Doctors are Gamblers

http://www.flickr.com/photos/robnwatkins/ / CC BY-NC-ND 2.0

Doctors are Gamblers.

One of the questions in surveys that determine what sort of career in medicine you want asks:

How much ambiguity can you tolerate?

read: How much are you willing NOT to know? The answer is surprisingly telling.

I thought that as a physician in training, I would learn how to become more confident in my diagnosis when in practice, this is a very difficult thing to achieve. Especially in a brief visit where there are no clear labs or studies to elucidate the answer. Take a simple cold. A patient comes in with a sniffly nose, fatigue and a sore throat and asks: do I have strep? You can do a throat culture, but that will take time. You can do a rapid strep antigen test, but the test is not sensitive and you may get a false negative. Even for the most common conditions, there is a great deal about which we DO NOT know, nor can we ever know. We don't even have the tools to test for a lot of the different viruses that may cause a common cold... and why bother? It'll go away on its own with some fluids and rest.

Take another common concern: Doc, what are my chances of getting a heart attack?
We gamble on answers like this when we prescribe medications to reduce risk factors for coronary artery disease like high cholesterol (diet, exercise and statins,) and diabetes (diet, exercise, and metformin.) We risk stratify patients based on a collection of factors that have been shown to lead to increased risk of a heart attack in the future. The biggest study of this is the Framingham Heart Study. From a collection of statistics gathered from anamnesis (patient history) and labs, we can determine the 10 year risk of a patient for having a heart attack!

That's pretty powerful. But it is still just a Chance.
And how often do you really have a discussion like THIS with your doctor?!?

You're a 57 year old male. Your total cholesterol is 275. That's high because it's bigger than 200. Your HDL(good) cholesterol is only 35. That's low because it's less than 40. On top of that, you're still smoking and your systolic blood pressure(big number) is 150 despite being on medications!

You know, that means you have a greater than 30% chance of getting a heart attack or something similar in the next ten years. Think about that.

If you quit smoking and exercised to bring your blood pressure down to normal (120,) you could pull your risk down to 18%. That's still high but if we put you on a medication to lower your cholesterol and it was brought down to a normal level, we'd bring it down to 12%!

We can cut your risk in half with some simple changes. What do you think about that?

We gamble with people's lives. Some people live gluttonous self-indulged lifestyles and never have any health problems. Other people are health nuts but suffer from multiple ailments.

We don't know what hand people are dealt... but we can help stack the deck in their favor.

Rights vs Expectations

Even though I disagree with a lot of what Happy Hospitalist writes when he waxes political, I find myself drawn to his blog. Perhaps it gives me something to react against. In any case, he wrote the following short bit yesterday:

Does America Have A Right To BASIC Health Care?

I hear it everyday. Affordable access to basic health care should be a right.

Could someone please define to me what constitutes basic in the basic health care arguement? I want to hear examples of what is basic health care and what would not be considered basic and why you have a right to one and not the other.

Why should we have a right to health care but not health? Should we not have a right to stay healthy? Should we not have a right to free gym memberships? How about a right to free vegetables. If you have a right to basic health care, we should also have a right to services that prevent the break down of health as well.

Right?

My response in the comments section:

There are a lot of things we take for granted -- clean water, sewage treatment, uncontaminated needles for IVs and sterilization procedures before surgery.

These are PUBLIC HEALTH measures that have greatly affected our quality of life. So much so that their effects are practically invisible.

When we say "basic," I think of something along the lines of "do or die." There are a lot of things that factor into this... obviously someone with untreated hypercholesterolemia and diabetes for 40 years who comes in with a heart attack could have received appropriate intervention before this life threatening event.

The question is this: What OUGHT to be covered?
Primary prevention: healthy living (free gym memberships, shelter, access to fruits and veggies)
Secondary prevention: screening for CAD risk factors (checking lipid panel per ATPIII recommendations or just total cholesterol per USPSTF.)
Tertiary prevention: intervening after disease is detected to prevent complications (starting off treatment with statins and metformin.)

A lot of people would argue that it is fully within the scope of medicine to intervene with Secondary and Tertiary preventive measures (which SHOULD be covered as basic health care to some degree.)

Primary prevention... like the rest of PUBLIC HEALTH falls more under the scope of the government in my opinion, not accounting for the occasional harassment by a PCP to "eat right and exercise." As needed, I'm sure there are a number of excellent docs who can go more in depth into personalized primary preventive measures but when this is not reimbursed... not many will opt to do it with all their patients!

This made me realize that the Rights argument is very progressive (in more ways than one.) We all expect some certain unalienable rights to Life, Liberty and the Pursuit of Happiness.

What does it mean to have a "right to Life"? This draws an issue like abortion (ugh! let's keep that at least 10 feet away for now) to the forefront when really, there is a much more fundamental right that this draws upon... one that I have not seen clearly defined or reflected upon. Is it a right to a healthy life? A right to live?

I think it is a Right to Live as others live. There is an element of Expectation to this as well. We expect that we can all live equally in a democratic society.

Access to healthcare is becoming more of an issue than our forefathers expected because our medical knowledge and power to intervene has increased dramatically. This has created new power relationships and health deficits in socioeconomic status that cross generations! It goes beyond doctors and hospitals. That's why the government must play a role "to Secure these Rights," "deriving their just Powers from the Consent of the Governed."

I expect this from my government. A lot of people are afraid that the government will mess this up and want it to stay out of the Healthcare debate as much as possible. This is not a dig, but merely an innocent question: Republicans/conservatives in congress, if you distrust government so much and are afraid of its collective incompetence, why are you in office? I would much prefer it if you created some solutions rather than saying "the best thing we can do is to stay out of it."

Atrial Fibrillation Treatments

Atrial fibrillation involves the two top small chambers of the heart. They quiver instead of coordinating a strong beat which makes patients with a fib often feel palpitations with an irregularly irregular heart beat.

Last year I had a patient with atrial fibrillation. She was hospitalized for a splenic infarct after discontinuing her warfarin because she found out she was pregnant. Luckily for her, it was only her spleen that got hit and she agreed to go back on the warfarin after an elective ITOP -- things did not work out as planned with her ex-boyfriend apparently. My chief resident had me read about the ground-breaking AFFIRM study, which showed that rate control was equivalent to rhythm control, with less drug side effects since antiarrhythmics can induce arrhythmias (go figure.)

This week I started my cardiology rotation with a day FULL of patients with atrial fibrillation -- some newly diagnosed, some medication induced, some status post valvular repair! It was as if the medical gods convened to help me learn something new.

My cardiologist encouraged me to read further on this subject so I found two other trials: ACTIVE-A and ACTIVE-W. I performed a Critically Appraised Topic (CAT) review on these different treatment options for anticoagulation in a-fib.

ACTIVE-A and W trials

View more documents from Clinton Pong.

After presenting the results to my preceptor, he asked me about mortality data. Unfortunately, I didn't look into that as closely as it was a small part of the primary end points (stroke, MI, non-cerebrovascular embolic events and vascular death.)

Enough about medical interventions.
Here's an excellent video on one of the surgical procedures for removing the ectopic foci in the pulmonary sleeves. I didn't know it was so involved with the computerized models using US and CT to create a digital image of the heart!
Atrial Fibrillation Ablation (Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, 2/11/2009) - MedlinePlus: Videos of Surgical Procedures