Chuck Lauer: Sometimes the best medicine is no medicine

Last year I was stunned by an article in the New York Times, and when I am asked to recommend a "good cardiologist" or in fact to go to a new specialist myself, I do so with that article and what it revealed in my mind.

I am often asked for a recommendation of a good cardiologist or orthopedic surgeon or some other specialist. Partly, this is due to my work, which has put me in touch with so many people in healthcare.

I can often call upon a friend in the C-suite, who in turn gives me a name of a leading practitioner. It also has to do with my having had a lot of medical procedures over the years, a consequence of a lifetime of rather extreme exercise (think hockey).

Sometimes the people calling me need a quick recommendation because a loved one has been admitted to the hospital on an emergency basis. Others are shopping for a second opinion or the best surgeon for the job. Regardless, I have always been happy to help.

However, last year I was stunned by an article in the New York Times, and when I am asked to recommend a "good cardiologist" or in fact to go to a new specialist myself, I do so with that article and what it revealed in my mind. The research paper appeared in JAMA Internal Medicine in February 2015. It gives you pause not only about cardiologists but also about what actually constitutes a "good doctor."

The author of the Times article was Ezekiel J. Emanuel, MD, who was one of the architects of what today is known as Obamacare. At the time he was a distinguished oncologist and a vice provost at the University of Pennsylvania. The JAMA study examined 10 years of data involving tens of thousands of hospital admissions for acute myocardial infarction. It found that patients with acute, life-threatening cardiac conditions did better when senior cardiologists were out of town. The study included some of the best hospitals in the United States.

"High-risk patients with heart failure and cardiac arrest, hospitalized in teaching hospitals, had lower 30-day mortality when cardiologists were away from the hospital attending national cardiology meetings. And the differences were not trivial — mortality decreased by about a third for some patients when those top doctors were away," Dr. Emanuel wrote. "Truly shocking and counterintuitive: Not having the country's famous senior heart doctors caring for you might increase your chance of surviving a cardiac arrest."
It seems the researchers did their due diligence, looking in vain to see if other kinds of doctors being away from the hospital also had an impact on cardiac mortality rates and how patients with other conditions fared during the cardiologists' absence. Dr. Emanuel is not sure why having the most experienced cardiologists around is bad for your longevity, but he speculates that while senior cardiologists are great researchers, the junior physicians, recently out of training, may actually be more adept clinically.

Another possible explanation suggested by the data is that senior cardiologists try more interventions. When the cardiologists were around, patients in cardiac arrest were significantly more likely to receive interventions such as stents to open up their coronary blood vessels.
Dr. Emanuel gives us another example of how more care can produce worse outcomes. A study from Israel of elderly patients with multiple health problems but still living in the community involved physicians discontinuing medicines to see if patients got better. "Not unusual in these types of elderly patients, on average they were taking more than seven medications," Emanuel writes.

In a systematic data-driven fashion, researchers discontinued almost five drugs per patient for more than 90 percent of patients. In only 2 percent of cases did the drugs have to be restarted. No patients had serious side effects and no patients died from stopping the drugs. Instead, almost all of the patients reported improvements in health, not to mention the saving of big money.
"We — both physicians and patients — usually think more treatment means better treatment," Dr. Emanuel wrote. "We often forget that every test and treatment can go wrong, produce side effects and lead to additional interventions that themselves can go wrong. We have learned this lesson with treatments like antibiotics for simple medical problems from sore throats to ear infections. Despite often repeating the mantra, 'First, do no harm,' doctors have difficulty with doing less, even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery."
There are practical implications for these findings. Doctors, Dr. Emanuel says, should provide patients with data about a proposed procedure or drug, including its rate of success and complications/side effects. Physicians should also routinely attempt to discontinue medications at least once a year.

Patients should ask doctors what difference an intervention might make. Would an invasive or expensive test change the approach to treatment? How much improvement in terms of prolongation of life or reduction of illness is a treatment going to make? How likely and severe are the side effects? And, is the hospital a teaching hospital? The JAMA Internal Medicine study found that mortality was higher overall in nonteaching hospitals.
I have benefited greatly from some interventions, but have also witnessed many unnecessary procedures and tests. We all ought to ask the questions Dr. Emanuel suggests — for our long-term health.

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