Doctoring ICD/Pacemaker

Words, ICDs, and Patient-Centered Medicine…

Guess what made the heart rhythm news wire yesterday?

It wasn’t a new medicine,

or a new stent,

not even a new ablation catheter,

and, it surely wasn’t a revolution in motivating people to exercise.

It was words. Rhetoric… It seems that one man, Dr John Wilson, read all of the major ICD trials, dating back more than a decade, and found that the study authors emphasized positive aspects of ICDs while giving less weight to their sobering complication rates.

As reported by Steve Stiles on, Dr Wilson likened such “message framing” to marketing strategies “that try to sell a product.”

Though his opinions bordered on the sensational, Dr Wilson gave advice that spoke strongly to me:

“I think the bulk of the information from these trials would suggest that these devices do make people live longer, but I think also it’s very likely that if patients were given a more balanced view about risks and benefits, fewer of them would be willing to take it on,”

And this, (my emphasis)

Guidelines, he said, “tend to make it sound like if something is found to be effective, it should be put in all patients with that problem, when in fact what should probably be said is: if it’s effective, patients should be given information about the benefit and the risk and allowed to use their own judgment to decide whether they’d prefer to live a little longer—in many cases just a couple of months longer—or possibly experience infection or get shocked multiple times with the defibrillator.” If patients received this type of information, “you’d probably find that a lot of them would be very skeptical about having these devices put in.”

That last paragraph slants a little too far to the negative, but it suffices to show how a patient-centered ICD conversation is a tough one. It also highlights the notion of how practicing medicine gets harder as we accumulate better (and more invasive) tools. (And yet another excuse reason why so many of us fall so woefully behind in the office.)

In selected patients, ICDs unequivocally provide statistical benefit, but there are risks, and alternatives—as in any invasive treatment. In this way, ICDs are akin to many other expensive and invasive therapies. Cancer chemotherapies like adriamycin, with its cardiac toxicity, come to mind, for example.

Most smart doctors read journal articles with a critical eye. They (should) know that the writers are passionate and convinced of their positive findings. Such is human nature.