Atrial fibrillation Doctoring Reflection

Can experience make it tougher for doctors?

You have probably read that experience makes for better doctors.

And of course this would be true–in the obvious ways, like with the hand-eye coordination required to do complex procedures, or more importantly, with the judgment of when to do them.

There’s no news here: everyone knows you want a doctor that’s been out of training awhile, but not so long that they have become weary, close-minded or physically diminished. Just the right amount of experience please.

But there’s also potential downsides struggles that come with experience. Tonight I would like to dwell on three ways in which experience is causing me angst.

But first, as background…

It was the very esteemed physician-turned-authors, Dr Groopman and his wife, Dr Hartzland, who wrote this thought-provoking WSJ essay–on how hidden influences may sway our medical decisions–that got me thinking about how I have evolved as a doctor. They were writing from the perspective of the patient. But in the exam room, there are two parties: patient and doctor.

# 1) The sobering view that experience brings:

Looking back at the history of a medical treatment is intensely sobering. It’s distressing to think how sure you were of a treatment that turned out not only to be ineffective, but downright dangerous. (Seldane, Vioxx (all NSAIDs?), and stenting non-symptomatic coronary blockages leap to mind; there are many more.)  Living through the history of medical folly forces experienced doctors to present patients a more measured outlook. (Perhaps it’s why many doctors run so far behind in the office.) But at the same time, doctors also see the benefits of the fury of medicine. Patients come back to the office better; their lives enhanced (or saved) by new catheters, new medicines or even an implanted device. What’s more, over-thinking a problem gives masters-of-the-obvious acid reflux. The dilemma: don’t over-think it, but don’t oversell it either.

# 2 ) How much science is needed?

New medicines and procedures are emerging rapidly. (Which is a very good thing.) Many of these advances boast striking statistical advantages but have yet to be tested in the real world. Complicating this struggle–new versus old–has been debacles like the Multaq story: where paid consultants continued to tout a drug that doesn’t work and may not be safe. Though far from the rule, this outlier case gives both doctors and patients pause about the validity of science conducted and funded by industry.

But on the matter of science: does every therapy require a prospectively-detailed evidence base?

Take the angioplasty story:

Older doctors can tell you the story of acute angioplasty (squishing open an occluded artery) during a heart attack. Years before randomized controlled clinical trials or outcomes research showed that physically opening a blocked artery during a heart attack was better than giving a clot-buster–that failed 20% of the time or caused catastrophic brain bleeding–heart doctors were saving lives with angioplasty. They treated patients as they would want if it were them–to get that artery open, pronto. Their common sense was spot on. The moral of the story: not everything that is good for people, or favorably reimbursed, can be vetted first by mountains of evidence.

Another example of a successful treatment without an outcomes evidence base is AF ablation:

Patients with AF that isn’t controlled by medicine or lifestyle change(s) face a tough choice. They can, of course, live with the disabling symptoms of AF–resetting (lowering) their wellness barometer. Or they can reach for the treasure that AF ablation holds: freedom from AF and the need for taking drugs. This treasure, however, comes with a cost: the risk of the procedure and the untested long-term results of AF ablation. For instance, we cannot tell an AF patient that burning the left atrium reduces their risk of stroke or extends their life. Right now, all we can honestly say is that ablation is more likely than drugs to control AF symptoms. (The CABANA trial—which is currently enrolling patients–compares AF drugs to ablation. This trial seeks to answer these outcomes questions.  But the answer is many years away. And even when the data comes out, the ablation tools used today will surely be outdated.)

#3) We can…but should we.

This struggle, my friends, grows harder by the day. As people live longer (and get sicker), the benefits of treatments reach an asymptote: the point where the benefits of aggressive treatment become neutralized by the risks. A few years ago, I thought of this plateau as the point where we say uncle. Enough.

But isn’t this kind of thinking wrong-minded? Would not a more enlightened–albeit far more time consuming and emotionally draining–way to approach this intersection near death be to ask people to consider their goals of treatment. Where are they on this curve?  Why does the default mindset hold that death is something that can be beaten? Or, why do many patients (and doctors) consider the human costs of delaying death as minimal; they are not.

In a recent JAMA appendix, I saw that there were thousands of residency slots for interventional radiology and cardiology, but only a mere hundred (or so) for palliative care.

It seems highly relevant to at least offer patients the choice of comfort-focused care rather than continued life-prolonging care. Paradoxically, earlier adoption of palliative care may sometimes actually prolong life. What was a kid to think when he saw his 89 year-old grandfather live another 5 years after throwing his pills away?

Suffice it to say, that many of us are evolving the way Dr Groopman has: toward at least considering the option of no treatment, or to use big words: towards minimalism.

We can, but should we?  I surely don’t know the answer. That bothers me.

You see…

Experience complicates things.


6 replies on “Can experience make it tougher for doctors?”

Good article, John. I find that as I get older I get less convinced by the scientific backing of much of what we do. I used to feel like most of what I did had a decent scientific basis, but as time went by the science either was undermined or the obvious answers were question and proven to be weak or even wrong. Antibiotics for sinusitis, cholesterol lowering (Zetia and Fenofibrate – do they do anything besides change numbers?), and bisphosphanates for osteoporosis are some things that come to mind for a PCP. All of these dogma (not to mention post-menopausal HRT to prevent heart disease) have been severely undermined in my time and have made some of what I do seem uncomfortably non-scientific. It weakens any criticism of alternative medicine as being unscientific when I am also doing lots of things that are unscientific.

Thanks for this. Good post.

Great post Dr. J- i’m always impressed by your obvious humanity and care for your patients and the wider community. If all health practitioners and politicians had the same perspective the health problems of western socities could be dramatically reduced. I’m fond of saying that modern medicine can give us extra years of life but not necessarily a good quality of life. It’s immature of a society to believe that it can receive top quality and highly costly medical care right up to the point of death- it’s simply unsustainable as we live longer. We need a mature debate about what constitutes appropriate health care across the age/health status continuum, a greater effort by our politicians to help to create a health inducing environment, and an acceptance by all that they are responsible for their own health, most of the time. I’m just going outside to watch the pigs coming in to land!

Thank you again, Dr. M for another insightful and interesting blog. Your writings and the article you referenced by Dr. Hartzband cut to the core of the dilemma we patients also face as well regarding treatments. Dr. Hartzband’s article, for example, shows the problems with statistics and numbers based medicine, or as I like to call it, the “If my ‘numbers’ are so damn good, why do I feel so damned bad?” question.

The internet is both a blessing and a curse, as we common folk now can google any medical problem, symptom, medication and treatment and can be instantly rewarded with 10,000 often very conflicting sources of information and mis-information.

What to do, for example, when statistics are found which seem to indicate that the treatment option might be worse than doing nothing. Interestingly, Dr. Hartzband uses exactly the example of statins statistics that are so confusing, and that I also researched.

Another example that I find confusing, both from a statistical and anecdotal standpoint, is the use of anti-coagulants in afib. Statistically, if you drill down deep enough into the numbers, the risk of having a debilitating embolic stroke is pretty darn low in the general population, and afib contributes only a fairly small percentage to that total number of embolic strokes annually. On the other hand, statistically, the risk of having a major bleed or hemorrhagic stroke from anti-coagulants seems to be almost the same as the risk of the embolic stroke. In addition, anti-coagulants can contribute to many other problems – GI bleeds, retinal problems resulting in blindness, skin disorders (what I call the “old man’s skin” look – full of bruises, ugly blood blisters and constant tearing – I never knew what caused that until recently) and many other so called ‘minor’ side effects. I personally don’t consider blindness a minor side effect. Yes, I did see that listed as a possible side effect on a medication info sheet once. The disclaimer was that “your Doctor has determined that the possible benefit from this medication out-ways the amazing array of potentially lethal side effects mentioned here. DO NOT stop taking this medication without your Doctor’s permission”. I love that “without your doctor’s permission” statement. I never realized that my Doctor owned me. I see that particular wording has been replaced by “consulting your Doctor” now on all the latest inserts.

Anecdotally, I don’t know a single person who has had any type of major stroke except one (not the result of afib). I do know people who have afib, are not on anti-coagulants, and have not had a stroke. I know of at least 5 people who have had their lives ended, ruined or complicated by coumadin or warfarin. Just this past Sunday, I met another one who now has seizures, poor memory and cognition, and is a shell of the person I knew a year ago – all from coumadin I guess that is a minor side effect by some standards of statistical thinking, as he was one of the unlucky 6% with hemorrhagic stroke, trying to prevent the 4% embolic stroke risk from afib.

Maybe I’m all off base. I would love it if one of the regular readers of this blog can give me some real world outcomes in patients you see regarding the anti-coagulation question. In real life, What do you see as the odds either way?

Dr. M, keep up your common sense patient based medicine – don’t give in to the statistical dark side 🙂 I see similar issues in my profession, where what statistically seemed like a good idea, the manual has instructions for, or “research shows us that” turns out to be anything from terrific to a horrible outcome in real life. Sometimes I just have to go with my gut feeling. Fortunately what I do doesn’t deal with life or death situations for individuals.

Your article gives me support.
At 76 I have had afib for about 20 years. I have never felt an erratic heart-beat. I was persuaded to go on aspirin. A few years ago, ‘because of age’ my doctor wanted me to go on warfarin. I really did not fancy turning into a semi invalid, carrying a card with me everywhere, and visiting hospital regularly to balance a highly ‘thinned’ bloodstream.As I have had a wholefood vegetarian diet for 60 years, and for some time have taken many natural supplements, recommended by scientific studies, to ‘thin’ the blood, I asked for some blood test to show how susceptible my blood was to clot in the heart. This was not possible I was told. The apparntly crude measure would change a normal 1 to 2.5, but was I already at 1.5 or 2, I wondered!
In summer I walk 2 to 6 hours, have used a mini-trampoline for 6 months, which is fun, and was starting to ‘sprint’ in short burst, apparently rather better than half an hour of leass energetic exercise. My blood pressure seems to be normal. Over six months I find that I have reduced my resting blood-pressure; it reads as low as 117/ 75, though, out of the blue, it has had both figures high, even when resting. I have always felt good, with no aches and pains.
2 months ago I had a TIA, causing me to drop my shopping. I got an ambulance to A and E. Consultant wanted me to go on warfarin, which I resisted. I stopped climbing the stairs to my 17th. floor flat, and ‘took it easy’ on his recommendation. However, 10 days ago I had a more moderate TIA, which rather concerns me.
My consultant said that warfarin would protect me 5 times as much as aspirin. I did check the figures. However, I also checked my lifestyle and supplements, which gave me much more protection in % terms. Still I find that, as a patient, I hardly have the experience to disagree with a consultant! He’s suggested Digabatrin, which does not need to be carefully balanced like warfarin, yet is much more expensive. (As I live in UK, this does not directly affect me, as treatment and drugs are free here). I still really wonder, whether this will really reduce my chance of stroke. No one has explained, and I can’t find it on the internet, why some of us get TIAs rather than full strokes. Is it because our healthy body copes very quickly to dissolve a clot?
Any guidance and ideas will be appreciated. Is it possible that the two clots I’ve apparently had, are part of my arteries becoming healthier and more floxible. Do I really want them more rigid? An expert opinion would be of interest.

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