We are doctors. We know. Don’t we?
Wide variations in the application of medical treatments often differ greatly, sometimes solely by adjoining county or state line. This shouldn’t be. That a place of residence, not a clinical scenario, determines one’s treatment, highlights the inherent uncertainty of medicine. Based on 200 million per year in research grants, outcomes research on the effectiveness of medical treatments looks destined to be a point of emphasis of Americare.
It is true, that we need to look carefully at the application of newer technologies. It is right to ask whether the new is better than the old. Just because industry, or industry-sponsored experts, or even bloggers say it is so, does not make it so. Studies are good, especially those that provide “real-life” data. Hopefully, the new Patient-Centered Outcomes Research Institute can use its $200 million a year to help us know whether our notions of successful treatment are really confirmed by the evidence.
But, they can skip some treatments I am sure work amazingly well.
Let’s take the nine-point “Plan,” also known as the “Program,” as applied to the chronic heart disease patient. (It has wide applicability to many different clinical scenarios.)
In my specific arena of electrophysiology, excluding AF drugs which actually suppress AF, I use treatments that have strong data supporting their benefits. Drugs like statins, ACE inhibitors, beta blockers, and aspirin all have real and substantiated benefit in prolonging life. Catheter ablation has been confirmed effective for most arrhythmias, even AF. ICDs used in appropriately selected patients, also have compelling mortality benefit. (Admittedly, in the selection of ICD patients, an injection of wisdom, perhaps from outcomes research would be welcome.)
In medicine, it is reckless to be too certain of anything. I am convinced however, that my nine-point “plan” for ICD patients works near flawlessly–absent any intrusion of the non-cardiac, like cancer, infection or trauma.
On the surface, one might think a patient whose heart is weak enough to warrant an internal defibrillator would illustrate illness more than health. On the contrary, these damaged hearts seem to soak up the benefits of the common-sense, generic-medicine laden plan.
In 1984 he had a heart attack, and despite a total lack of said outcomes-based-research showing that the “squishing” of blockages was supported by any scientific data, he underwent an emergency angioplasty. Six years later, in 1990, he again had a blockage opened by the same doctors. On both occasions, his doctors had in front of them a simple equation: ‘”x” was a man suffering certain irreversible heart damage; “y” was new tools to open a blockage; and “z” was the common sense and nerves to use the new tools.
Twenty five years later, despite his seventy four birthdays, he appears trim and fit, in a functional sort of way–unlike the starving over-trainied athletic way. He grins at me as he peers out from under the long bill of the baseball cap emblazoned with a fertilizer logo. He and his wife of many years look at each other like they really enjoy each others company. You can just tell. He spent the previous weekend outdoors in the torrential rains, volunteering his help for the flood victims of his rural county. For years, he has adhered to the regimen of the big four medicines: ACE, Beta-blocker, Aspirin, and Statins. Not because he googled them, but because I told him he should. His clear conscious allows him to sleep well, his wife offered.
My grinning farmer illustrates the 9-point plan, for which I do not need outcomes based research to confirm its success. After benefiting from visionary doctors in the 1980’s my patient has lived the following plan…
- ACE/ARB inhibitor (cost: 4.00/month)
- Beta-Blocker (cost: 4.00/month)
- Aspirin (cost: 1.00/month)
- Statin (cost: starting at 4.00/month)
- Exercise: (cost: sneakers and jacket)
- Nutritional restraint: (cost: 0.00)
- Goodwill to others: (cost: 0.00)
- Lifelong companionship (costs: variable)
- Sleep hygiene (costs: variable, but not too much)
The sonogram may show a weak heart, and weak hearts are supposed to limit longevity, but those that live the plan seem to just keep showing up every year for their routine checks. I don’t do many surveillance stress tests, but others do, and remarkably his ejection fraction has improved from 25% to 40% over the past decade.
His success is not an anomaly. I have grown old enough to gather a herd of similar patients.
Stunning advances in the technology of medicine, like ICDs, stents, and ablation excite us doctors greatly. Outcomes research will help sort out some of the specifics of their application–my guess is though, most of their conclusions would be predictable by masters of the obvious. No matter how nifty the procedure is, adherence to the Plan will always be a necessary component for maximum benefit.
If the Patient Centered Outcomes Research Institute needs any more ideas, they should look in the blog-o-sphere.