Fear/Courage Interviews

Being innovative or conservative?

What does it mean to be a brave doctor today?

Interview with
Eric Topol

Vice President Scripps research translational institute, La Jolla, California

John Mandrola

Baptist health Louisville, Kentucky

By July 2019June 24th, 2020No Comments

With regard to the antinomy between fear and courage in relation to innovation, below, we report an interview with John Mandrola and Eric Topol, both cardiologists and key opinion leaders in the world medical community due to their positions and reflections about the most recent innovations in medicine. We believe that their complementary viewpoints can lead to an open discussion, which doctors and patients need to make sound and informed decisions.

Etymologically, to innovate (from the latin “in-novare”) means to change the order of things with the aim to do new –better- things. Human attitude toward innovation has deeply changed over the centuries by alternating feelings of fear, and subsequent closure, to an uncritical embracement of most innovations. Where are we now and how, in medicine, can we distinguish innovations that are really meaningful from the trivial ones?
ET For medicine, the expectations of innovation have changed. To be accepted, there needs to be improved outcomes and at lower cost, whereas in the past satisfying the outcome improvement was accepted on its own. But we’re in the midst of an economic healthcare crisis, so frugal innovation and even things that save costs without affecting outcomes will be viewed more favourably.

JM There is tension between innovation and low-value care. After two-decades of practice in electrophysiology, I have witnessed many benefits of innovation. Two of the procedures that I do most often today—cardiac resynchronization therapy (CRT) and atrial fibrillation ablation–did not exist when I trained more than two decades ago. Yet both of these procedures now face potential extinction: less expensive his-bundle pacing [1] may largely replace CRT, and aggressive cardiometabolic risk factor modification [2,3] may dramatically reduce the need for AF ablation. Notably, gains in cardiology pale in comparison to other branches of medicine. HIV infection used to be a death sentence; no more. And many forms of cancer have been transformed into chronic conditions.

Indeed, innovation has made this a great time to be sick. The tension comes in measuring these gains. Many advances touted as big gains offer marginal if any benefits. In a piece for Primary Care: Clinics in Office Practice [4], Andrew Foy (Penn State University) and I described low value care as a flat-of-the-curve practice. Therapies that cost a lot but deliver minimal gains reside on the flat portion of the diminishing utility curve. Stress-testing with imaging in patients with low-risk chest pain, drug-eluting over bare metal stents, mechanical support for high-risk interventions, and brand name drugs over generics are examples of everyday flat of the curve practices.

Many forces obscure the actual value of a new innovation. The obvious force, especially in the US system, is profit. Sadly, much of US cardiology is supply-induced rather than demand-induced. But profits are not the only force obscuring the value of new therapy. Behavioural psychologists have shown that both physicians and patients struggle with probabilistic thinking. Couple that with pervasive spin [5], also known as manipulative language, in the cardiovascular literature, and it becomes easy to understand how an innovation can be overvalued.

In the end, truly innovative therapies (antibiotics, repair of hip fractures, stenting in the setting of acute myocardial infarction) sell themselves.

Your latest book, Deep Medicine [6] is focused on a counterintuitive and brave idea: the trust that next level artificial intelligence models will support physicians in making patient care more human. What does it mean to be brave for a doctor and for a researcher, today?
ET The problem we have is that medicine has been de-humanized with little time between patients and their doctors. Little time for doctors to think. As a result, there has been serious and steady erosion of this critical relationship that relies on trust and presence, which must be restored. The gift of time from AI—by off-loading tasks to machines, and giving patients more charge with their data and algorithms to support interpretation—has great promise to move us in the right direction (even though it is counter-intuitive/paradoxical).

One of your latest articles “The case for being a medical conservative” [7] is focused on a counterintuitive and brave idea: the need to be conservative physicians during an era of innovation. What does it mean to be brave for a doctor and for a researcher, today?
JM Our medical conservative essay was born by words from a prominent health care journalist who likened critical appraisal of flawed evidence to nihilism. This made us mad.

My three co-authors on the medical conservative essay and I do not oppose progress; nor do we oppose private enterprise or capitalism. Rather, we oppose the accumulation of private wealth when it occurs under the pretext of “science,” without meaningful improvement in patient outcomes.

The problem is that true medical progress is hard. Not only have we just come through a golden era in medicine, e.g. the invention of antibiotics, nature has gifted humans with both amazing healing properties and an expiration date. These two facts have transformed the challenge of the cardiologist today from can we do this procedure to should we do this procedure?

As for being brave, I think this is too strong a word. Warriors are brave. I would call physicians who adopt new interventions only when the evidence is strong and unbiased good doctors. I would call scientists who embrace an experiment not on whether its results were positive but on the vigor of its methods good scientists.

The main reason we explained what it means to be a medical conservative is that we want to give permission to the many professional clinicians out there who face pressure to accept less than convincing evidence. I recently advised my colleague that a procedure was not warranted in a specific case. He immediately pulled up the guidelines on his smartphone and said I was wrong because the procedure in question was codified in the guidelines. The problem is that guidelines often stem from flawed evidence. Too often, I witness the use of guidelines as a reason to provide care that stands to help the hospital and physician far more than it will the patient.

Thus, we aimed to encourage the critical appraisal of the evidence underpinning the guidelines. We make it clear that pointing out the limits of a study is not an attack on the authors of the study. Without robust and independent critical appraisal of science, we risk promulgating one of medicine’s greatest risks: hubris.

In the biomedical field, some technological innovations have contributed to the overdetection of abnormalities of uncertain significance, with a consequent increase in the risks of overdiagnosis and overtreatment. In regard to these pressing issues, to what extent should we encourage the development of Digital Health and to what extent should we rather fear it?
ET We must always be cognizant of overuse of technology and the chance it  engenders false positives and incidental findings. We have so much of that now, what I call “Shallow Medicine” because so many tests are ordered by reflexes without adequate forethought. Technology cannot and should not be used in a promiscuous fashion, but rather it, too, needs to be applied very selectively, on an individualized basis. And only after the technology has been carefully and rigorously validated.

JM While medical progress has made this a great time to be sick. The flipside is that tech has made it an increasingly hazardous time to be well. That’s because of disease creep. It used to be that a person who had no complaints had nothing to fear from a doctor. Now that “well” person could have any number of potential diseases—which could be investigated or treated. Disease creation creates fear. And fear crushes the ability to make good decisions.

A mildly dilated blood vessel is called an “aneurysm;” a mild elevation of blood sugar is pre-diabetes; abnormal histology of breast biopsy is ductal carcinoma in situ, and even a blood pressure of 135 can be called hypertension.

These may be well-intentioned changes, but lowering the bar of what we call disease puts society at great risk of iatrogenesis. The confusion centers on the continuous nature of these parameters. Treating severe hypertension, hyperglycemia and large aneurysms is undoubtedly beneficial, simply because harm from nontreatment is more hazardous than the harm of treatment. But as we lower the threshold for who gets treatments, the risk-harm calculus tilts towards harm.

The digital health revolution exacerbates this issue. Nearly every week I get a message in the electronic health record alerting me to a short-duration episode of atrial fibrillation (AF). We never had this issue in the past; AF required a patient to feel something, present to the doctor and have an ECG that recorded the arrhythmia. AF had to last long enough to prompt medical attention. Trials showed that treating these patients with AF who had risk factors for stroke with anticoagulants provided a net benefit because the lower rate of stroke was greater than the increase risk of bleeding.

Now, watches, smartphone apps, patch ECGs and pacer telemetry have allowed us to discover very short-duration AF. We don’t know whether treating these patients with anticoagulants will provide the same net benefit. If we are wrong, and anticoagulation is associated with net harm in these millions of patients, the amount of harm could be massive.

My greatest concern about the expansion of technology and the monitoring that comes with it is not direct clinical harm. It’s what the late philosopher Ivan Illich called social and cultural iatrogenesis [8].

Namely, Illich believed that truly healthy people adapt—adapt to ageing, to healing when damaged, to suffering and then to the peaceful expectation of death. But as medicine, via its technological means, transforms pain, illness and death from a personal challenge into a technical challenge, medical practice steals the potential of people to deal with their human condition in an autonomous way.

I think Petr Skrabanek said it best: “the pursuit of health is a symptom of unhealth” [9].

In my day to day work caring for patients with arrhythmias, I most often advise that people disconnect from devices—and go out an enjoy nature without any data.

I may be wrong, but medicine will remain pure—beautiful even–when we treat the infirmed, those who seek out our help. And conversely, medicine will be most dangerous when we tell people who have no complaints that they need our help.

References

[1] Upadhyay GA, Vijayaraman P, Nayak HM, et al. His corrective pacing or biventricular pacing for cardiac resynchronization in heart failure. J Am Coll Cardiol 2019: 26230.
[2] JPathak RK, Middeldorp ME, Meredith M, et al. Long-Term eff ect of goal-directed weight management in an atrial fibrillation cohort: a long-term follow-up study (Legacy). Am Coll Cardiol 2015;65:2159-69.
[3] Pathak RK, Elliott A, Middeldorp ME, et al. Impact of CARDIOrespiratory FITness on arrhythmia recurrence in obese individuals with atrial fibrillation: The CARDIO-FIT Study. J Am Coll Cardiol 2015;66:985-96.
[4] Foy AJ, Mandrola JM. Heavy heart: the economic burden of heart disease in the United States now and in the future. Prim Care 2018;45:17-24.
[5] Khan MS, Lateef N, Siddiqi TJ, et al. Level and prevalence of spin in published cardiovascular randomized clinical trial reports with statistically nonsignificant primary outcomes: a systematic review. JAMA Netw Open 2019;2: e192622.
[6] Topol E. Deep medicine. How artificial intelligence can make healthcare human again. New York: Basic Books, 2019.
[7]. Mandrola J, Cifu A, Prasad V, Foy A. The case for being a medical conservative. Am J Med 2019;S0002-9343(19)30167-6.
[8] Illich I. Medical nemesis. Lancet 1974; 303:918.
[9] Skrabanek P. The death of humane medicine and the rise of coercive healthism. London: Social Affairs Unit, 1994.

Camilla Alderighi, Raffaele Rasoini

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