"Fully Consensual Heart Disease Treatment"
When he was a surgeon at the Cleveland Clinic,
Dr. Caldwell Esselstyn published a controversial paper in the American Journal of Cardiology.
Heart bypass operations carry significant risks,
including the potential to cause further heart damage, stroke, brain dysfunction.
Angioplasty isn’t much better, also carrying significant mortality and morbidity,
and often doesn’t work, in terms of decreasing risk
of subsequent heart attack or death.
So, it seems we have an enormous paradox.
The disease that is the leading killer of men and women
in Western civilization is largely untreated.
The benefits of the invasive procedures are at best temporary,
with most patients eventually succumbing to their disease.
In cancer we call that palliative care,
where we just kind of throw up our hands,
throw in the towel and give up actually trying to treat the disease.
So why does this juggernaut of invasive procedures persist?
Well one reason is that performing surgical interventions
has the potential for enormous financial reward.
That’s considered one of the barriers to the practice of preventive cardiology - adequate return.
Diet and lifestyle interventions loses money for the physician.
Although the practice of preventive cardiology is not as lucrative,
this article was hoping to nudge cardiologists in that direction
by appealing to less tangible benefits.
Another barrier is doctors don’t think patients want it.
Physician surveys show that doctors often don’t even bring up diet and lifestyle options,
assuming that patients would prefer for example
to be on cholesterol-lowering drugs every day for the rest of their lives.
That may be true for some, but it’s up to the patient to decide.
According to the official AMA Code of Medical Ethics,
physicians are supposed to disclose all relevant medical information to patients.
The patient’s right of self-decision can be effectively exercised
only if the patient possesses enough information to enable an informed choice.
The physician's obligation is to present the medical facts accurately to the patient.
For example, before starting someone at moderate risk on a cholesterol-lowering statin drug,
a physician might ideally say something like
“You should know that for folks in your situation,
the number of individuals who must be treated with a statin
to prevent one death from a cardiovascular event such as a heart attack or stroke—
is generally between 60 and 100,
which means that if I treated 60 people in your position,
1 might benefit and 59 would not.
As these numbers show, it is important for you to know
that most of the people who take a statin will not benefit from doing so
and, moreover, that statins can have side effects,
such as muscle pain, liver damage, upset stomach,
even in people who do not benefit from the medication.
I am giving you this information so that you can weigh the risks and benefits
of drugs versus diet and then make an informed decision.”
Yet how many physicians have these kinds
of frank and open discussions with their patients?
Non-disclosure of medical information by doctors,
that kind of paternalism is supposed to be a thing of the past,
but now physicians are supposed to honor informed consent,
unless the patient's in a coma or something or it's an emergency.
But too many physicians continue to treat their patients
as if…they were unconscious.
At the end of this long roundtable discussion on angioplasty and stents,
the editor-in-chief of the American Journal of Cardiology
reminded the participants of an important fact to place it all in context.
Atherosclerosis is due to high cholesterol,
which is due to poor dietary choices,
and so if we all existed on a plant-based diet,
we would not have even needed this discussion.