Dr John M

cardiac electrophysiologist, cyclist, learner

Not Challenging Science is Anti-Science

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Freedom of speech is in the news. Intolerance of ideas isn’t just affecting our colleges and universities.

I think illiberalism has spread to health and medicine. For many reasons, scientists and clinicians alike have grown weary of debate.

This is bad. The philosopher Karl Popper said science advances through falsification.

Without the challenge of ideas, dogma persists, progress stops.

Click on the hyperlink below to read my latest on theHeart.org | Medscape Cardiology.

Freedom of Speech Is Also Needed in Health and Medicine

JMM

On a quest to understand medical evidence …

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One of the biggest challenges in medicine and science is understanding correlation and causation.

Medicine has become increasingly evidence-based. But what does the evidence really say? Is a study signal or noise? Does enough correlation mean causation (e.g. smoking causes cancer)?  How much hope can we put on big data?

In the last few years, I’ve been on a quest to understand evidence. I am in the beginning stages–akin to a cat-4 bike racer.

Sometimes a piece comes along that really helps.

This one is long. You can’t read it while waiting in line for coffee. It takes time to digest it all.

But I think it helps explain the many biases of evidence.

It’s called Correlation, Causation and Confusion. 

(http://www.thenewatlantis.com/publications/correlation-causation-and-confusion)

JMM

Hat-tip to

Dr. Anish Koka  (@anish_koka) https://twitter.com/anish_koka 

Dr. Saurabh Jha (@roguerad) https://twitter.com/RogueRad

 

A Corrosive Force in Medical Care

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It comes in a large white envelope each month. It’s marked confidential.

When I hold it up to the light, I can see through the envelope. I can’t see the details, but the colored graphs give it away.

It’s my monthly productivity report. Most employed doctors get these graphs.

These “dashboards” of value include your own productivity as well as many graphs on how you stack up with other doctors across the country. It shows your employer if you are a hard worker.

The measure of productivity we use is called the relative value unit or RVU.

Doing an ablation, cath, stent or valve replacement earns a bunch of RVUs.

Listening to patients, examining patients, counseling patients, hugging patients earns very few RVUs.

Doing important research, teaching colleagues, and reading the medical evidence earns zero RVUs.

Too often, in too many medical systems, RVUs have become the primary unit of success.

No, you can’t be a mean and nasty doctor. And no, you can’t be a totally unskilled doctor who has too many complications.

But short of those extremes, if you make few waves, have good templates on your electronic health record so documentation is complete, and do tons of procedures, you are valuable.

If, on the other hand, you like slow conservative medicine, or narrative notes rather than templates, or worse, if you are thoughtful and frank about silly policies, you become an outlier. If you do these things, your RVU tally usually does not reach the 75% of standard. Then trouble can come to you.

These trends are not so problematic for people close to the end of their career.

What’s really scary, though, is that this is the milieu in which a younger generation is learning the craft. I was shocked to learn that a major teaching center (will remain nameless) has its teaching faculty on 100% productivity compensation. Imagine that. Teachers of young people whose paychecks are determined by how many RVUs they generate.

This, my friends, is happening in many of the places you go to get health care.

It’s why I tweeted this yesterday.

Productivity and the RVU has no place in medical care. There needs to be a different system of valuing the care of people with disease.

JMM

We get what we tolerate…

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Richard Fries, a cycling-safety advocate in Boston, uses the phrase we get what we tolerate to describe the dire situation of drivers killing cyclists and pedestrians. Many humans die from these collisions because we tolerate it. An inattentive driver kills a person on a bike; then nothing changes.

The phrase applies well to other dubious policies in the US. Before a gunman slaughtered 60 innocent people with a machine gun in Las Vegas Sunday night, I had planned to use the we get what we tolerate phrase in health care policy.

I was going to argue that US citizens pay too much for medication, navigate a morass of bureaucracy to get to their doctor, and succumb to capricious insurance companies for important medical decisions because we tolerate it. We get an unjust healthcare system because it’s what we tolerate.

Then came another gun massacre.

We also tolerate gun violence. Every damn time a mass slaughter occurs, the “thoughts and prayers” go out, and nothing changes. The comparative graphs of US gun violence to any other country boggle the mind.

During a fishing trip in Alaska this summer, the boat captain told me nearly every Alaskan has a gun. Guns, he said, are necessary if you live in the wilderness. I then asked if they have gun violence in Alaska. “Almost none,” he said.

The thing is: most of the US is not an Alaskan wilderness. Bears do not wander into most of our cities and suburbs. The lack of gun violence in Alaska, therefore, does not argue for arming teachers in suburban schools.

I don’t fancy guns, but I understand some people do. That is fine.

But, similar to the healthcare debate, it seems we could start a civil discourse with new set points. For instance, let’s agree on the notion that citizens need not own assault weapons, which are essentially war machines. Could we at least discuss how to register and regulate gun purchases?

I suspect a majority of citizens–even most gun owners–would favor a ban on assault weapons and some degree of gun registration.

Consider the we get what we tolerate phrase in relation to other public safety issues:

If plane crashes killed a fraction of those killed in gun massacres, there would be an outcry for aviation safety.

When infections threaten the population, people clamor for preventive therapies.

Society gets aviation safety and protection against microbes because we don’t tolerate unsafe planes and the spread of dangerous infections.

When we decide not to tolerate gun violence, dangerous drivers, and an unjust ineffective healthcare system, things might change.

JMM

Big lessons from my error

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I was furiously tapping on the computer when he asked: “Doc, what happens if I don’t have the procedure you are recommending?”

Glee spread through my body. I grinned and nearly jumped up from the stool to hug him. I enthusiastically answered.

Few patients ask this vital question.

I tweeted about the encounter:

A number of people noted my error:

These people are correct.

I should have explained the expectations of not doing the procedure. My patient should not have had to ask.

In this case, I hadn’t described what would happen without the procedure because he had come to me for a problem that was causing him to feel poorly, and the fix I offered was easy, elegant and low-risk.

My enthusiasm to help got in the way of offering the option of not having the procedure.

…

It turns out that my lousy job of providing informed consent was not the only criticism of this encounter.

Dr. Ajay Kirtane is a thoughtful and prominent interventional cardiologist. He tweeted another line of criticism:

Dr. Kirtane’s comment highlights the problem of underuse.

I suspect he sees many suitable patients who have not been offered cutting-edge therapy.

Of course, inequity is a fundamental flaw in US healthcare. It’s an ugly blemish for our nation.

Once a month, on Saturdays, I see underserved and low-income patients in the Have-A-Heart clinic. The difference between this clinic and my regular job is stark.

In my regular job, in a well-endowed private hospital in a rich suburb, the challenge is improving decision quality and reducing harm from over-diagnosis and over-treatment. In the Have-A-Heart clinic, the challenge is simply to deliver basic medical care.

I am not a policy expert, but I think our enormous waste of medical resources–created mostly by fear-mongering, disease creation, over-diagnosis and over-treatment–causes, or at least exacerbates, underuse.

So to my colleague, Dr. Kirtane, I respectfully propose that over-diagnosis and over-treatment is the disease and underuse is a symptom. If we treat the disease, symptoms will likely improve.

The bottom-line for patients:

If you are well; if you have no complaints, be damn suspicious of any medical intervention, especially screening. Take this paper to your doctor and have her/him explain how you would benefit from screening. Although some (high-risk) people might benefit, the real beneficiaries of screening are hospitals, doctors and industry.

If you have a problem, and your doctor proposes an intervention, be sure to get answers to the four crucial questions. Enthusiastic doctors may forget to give you all the scenarios.

If your healthcare experience is lacking; if it’s hard to get an appointment; if it’s hard to find time with the doctor; if it’s too expensive; then it may be time to ask public leaders to address two core problems in US healthcare: waste and inequity. Absent from the debate in Washington now is any reform of these core problems.

JMM

Statins, Like All Medicines, Are Neither Good Nor Bad

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We have to talk about drugs.

No, not illicit drugs, but medications used by doctors and patients.

Plaintiff attorneys run ads on TV that fool people into thinking certain meds are bad. The current one I deal with is the clot-blocking drug rivaroxaban (Xarelto.) Before that, it was dabigatran (Pradaxa). If, or when, the makers of rivaroxaban settle a class action suit, you can bet apixaban (Eliquis) will be next.

These ads are a problem because they use fear persuasion (see Scott Adams’ blog), and because they can induce patients to stop taking or not start a beneficial medicine.

Lots of other medications suffer from a “bad” or “toxic” branding. Some people think statins are bad; many people think amiodarone is toxic. Warfarin (Coumadin) still suffers from the branding of rat poison.

I want to be clear: medications are neither bad nor good. Medications are chemicals that act on cells in the body in an attempt to create benefit. All medications can be toxic.

Toxicity turns mostly on dose. (Chance can also play a role in toxicity.)

Warfarin kills rats because the rodents keep eating the pellets and the drug builds up to high doses. In humans, we adjust the dose.

When patients tell me certain medications are toxic, I remind them that too much water, taken by endurance athletes, can cause dangerously low sodium levels that may lead to seizures. Oxygen given at high doses for too long in patients on ventilators can damage the lungs. Life saving-antibiotics can cause life-threatening colon infections.

I would urge doctors and patients to frame medications with the big four questions:

Four Crucial Qustions

As an exercise, let’s apply the four questions to the statin drugs (we exclude from this discussion people with familial hypercholesterolemia):

What are the benefits of taking statins?

There is only one benefit of statins: to reduce the future probability of a heart attack, stroke or death. Do not make the mistake of thinking statins are for cholesterol lowering. The drugs do lower cholesterol levels, but that’s a mere blood test. There are plenty of drugs that lower cholesterol but do not reduce the risk of heart attack or stroke.

The benefit of statins, therefore, is a probabilistic one. It’s like a lottery. You take the pill every day in hopes it will prevent a serious cardiac event in the future.

Numerous randomized controlled clinical trials (the highest level medical evidence) confirm that statins do reduce the probability of a cardiac event.

In absolute terms, the degree of statin benefit depends on whether a person has had a cardiac event.

For those without a previous heart attack, stent, bypass or stroke, statin benefits are small—no mortality benefit and about a 1% reduction of nonfatal cardiac events over the next 5 years. Doctors call this primary prevention.

For people with a history of a cardiac event or stroke due to a blockage of some sort, statin benefits are greater—about a 1.2% lower risk of dying and 2.5-3% lower risk of a non-fatal heart attack over the next 5 years. Doctors call this secondary prevention.

What are the harms of statins?

The best known harm of statins are muscle issues. I use the word issues rather than damage because true muscle damage is rare—about 5 in 10,000.

The actual frequency of muscle symptoms is hotly debated. Randomized controlled trials (in which patients don’t know whether they are taking the statin or placebo) report very small increases in muscle complaints—about a 1-2% increase. Observational studies, however, reveal higher rates of statin muscle complaints—in the range of 10-20%.

The second potential harm of statins is a small increase in diabetes. One of the smartest doctors on the Internet, Dr. Richard Lehman, says “the issue of [statin] induced type 2 diabetes is just an artifact of the way we define the threshold for T2DM. Statins often cause a small rise in blood sugar, which would only be of significance if it was associated with an increase in macrovascular or microvascular disease. On the contrary, statins reduce macrovascular disease end-points, and there is no evidence to suggest that they increase eye or kidney microvascular disease (which are very rare in the glucose range we are talking about).”

A third potential harm of statins is the burden of taking a pill every day. Scientists call this pill “disutility” and its measured in how much extension of life one would trade for taking a pill every day. People have different feelings about pill burden.

Another possible (emphasis here on possible) harm of statins is that the drugs may interact in a negative way with lifestyle. In a 2014 theheart.org | Medscape Cardiology column that went a bit viral (647 comments), I cited two observational studies, one that reported a higher calorie intake of statin users and the other less physical activity in male statin users.

Are there simpler safer options?

Opinion alert here: I strongly suspect that a healthy lifestyle delivers similar benefits.

Eating modest amounts of real food, not processed food in packages, doing regular exercise and managing stress would likely deliver lots of probabilistic benefits for reducing the odds of having heart disease.

This “intervention” however, has not been compared to statins in randomized controlled trials. Cardiologists Aseem Malhotra, Rita Redberg and Pascal Meier, writing in the British Journal of Sports Medicine, point to the obvious reason for this: “There is no business model or market to help spread this simple yet powerful intervention.”

What happens if I do nothing?

The most likely outcome of not taking statins is the same as if you take one—nothing. In the best case, that of secondary prevention, the risk reduction for nonfatal cardiac events is about 2.5-3%. That means one has to treat about 39 patients for five years to prevent one event. The odds are you would be in the 38 of 39 category, but you don’t know.

Doctors think this is a good trade. If these stats are applied to populations, many heart attacks can be prevented.

The ultimate decision is up to you. You are not a population.

JMM

You can do this exercise for any medical intervention or medication. Why we don’t do it more often is hard for me to understand.

Trust and Medical Science

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Concerned citizens will march this weekend to defend science.

Standing up for science is a worthy cause. Look at what medical science has accomplished in recent times: serious diseases, HIV, heart attack, many forms of cancer, have been tamed by the advance of science.

We need more not less science. It’s nuts to cut funding to the NIH.

But science, especially medical science, has a trust problem.

My editor at theheart.org | Medscape Cardiology asked me to write a piece exploring the broken trust.

The title of the essay is: Want More Trust in Medical Science? Embrace Uncertainty and Cut the Hype

The essay has three sections.

I first addressed the lack of skepticism among my colleagues. I argue that doctors have become a rapturous audience for medical news. We too easily accept flawed evidence. Our embrace of a flawed dissolving coronary stent and a left atrial appendage closure device serve as good examples of misplaced optimism.

In the second section of the essay, I explore the problem with overselling science. Here’s an except:

Science does not do itself. Humans—bent on having a successful academic career—do science. This means positive results can become the goal rather than the pursuit of scientific truth.

I spent three paragraphs on evangelism over screening healthy people.

It crushes the public trust to say “screening saves lives” when the evidence doesn’t support the claim. This is not a typo. I cite numerous studies that show common screening tests, mammography, PSA tests, colonoscopy, when put to the test of a randomized controlled trial, do not lower overall death rates.

The obfuscation comes when screening advocates tout lower disease-specific death rates. Viz, mammography may (slightly) lower the chance of dying from breast cancer but it has no significant effect on all-cause death. Through a colleague on Twitter, I found a wonderful quote on the folly of trying to reduce your risk of dying from one sort of disease.

“If you are a patient contemplating some screening test, and the result of that test or treatment is no measurable reduction in the rate of death at some clinically relevant later point in time, then why have the test or treatment—unless the patient, for some reason, has a desire to die from condition A instead of condition B.”

Did you know the father of evidence-based medicine, the late Dr. David Sackett, said preventive medicine displayed all three elements of arrogance: it was aggressively assertive, presumptuous, and overbearing? If I were in charge of medical education, his beautiful essay would be required reading.

In the third part of the essay, I call upon medical journal editors to help the trust problem. They could force scientists to put limitations of the study into the abstract; they could make the peer review process more transparent, and they could insist authors present results in absolute terms. This latter issue is crucial. A drug may reduce the risk of having an event by 30% relative to placebo, but the absolute risk reduction may be less than one percent.

Science advocates, in my view, would be more resistant to ideological attacks if they encouraged skepticism, reduced hype and embraced transparency.

People can handle the truth: science is supposed to move slowly.

JMM

Fight On Healthcare Reform Misses Core Problems

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Politicians and policy makers are fighting over new health reform proposals.

This debate misses the core problems in US healthcare.

Look at this graph from the Our World In Data website:

From Our World In Data website

It shows that Americans pay too much for lousy health outcomes.

Fixing the problem on that graph should be the focus of reform.

I am no policy wonk but here are some obvious problems and potential solutions with our delivery system:

I – Profit-driven healthcare must go. As long as health is big business, it will be impossible to control costs.

Fee-for-service (FFS) payment models favor doing more things to people. The more you do, the more you and your employer (usually the hospital) make.

Some might argue new payment models are moving away from FFS and towards value-based compensation. These new payment reforms are a joke. First, quality measures do not reflect real quality. Most doctors who touch patients feel quality measures reduce quality. Second, the new models favor gaming the system. In the past, an AF doctor would document AF as the problem addressed. Now, most AF doctors will list numerous other diagnoses, such as overweight, stress syndrome, high blood sugar, hypertension, sleep apnea etc. Why? Because the new game is to make patients seem complicated.

II – Speak Hard Truths. Someone needs to say that our country cannot afford to keep delivering low-value care. Doctors know what low value care is, but we keep delivering it because we are paid to do so, and because people conflate getting more care with good care.

The VA healthcare system takes a lot criticism but studies show their outcomes are similar to hospitals in the private sector. That’s not surprising because when you have to care for large groups of people with a fixed amount of money, you make choices: the sick get needed care and you burn less money on low-value care.

It’s important here to say that less care is not always the right choice. Sometimes more care is the right call. The problem now is that wasteful care of the haves make it less likely that the have-nots get essential care.

Our lack of courage on making hard choices leads to inequities of health outcomes among the less fortunate. That is an ugly blemish on our country.

III – Take better care of the dying. End of life care in the US is a mess. Cardiologists and cancer doctors could help the situation because so many people die of heart disease and cancer. Atul Gawande wrote that hope (for the tail of the bell curve) is not a plan.

If people knew the reality of their illness and the reality of their therapies, more would choose care that centered on comfort. When people die slowly attached to machines in the hospital or in nursing homes, everyone loses.

We don’t have to deny care to the elderly—just tell them the damn truth. The default should be that death is normal. Yes, we would like to delay it, but this comes with trade-offs.

IV – Slow the growth of non-caregivers. The complexity of our healthcare system drives the need for administrators. Numerous studies have shown that doctors spend increasing chunks of time doing paperwork, billing and non-clinical care duties. That’s a problem because it decreases access to care, distracts the caregivers and adds cost.

If doctors were salaried, and there was no need to game the billing systems, we could use those extra hours talking with patients rather than just ordering tests on them. Healthcare reform measures should decrease complexity so doctors and patients can spend more time together.

JMM

Should AF ablation require approval from a heart team?

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A patient presents with atrial fibrillation (AF) and a rapid rate. He doesn’t know he is in AF; all he knows is that he is short of breath and weak.

The doctors do the normal stuff. He is treated with drugs to slow the rate and undergoes cardioversion. During the hospital stay, he receives a stress test and an implantable loop recorder.

He goes home on a couple of medications. The expensive implanted monitor shows rare episodes of short-lived AF, less than 1% of the time. The patient feels great.

But here’s the kicker: his doctor recommends an AF ablation.

This is nuts. The man has had one episode of AF. He has no underlying heart disease. And he feels well while taking only basic meds. There’s been no discussion of weight loss, exercise, alcohol reduction, or sleep evaluation.

I don’t know how often this happens in the real world, but I suspect that it’s happening more and more. The number of doctors trained in electrophysiology have increased. And, trainees in academic centers spend most of their time mastering the AF ablation procedure.

The Dartmouth Atlas of Healthcare group have shown cardiology to be a supply-sensitive service. Meaning, the more cardiologists there are in an area, the more procedures get done. This build-it-and-they-will-come problem dogs much of US healthcare, not only cardiology. Think MRI and CT centers.

Might a solution to the overuse of AF ablation be a multi-disciplinary heart team?

We already do this for some heart valve surgeries, specifically, transaortic valve replacement (TAVR).

AF ablation is a multi-hour procedure that requires general anesthesia. Up to 80 burns are made in the left atrium, some close to the esophagus and phrenic nerve. There are significant risks to the procedure. The honest long-term success rate barely tops 50%. (Success rates depend somewhat on the type of AF.)

Then there are the repeat procedures. Many patients have to undergo a second procedure, or even third or fourth procedures. (All at many thousands of dollars per case.)

If doctors recommending the procedure had to present the patient to a team of peers, there may be more discussion about the sobering realities of AF care. Questions could arise:

  • Have you checked the patient for sleep apnea?
  • Have you asked him to reduce his alcohol intake or weight?
  • Will the AF resolve after the stress of a divorce has worn off?
  • Does the patient know there’s not a shred of evidence that AF ablation reduces stroke or death rates?
  • Does the patient know that AF is not deadly heart disease? In other words, has fear been sufficiently extracted from the decision?

I recognize that not every decision in medicine should be made by committee. AF ablation, however, might fit some sort of internal review.

The European Heart Journal just published a terrific review on the treatment of persistent AF. In this paper, the treatment of risk factors gets strong mention–as does the sobering results of AF ablation in more advanced forms of AF, and the vast uncertainty surrounding treatment approaches.

I’m not against AF ablation; I perform the procedure often. But after I’m sure all other aspects of atrial-health have been addressed, and the patient is fully informed. It’s a huge mistake to equate AF ablation with ablation of other focal (emphasis on focal) rhythm problems, like supraventricular tachycardia.

I’d have no trouble justifying my AF ablation procedures to a heart team.

JMM

Is AF ablation a big placebo?

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Turkish authors boldly raised this question in a recent editorial.

They likened AF ablation to renal denervation, a procedure in which RF ablation in the kidneys was felt to reduce BP. Many studies showed kidney ablation markedly lowered BP. Then a trial was done with a sham control (people got part of the procedure but did not have burns to the kidneys) and there was no difference.

Does AF ablation work the same way? Is it a big placebo? In over 5000 reports of AF ablation in the medical literature, not one is a true sham-controlled study.

People will argue AF ablation works; there are recordings before and after ablation (I have such tracings).

Then there are these scenarios: A patient has incapacitating AF. Then he has an ablation. He feels much better. At follow-up three months later, he thanks me for giving him his life back. But…sit down for this… he’s in AF by the ECG.

People will say a sham control study of AF ablation is unethical because of harm.

Well, think of the thousands (perhaps millions) of patients who would have had their kidney’s ablated if not for a proper trial. Another example of placebo effect comes in using pacemakers for vasovagal syncope (fainting). The first study of pacemaker versus drug in vagal syncope showed pacemakers worked, but the second study in which pacemakers were used as a sham (either on or off), found no difference.

There’s also never been a sham-control study of stents for the relief of angina. Gulp.

We know that the bigger the placebo, the stronger its effect.

I’m not posting on this because I know the answer, or because I don’t believe in what I do. I’m posting about this because it is intensely curious–and because it gets to the difference between being a doctor (a wise advisor) versus a robotic provider. Doctors, because of our position, may be able to deliver bigger placebos.

Three links are worth reviewing:

Dr. Brain Olshansky is a full professor in EP and he has over 200 peer-reviewed publications. He is solidly “in the club.”

Here is his (free) 2007 state of the art paper in the Journal of the American College of Cardiology: Placebo and Nocebo in Cardiovascular Health Implications for Healthcare, Research, and the Doctor-Patient Relationship

Here is a recent Grand Rounds lecture he gave: (The AF ablation part is in the middle, but you shortchange yourself by not watching the entire hour.)

I also attach this NEJM editorial from Rita Redberg on the importance of sham controls in medical device trials.

And a final thought: there are people working hard to learn more about the brain-heart connection in AF.

JMM

Wisdom…

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…the quality of having experience, knowledge, and good judgment.

I read today a collection of words that exude wisdom. I share it with you because the purpose of this blog is to do create value through education.

Peggy Girshman was an award-winning health journalist. When ill with a life-limiting illness, she wrote her own eulogy. NPR published it today after her death.

Must-read is an overused phrase, but it modifies perfectly her words. Here are a few excerpts, with my thoughts.

Work-Life Balance: Though Girshman wished she could have worked longer, “to convince someone I was right,” she also wished she had divided her life to spend more time with her family. That one is hard to see in real time, isn’t it?

Low-grade Cancers: To “folks” with Stage 0 or less cancers, especially DCIS (ductal carcinoma in situ), or prostate cancer, Girshman advised resisting the “get it out of me” temptation. Why? Because approximately half don’t go on to become invasive cancers, and “you shouldn’t do all kinds of bad things to your body unnecessarily.”

I’m no oncologist, but I know this: medical care comes with both benefit and harm. We are doing a better job these days of explaining both–but the best medical decision happens when fear and ignorance are removed. (Credit there goes to Harlan Krumholz.) Most of what I do in a heart rhythm clinic is fear extraction.

Burden of Care: To women, Girshman warned that “breast conserving” surgery does not conserve the breast. And radiation therapy was the “biggest mistake of her life.”

Here, hindsight is sharp, but doctors can surely do a better job of painting a more honest picture of the burden of healthcare. LifeVest, and AF ablation come to mind in cardiology. Daily pills, too, come with significant burden.

Evidence: Though John Oliver will get more press, Girshman speaks passionately about evidence. Beware of anecdote and trust the scientific method, she advises. “Belief is powerful The placebo effect exists.”

The older I get the more this resonates with me. Drs. Vinay Prasad and Adam Cifu have written a masterful book on evidence, one that has changed my approach to patient care and critical appraisal of science. Go read Ending Medical Reversals; you won’t be disappointed.

Lifestyle: Girshman says…”please stop with the lifestyle advice…Don’t knock people about what they’re eating, how much and when.” Of course, she argues, everyone knows eating real food, and less of it, will lower one’s chances of getting disease. But Girshman wisely suggests convincing yourself that “people get sick for so many reasons that we don’t know about. One little mutation in one little cell.”

She asks us to stop judging people about the healthiness of their lifestyle. For instance, never ask someone with lung cancer if they smoked. Don’t even think it, she advises. You might leave cyclists without helmets alone too.

Of all my changes in thinking in the last half decade, none has been more profound than giving lifestyle advice.

Girshman’s stance makes me want to stand and cheer. I remain a fierce advocate for good health through good choices, and I believe nutrition, exercise and sleep are the most potent medicine, especially for heart rhythm disorders like AF, but healthcare people overstep their bounds when they delve into population health. A society’s health comes from good education, social supports, safety, available healthy food and walkable neighborhoods–not preachy doctors, vascular screening, mobile mammography and the like.

When I see an obese patient with AF, I frame weight loss as a potent anti-arrhythmic treatment. When I see an obese patient with high blood pressure, I tell her exercise and calorie restriction will beat any pill. But when I see an obese person with no medical problems, I do my best to advise them about the benefits of lifestyle choices, but I’m not their mother. I’m a mere advisor, and a damn imperfect one at that. Ask my wife and kids, or the guy serving burgers at my hospital.

A short book changed my view of public health. You should think twice before reading Petr Skrabanek’s The Death of Humane Medicine. Unseeing will not be possible.

JMM

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