Earlier this year, former President George W Bush had a stent procedure on his heart. A model of physical fitness who rode 30 miles in the heat on a bike ride for veterans, he had a series of tests that led to him undergoing the procedure in one heart vessel. This was initially lauded in the media as a successful exercise in early detection and treatment.
Soon after, articles began appearing in publications such as the Washington Post labeling the procedure as unnecessary. These authors correctly pointed out that he was not having symptoms (at least none that were publically reported), his physical fitness was outstanding, and therefore no heart testing was indicated. The best evidence is that any potential procedures would not extend his life, only increase the risk of him receiving a procedure, which is exactly what happened.
His journey started probably with one of these “executive physicals” touted by the so-called “wellness centers” that exist in every major American city.
The procedural ologists must have bristled at the accusations, so a second wave of articles was then published that claimed he had a “95% blockage” of one of his coronary arteries. This purported fact was claimed to mean the artery was “potentially life-threatening.”
Once again, the fear mongers were at it again, exaggerating the impact of the disease and the ability of health technology to do anything about it.
This concept is even hard for some doctors to understand, but the reality is that it absolutely didn’t matter that the blockage was 95% or 99% or 2%. So many ologists, and even a few primary care physicians, have a greater sense of control of their patients’ future based on knowledge of body part details than is justified by the results of high-quality evidence. In the family medicine world, this is the distinction between what we call Disease-Oriented Evidence – the fact that the artery was 95% blocked – vs. Patient-Oriented Evidence – the fact that many studies have proven that intervening would make no difference with his set of circumstances.
How can this be? On one level, it doesn’t matter if we understand why, the evidence is the evidence. On another level, when researchers try to make sense of evidence that flies in the face of a small disease marker, they come up with new theories. In President Bush’s case, his continued physical activity, in the face of one vessel that was slowly and stably narrowing, caused collateral blood flow from the two good arteries to supply the area of his heart muscle that had been supplied by the blocked vessel. It is not unusual in heart catheterizations to observe vessels that are 100% blocked with no evidence of a previous heart attack. Collateral flow likely explains why this is.
The truth is that President Bush had a situation where the most important information for the doctor to obtain was a conversation about how his biking was going. After learning it was strenuous and pain-free, any worries about his heart should have ceased. But American doctors aren’t paid to listen, are they?