Dr John M

cardiac electrophysiologist, cyclist, learner

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New column and podcast up:

October 4, 2020 By Dr John

Last week, I wrote a column on one of the most controversial clinical trials in cardiology.

The EXCEL trial pitted stents vs bypass surgery for people who have left main coronary artery disease. The trial has been beset with controversy.

The three areas of debate surround the definition of MI (or heart attack), the increased risk of death in the stent arm, and selective publishing of data.

Here is the column: Latest EXCEL MI Analysis Settles Nothing; Flaws Remain

You should study this one because it hints at how precarious medical evidence can be.


On the This Week in Cardiology podcast, I discuss EXCEL, but also the issue of trust in science.

This includes a few words on the matter of silly studies that still garner media attention. I’ve come to name these studies, howlers.

One of the reasons behind this is the business model of medical publishing. Medical journals, like any media outlet, need attention. Coffee studies bring attention; statistics studies not so much.

The pandemic has brought oodles of silly studies.

A classic example is the broken study on cardiac MRI in recovered COVID patients. This one had to be corrected due to a slew of errors and now shows no concerning signal of cardiac harm from COVID. But it has hundreds of thousands of page views and will surely bump up the impact factor of the journal that published it.

I discussed CMR, COVID and sports participation a few weeks ago.

The problem with howlers is that they hurt public trust in science. One week coffee is good, the next it is not. Don’t wear masks, do wear masks.

I also discuss the Vitamin D and COVID19 issue. Teaser: it’s folly.

Science leaders, I think, ought to be more candid about the limits of science, the uncertainty. Let the public in on the truth.

You know, a Karl Popper-like message.

Finally, there was big news in nutrition science: a group at the UCSF actually did a randomized controlled trial. This is huge because most nutrition science stems from flawed observational studies.

Here is the pod link: https://podcasts.apple.com/us/podcast/this-week-in-cardiology/id991125169

Let me know what you think. Remember, if you like the pod, give it a good rating so others can find it.

JMM

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Filed Under: Doctoring, General Cardiology, Knowledge Tagged With: COVID19, Evidence, Evidence-based medicine

Lecture on Scientific Bias in Cardiology

September 30, 2020 By Dr John

Last month I gave a lecture in Brazil (via my house in Kentucky) on scientific bias in cardiology.

It’s about 20 minutes. Dr Bob Kaplan from Stanford also spoke on issues relating to how FDA approves drugs–a timely topic.

Many of you know that I espouse a medically conservative approach to medical practice.

My lecture explains some of the reasons I take that approach. I try to make the case for a humble approach to medical evidence and what doctors can do.

We have a 30 minute discussion after the lecture. That was fun.

The intro and moderator is my friend and colleague Dr Luis Correia, who is an excellent doctor to follow on Twitter: @LuisCLCorreia

Here is the Youtube link:

JMM

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Filed Under: Doctoring, General Cardiology, General Medicine, Knowledge Tagged With: Evidence, Evidence-based medicine

Is healthcare careful? Is it kind?

January 24, 2015 By Dr John

Research now indicates 50% of middle–aged people live with one chronic disease. Translation: half of middle-aged people are not healthy. (You don’t need a reference there. Just walk out into the world and look around.)

This new normal creates a challenge for caregivers. How will we care for the onslaught of chronic disease?

Surely not with the current model of care. What happens now is that doctors treat diseases–and even “pre-diseases.” We once had diabetes and hypertension and heart failure. We now have pre-diabetes, pre-hypertension and Stage A (no symptoms and no findings) heart failure.

Guidelines statements promote disease-specific numeric measures, such as blood pressure, glucose and cholesterol levels. Patients not at goal get more medication. Then guidelines spawn quality measures, which intensifies already burdensome care. Hit doctors with sticks, feed them carrots, the result is the same: more pills and procedures.

Here is the problem: People are not diseases. Guidelines are context blind. As the burden of healthcare overcomes the capacity (physical, mental, emotional and financial) of the patient, she makes choices of what to do. Said another way: life gets in the way of healthcare. No one wants to spend their life being a patient.

Dr. Victor Montori (@vmontori) is an endocrinologist at Mayo Clinic. His idea for making healthcare more effective is to shun disease-specific context-blind surrogates. Montori and his team have asked us to consider a minimally disruptive approach to healthcare. Quality care in their model happens when patients improve their ability to function–or enjoy life.

Their two new words in healthcare are work and capacity. Minimally disruptive care seeks to decrease the work of care while increasing the capacity of the patient to do the work.

This is not health policy gibberish. Think about it. We are losing the fight against chronic disease. When something is not working, you change the strategy.

Montori’s suggestions are simple: 1) Start by using the right language. Assess the burden of care and think about the patient’s capacity to do all that we prescribe. 2) Guideline writers must add context, otherwise guidelines will become irrelevant. 3) Use shared-decision making. If you have to treat 140 patients with a statin medication to prevent one heart attack (meaning 139 patients take the drug without benefit), it makes sense to incorporate the patient’s goals. 4.) Think about deprescribing, not just in the elderly, but in relation to decreasing the work of healthcare.

Here is a 45-minute lecture Montori gave to a group of primary care doctors. About half-way through the video, he describes a patient named John. John is real life. And once you hear John’s story, it is impossible to think we are on the right path.

JMM

h/t Carolyn Thomas of the Heart Sisters Blog.

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Filed Under: Doctoring, Health Care, Healthy Living Tagged With: Evidence-based medicine, Minimally-disruptive medicine, shared decsion-making, Victor Montori

John Mandrola, MD

Welcome, Enjoy, Interact. john-mandrola I am a cardiac electrophysiologist practicing in Louisville KY. I am also a husband to a palliative care doctor, a father, a bike racer, and a regular columnist at theHeart.org | Medscape

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Find me on theheart.org | Medscape Cardiology

  • Electrophysiology commentary on Medscape/Cardiology

Mandrola on Medscape

  • My Medscape column on general medical matters

For patients...Educational posts

  • 13 things to know about Atrial Fibrillation — 2014
  • A new cure of AF
  • Adding a new verb to doctoring: To deprescribe is to do a lot
  • AF ablation — 2015 A Cautionary Note
  • AF Ablation in 2012–An easier journey?
  • Atrial Flutter — 15 facts you may want to know.
  • Benign PVCs: A heart rhythm doctor’s approach.
  • Caution with early Cardioversion
  • Decisions of 2 low-risk cases of PAF
  • Defining success in AF ablation in 2014
  • Four commonly asked questions on AF ablation
  • Inflammation and AF — Get off the gas
  • Ten things to expect after AF ablation
  • The medical decsion as a gamble
  • The most important verb in our health crisis
  • Wellness Requires Ownership

 

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