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Experience In Medicine Has Its Downsides

You have probably read that experience makes for better doctors.

And of course this would be true–in the obvious ways, like with the hand-eye coordination required to do complex procedures, or more importantly, with the judgment of when to do them.

There’s no news here: everyone knows you want a doctor that’s been out of training awhile, but not so long that they have become weary, close-minded or physically diminished. Just the right amount of experience please.

But there’s also potential downsides and struggles that come with experience. Tonight I would like to dwell on three ways in which experience is causing me angst.

But first, as background…

It was the very esteemed physician-turned-authors, Dr. Groopman and his wife, Dr. Hartzland, who wrote this thought-provoking WSJ essay–on how hidden influences may sway our medical decisions–that got me thinking about how I have evolved as a doctor. They were writing from the perspective of the patient. But in the exam room, there are two parties: patient and doctor.

# 1) The sobering view that experience brings: Read more »

*This blog post was originally published at Dr John M*

Gender Disparities In Heart Attack Treatment: Women More Likely To Die

One-third (33.5%) of female heart attack patients receive surgery or angioplasty compared to nearly half (45.6%) of men, and among heart attack patients receiving an intervention such as coronary bypass surgery or angioplasty, women had a 30% higher death rate compared to men, reports HealthGrades.

The findings are based on an analysis of more than 5 million Medicare patient records from 2007 to 2009 and focused on 16 of the most common procedures and diagnoses among women.

The most noticeable disparities were in cardiovascular care. Heart disease is the #1 killer of women in America, surpassing all forms of cancer combined, the company said in a press release. Read more »

*This blog post was originally published at ACP Internist*

Understanding Treatment: The Communication Disconnect Between Doctors And Patients

Over the long week­end I caught up on some read­ing. One arti­cle* stands out. It’s on informed con­sent, and the stun­ning dis­con­nect between physi­cians’ and patients’ under­stand­ing of a procedure’s value.

The study, pub­lished in the Sept 7th Annals of Inter­nal Med­i­cine, used sur­vey meth­ods to eval­u­ate 153 car­di­ol­ogy patients’ under­stand­ing of the poten­tial ben­e­fit of per­cu­ta­neous coro­nary inter­ven­tion (PCI or angio­plasty). The inves­ti­ga­tors, at Baystate Med­ical Cen­ter in Mass­a­chu­setts, com­pared patients’ responses to those of car­di­ol­o­gists who obtained con­sent and who per­formed the pro­ce­dure. As out­lined in the article’s intro­duc­tion, PCI reduces heart attacks in patients with acute coro­nary syn­drome — a more unsta­ble sit­u­a­tion than is chronic sta­ble angina, in which case PCI relieves pain and improves qual­ity of life but has no ben­e­fit in terms of recur­rent myocar­dial infarc­tion (MI) or survival.

The main result was that, after dis­cussing the pro­ce­dure with a car­di­ol­o­gist and sign­ing the form, 88 percent of the patients, who almost all had chronic sta­ble angina, believed that PCI would reduce their per­sonal risk for hav­ing a heart attack. Only 17 percent of the car­di­ol­o­gists, who com­pleted sur­veys about these par­tic­u­lar patients and the poten­tial ben­e­fit of PCI for patients fac­ing sim­i­lar sce­nar­ios, indi­cated that PCI would reduce the like­li­hood of MI.

This strik­ing dif­fer­ence in patients’ and doc­tors’ per­cep­tions is all the more sig­nif­i­cant because 96 percent of the patients “felt that they knew why they might undergo PCI, and more than half stated that they were actively involved in the decision-making.” Read more »

*This blog post was originally published at Medical Lessons*

Cardiac Stents Alone Don’t Work

I have a friend who had a blocked cardiac artery. A couple of years ago he had angioplasty on it, and his doctor inserted stents. The stents got rid of his chest pain and other symptoms, but didn’t do anything to get at the underlying cause of the blockage, which had to do with an unhappy combination of genetics and a –- perfectly admirable –- taste for rich, fatty foods. Like steak. (More on that in a moment.)

Before having the procedure, his doctors spent a lot of time with him explaining what the surgery would and wouldn’t do. In particular, the doctors explained that the stents would do their job, but he had to do his. He needed to eat better, exercise more, and take his medications. He’s followed most of that advice, and is doing well.

Unfortunately, his experience is not typical. A recently published study found that more than 80 percent of patients who had gotten angioplasty and stents thought they were alone a cure for their problems.

These patients are wrong. So how can it be that they are coming to this strange conclusion? According to some, it’s the doctors’ fault. Read more »

*This blog post was originally published at See First Blog*

Lithium for ALS – Angioplasty for MS: Why We Should Be Cautious About Medical “Breakthroughs”

Peter Lipson reported Monday about new research suggesting that Multiple Sclerosis may be caused by venous blockage. He correctly characterized some of the hype surrounding this story as “irrational exuberance.”

This is a phenomenon all too common in the media – taking the preliminary research of an individual or group (always presented as a maverick) and declaring it a “stunning breakthrough,” combined with the ubiquitous personal anecdote of someone “saved” by the new treatment.

The medical community, meanwhile, responds with appropriate caution and healthy skepticism. Looks interesting – let’s see some more research. There is a reason for such a response from experts – experience. Read more »

*This blog post was originally published at Science-Based Medicine*

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