Another Interesting Blog From Dr. M

"The trick of hope — and the medical decision

Posted: 31 Mar 2015 04:36 AM PDT

Last night, during the intro show for the PBS documentary, Cancer: The Emperor of All Maladies, a Ken Burns film based on the book by Siddhartha Mukherjee, Katie Couric interviews both Ken Burns and Dr. Mukherjee.

The moment occurred about 10 minutes into the video.

There is a poignant scene in which two young parents struggle with the decision to enroll Olivia, their 17-month-old baby who has leukemia, into a randomized clinical trial to test one treatment over another. When the doctor tells the parents a computer randomization will determine Olivia’s treatment, you see anguish in their faces. They don’t want that. The parents want the treatment–the one that works. Presumably the active arm.

Immediately after that scene the producers cut to the interview. Focus on Dr. Mukherjee’s answer.

Katie Couric: We see Olivia’s parents agonizing over whether to participate in this clinic trial. It seems a sort of Russian Roulette with this person most precious to you.

Siddhartha Mukherjee: Medicine is the most human of all the sciences that is stuck with the least human of all the experiments. And that is the randomized trial. Randomization doesn’t exist because doctors are maligned or because medicine is nasty. It exists for precisely the opposite reason. Because we hope too much. We are so hopeful, we want things to work so badly, that we will trick ourselves to believing that things are working. And there is nothing as toxic or lethal as that trick, the trick of hope.

I loved that statement. I live these tricks every day. We doctors trick ourselves. Patients, too, allow themselves to be tricked. Why? Because of our innate bias towards the hope of action.

In a recent Medicine peer review meeting at my hospital, we had a diabetes specialist speak about the importance of monitoring blood sugar. Why? Because hospital medicine writ large was tricked into believing aggressive blood sugar control was best. Now, we struggle with outbreaks of low blood sugar–a life-threatening problem.

In the care of patients with atrial fibrillation, I fight the trick of hope and the bias of treatment nearly every day. Doctors and patients want AF fixed. The problem with AF care–similar to cancer care–is that treatment can be more deadly than the disease. Both parties get tricked into believing things are working.

Dr. Mukherjee helps us understand the take-home message of the medical decision:

See the trick. Face the bias. Always start from a place of uncertainty. Uncertainty is normal and good. Move slowly from that place. Be afraid, very afraid, when a medical person says he is certain, or uses that bad word…need. As in you need this treatment.

If we were less sure of ourselves, perhaps we would be less susceptible to being tricked.

JMM"

In my opinion Dr. Mandrola is a real minimalist when it comes to afib treatment. He may be great in other areas, but when it comes to afib he is constantly steering folks with afib away from both meds and especially ablation. I will lay odds that Dr. Mandrola does not have afib.

You are darned right, I have hope and lots of it. That is why I am constantly researching the best treatments from all medical diciplines. I research diet, ablation procedures, drug trials, the most successful ablation doctors and on and on.
I do not think my hope is misplaced. Medicine advances, duh!

John,

" I will lay odds that Dr. Mandrola does not have afib."

In fact he has had it. Had to take flec to convert. He blogged about a few years ago. <[www.drjohnm.org]

George

George,
Thanks for the correction. I lost that bet!

I still think, though, that Dr. Mandrola overstates the downside of afib treatments. Perhaps he does not make the distinctions necessary between treatments in the hands of top-tier EPs and the rest of the EPs. Yes, afib treatments can have significant downsides, but mostly in the hands of those who do not have sufficient experience or who are not keeping up with the latest findings in research.

JohnB

My main issue with Dr Mandrola is not that there isn't some good points in his arguments many times, but that he so often then takes a good point and shoots to the moon with it and winds up flying off the handle going way overboard, in my view, in his pronouncements that: ...... (insert here the latest topic of his newest 'discovery') .... is 'the latest paradigm shift in the treatment of AFIB that surely changes everything'.

I like and fully support his relatively new spirit of looking gradually more toward an integrative approach to health care, as this website and all of our core values here have been based on for the last 16 years. But I find so many of his posts maddeningly frustrating when he tends to take an almost messianic tone toward pronouncing the next great break through in the EP/Cardio world, be it this new life style risk factor reduction protocol, or FIRM ablation which he jumped on the bandwagon much too early on, and yet still four years later there are more questions and doubts about just what exactly FIRM might bring to ablations over and above the already established top tier procedures for addressing non-PV triggers such as those proven methods as Bordeaux and Natale protocols and others. Especially when these same mentioned large centers have done a couple years of investigation with the system now and have yet to convert over to using it in their mainstream ablation protocols en mass.

Same with the new rage of 'discovering' that life style risk factor modification might be a novel idea to address and lessen AFIB burden in a significant number of patients. Of course, this makes all kinds of sense and is not a new idea by any means as our very 16 year existence as a website based mainly on supporting a truly integrative approach to AFIB and overall health care stands testimony too.

Even among the cardio world, many physicians instinctively know from years of experience that when a very overweight person comes in with AFIB they have stacked the deck strongly against a long term good outcome until, and if, they make a heroic effort to shed many of those unwanted and harmful excess baggage. Noting that it is true that a more dedicated effort much be launched to convince more EPs Cardios and most importantly front line GP or PCP docs as well as education bringing in elementary schools about how to eat and take care of one's health better for any real improvements to happen across the board.

But now elevating this very worthwhile and interestingly small study run by a bright young EP fellow out of Adelaide Australia in which around a some odd 130 previously overweight patients benefited from a greatly reduced AFIB burden due to following a carefully structured and guided intensive weight loss and fitness regime that is now being trumpeted as 'proof' that AFIB ablation has just been rendered to be a rarely needed occurrence and should rarely be considered now instead replaced by a kind of Boot camp fat reduction clinics run by thousands of Nurse Ratchets across the globe cracking the whip and making sure no one sneaks in a twinkie during curfew :-).

Its just a ludicrous conclusion to jump too even though it is based on this very promising study when you read what it really says, and the overstated promise Dr M implies then comes across as more breathless over the top and highly premature speculation, at the very least, which in this case does as much harm and spreads as much confusion as it does clarity I'm afraid.

I do think Dr M's heart is in the right place and he certainly means well and many of his points are very valid and worth emphasizing in my view as well, just tone it down this war on ablations which used to be one of his main focus, and take a moment and a deep breath before announcing the next new big new breakthrough stuff please, at least until we get a few independent longer term studies verifying the longer term effect on a MUCH larger group of Afibbers in other parts of the world.We need a lot more solid evidence that whatever exciting theory is in question really does work at such a breakthrough level as he presumes before plastering it all over the web.

What is so frustrating to me is that he takes the very great ideas of promoting and adopting the personal responsibility dietary, weight loss and other co-factor reduction methods we have championed here for so long and yet then proceeds to inadvertantly water the whole thing down by grossly over promising in such a big way what they can really achieve in the real world!

Yes, Dr M does plays lip service at the end of his spiel, almost as if a disclaimer, on this 'paradigm-shift new discovery' that taking good care of yourself and losing excess weight and eating and exercising better is a healthy idea ...by saying that there is still a roll for ablation although a rare and minor one in his view. Whatever the angle, it seems clear he has drunk a gallon of the Koolaid already and is off to the races with this thing and as a journalist that he mostly now is, I can understand the urge and appeal to lead the charge for the next big thing.

My big concern is that these over the top 'jump on the bandwagon' pronouncements based on the slimmest of evidence, will tend to discredit rather than promote the very good points he and the Australian studies he is trying to highlight do very much make, Im afraid.

All of this is basically over the results with around 130 plus over-weight Australians with various degrees of AFIB who were managed by a dedicated medical clinic approach guided by trained cardio nurses including those with nutritional backgrounds, but not cardiologist, in helping the main study group of very overweight people buckle down and commit to real dedicated weight loss over time ,... think 'The Biggest Loser' TV reality show for example ... And they had a big success in reducing AFIB burden significantly.

No surprise here, and hallelujah! A number of other studies done with a bit less stringent weight loss guidance, but still pretty strict, have shown similar if not quite as pronounced results too and these are all great and reinforce our central message as well. But for all the good common sense of making such steps the key first step when ever you have an overnight person with AFIB come into the office a number one priority in their treatment, calling it a step that will relegate AFIB ablation to a rare occurrence is just plain irresponsible and unsupportable.

We have shown that time and again here how valuable good dietary changes, nutrient repletions, stress reduction, moderate consistent exercise and sleep apnea treatment as well as control of metabolic syndrome/ 'diabesity' and hypertension can be in helping to greatly reduce AFIB burden. And when started early enough, can not infrequently help put the genie entirely back in the bottle long term as well.... All well and good!

But we here at afibbers.org have also discovered the limitations of these methods, by themselves, in achieving true long term success with intractable AFIB that so often requires the help of an expert ablation process along with these smart and essential life style risk factor modification methods, when real freedom from AFIB is the goal.

George, it is true that Dr M had a couple transient bouts of AFIB in the past that were clearly from overtraining effect during long bike rides from his reports that I have read at least. However, I've not heard him report any such thing in a number of years and it seems as if his run-in with AFIB may well have been a limited occurrence.

As we all well know, the mind is a funny thing when it comes to AFIB and is uncanny at suddenly flipping around 180 degrees and minimizing what just previously felt awful and terrible and that you would do anything to stop not even 5 hours earlier while still in the grip of the beast and before converting back into NSR when any thoughts of needing further treatment or even an ablation often fade into the sunset, replaced once again by a liaise faire attitude toward to the condition from a personal feeling perspective. As such, I would hardly classify his apparently rather limited exposure to exercise-induced AFIB as him really knowing what it is like to live long term with the condition.

He may have a better sense of what it feels like to be in AFIB short term than an EP who has lived in NSR every moment of their lives, but a more limited experience like he has reported so far is entirely different as well than living with the ever present Sword of Damocles hanging over your head for years on end, only to have it swing through and strike without a moments notice time and again throughout one's life in the most disruptive and disappointing manner.

In fact, if his AFIB history has been as limited in scope as he has written publicly about, you might make a better argument that such a limited exposure could even make him more likely to possibly dismiss the impact of living with it long term when his own experience was so relatively short and manageable?

Whatever the case, I do enjoy much of Dr Mandrola's blog writings on many topics, but I also truly wish he would find more balance and a bit less 'breaking news' enthusiasm for these otherwise good and worthy ideas and helpful adjuncts to a truly integrative and holistic fight in which ALL the best tools are marshaled together for our best possible outcomes.

Shannon