advocated for in the past.
Primary PCI is high value care. Some “prevention” interventions could be construed as low value. But not all prevention is equal. Primary prevention of an otherwise “healthy” asymptomatic person (as you have illustrated here) is one thing; secondary prevention of someone who has already had a prior event is another. And the difference is in the NNT.
In that sense, you don’t necessarily need to be acutely/gravely sick, like a STEMI with C-shock, to really reap benefit from care. And one way we can objectively assess the size of benefit is of course via NNT of the proposed intervention. And as for the “value” component, to further look at the ICER.
I definitely agree about the ACC HF stages…pointless scale that I don’t use, if for no other reason that it is not utilized as inclusion criteria for clinical trials.
Excess profit creates soft thinking in the medical establishment.
Finally got around to testing this, thanks for the perspective. I went back and read the CAC article in AAFP. As a family doc I appreciate the perspective even more. Much of what I do is explaining why I’m NOT recommending a medicine, test, or treatment. Patients often lose trust and confidence when you’re NOT doing a lot of doctoring.
And in the spirit of “don’t hate the player, hate the game,” I think the omnipresent threat of malpractice looms over our best intentions as doctors. We are faulted for “not doing” more than for “doing.” And malpractice is a traumatic, potentially ruinous claim.
If the rules of the game were changed, and we had specialized malpractice courts instead of layperson juries who want to “stick it to the man” (a recent quote from a juror in the Philadephia area after finding an orthopedic surgeon liable for $41 million dollars) - then maybe doctors would feel more free to “do less” as a beneficent act.
You know?
I have been reading and listening a lot of your pieces and podcast for about 3-4 years.
But this one is one of my favorites, if not my favorite. It should be on the front page of every journals, medical or not. So well written and thought.
Thank you. Even more for making me add "medical nemesis" to my (long) book wishing list.
I came to your blog because of my afib, but work in the OB part of the medical world. I think there might be a different perspective on the role of preventative medicine at the OB and Pediatric end of the life spectrum of healthcare than in adult cardiology. It is not as though the same pitfalls don't exist, but the payoffs for successful preventative interventions can be lifelong.
A thought provoking read! Thank you. Much prolonged suffering arises from the inability of patients, and doctors, to give a "value for dying". Mitch Albom in his book 'Tuesdays with Morrie', gives us hints on why we can truly live only when we can find meaning for dying.
It is a legitimate question as to where the responsibility for well care belongs. Even if medicine were the place the cost is not far to high to be achievable. The biggest issue to me is food. If we cannot teach better nutrition and convince people to put it into practice not much will change. Does that belong in the home, in the school, in the local government. In the past the access to food was more limited and sourced more naturally. Advances in food access are valuable but the consumption issue is massive as is the abuse of many unhealthy snacks due to sugar and salt intake. The food industry needs to be part of the solution. Where is the FDA. I am not a fan of more regulation and policing people is not the answer. But education is.
What are your thoughts on treatment of cardiac sarcoidosis and related heart failure and arrhythmias associated with cardiac sarcoid scarring? Have maintained a very active lifestyle since diagnosis and treatment in 2016 and ICD/PPM implant in 2017. However, last 6 months have been a real struggle. My treatment team blames Sarcoidosis Associated Fatigue. Thanks!
Also... as a nurse... I’ve heard that 200,000 to 400,000 are injured or killed per year by medical mistakes... and they don’t even really track it. Many times they don’t even make the patient aware of the mistake. So with that... we don’t really know how many are harmed or saved.
Just ask how much they make off obesity in the USA?!!!
Investments in PREVENTION should be at the real-food, exercise, and lifestyle end of things, not at the medical end.
John -- Great post. This idea is contrarian especially in the public commons where platitudes rule. I might add that sick care and prevention are not necessarily mutually exclusive. I would suspect that with some of your patient encounters there are opportunities to instill new health habits. You are in a unique position to impact folks when they're most vulnerable. Thank you for a great post...
As a doctor who has come to many of the same conclusions as yourself, I find myself wondering if maybe this is slightly off the mark.
It's reasonable, in my mind, for medicine to be involved in prevention. Yet at the same time i agree with you that this may be causing more harm than good. The problem is not with 'medicine', but because unfortunately the training and practice of doctors is so poor they cannot restrain themselves from doing an unnecessary test or intervention. The training and ethos of medicine today lacks so much awareness of the harm it is capable of that we have to prevent a doctor from touching a "well patient" because he will more likely than not turn a well patient into a sick patient. This doesn't mean that medicine should not have a major role in prevention. It is instead an indictment of the level of basic medical competence in our world today.
Dr. Mandrola,
Excellent article. As a medical student, it is very useful to consider these thoughtful critiques of ways of thinking that are very in vogue. You said “don’t even get me started on digital health”, but I would love to hear from you on what your thoughts and hesitancies are on that particular subject.
Thank you.
Reading the paper about coronary artery calcium scans, I guess you would never prescribe a calcium scan for an individual who has had two nuclear imaging scans in 7 years (with similar results) and has been on statins for 20 years. Aren't calcium artery scans more difficult to interpret for individuals that have been on statins ??
Interesting piece. I would merge the concepts here with the high value vs low value care concept you have advocated for in the past.
Primary PCI is high value care. Some “prevention” interventions could be construed as low value. But not all prevention is equal. Primary prevention of an otherwise “healthy” asymptomatic person (as you have illustrated here) is one thing; secondary prevention of someone who has already had a prior event is another. And the difference is in the NNT.
In that sense, you don’t necessarily need to be acutely/gravely sick, like a STEMI with C-shock, to really reap benefit from care. And one way we can objectively assess the size of benefit is of course via NNT of the proposed intervention. And as for the “value” component, to further look at the ICER.
I definitely agree about the ACC HF stages…pointless scale that I don’t use, if for no other reason that it is not utilized as inclusion criteria for clinical trials.
How about a new diagnostic code for 'pre-death', AKA life?