This article is dedicated to my dear brother Jeff, may he rest in peace, taken from those who loved him by a heart attack at only 59 years old. May the information I’ve spent many months researching help you, and those you love.
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Arrogant Armor
When confidence is present in abundant disproportion to the level of competence, is it arrogance? Or for the threshold of arrogance to be met, must it also include condescension, bragging, and being an all-around jerk? I’m not sure where that fine line falls, but I’m pretty sure that I had crossed it for the first couple of years of medical practice.
Fresh out of residency in 1996, full of textbook knowledge, boundless determination, and still in possession of most of my hair—I didn’t know what I didn’t know.
I remember one particularly shameful episode from over 25 years ago. I was at a medical conference in Michigan, hovering around the lunch buffet, going back for more watermelon, when I was approached by a short, stocky, slow-witted bald man who turned out to be an alternative medicine doctor.
At the time, to my discredit, I judged the book by its cover. Starting back in 1999, several major medical centers began incorporating integrative medicine into their programs, and it’s become far more mainstream ever since. But that wasn’t the case during my medical training—During my residency experience as an allopathic doctor in the mid-90’s, alternative medicine was openly ridiculed.
I’d like to think that I’m impervious to brainwashing, but sadly no. I remain human—Flawed and influenced by others around me. And as soon as I learned that he was an alternative medicine doctor, there was nothing he could say that I’d take seriously.
He told me that his vascular disease patients were getting remarkably better with a certain medical intervention (which I’ll discuss later, but I want to do so fully to give a nuanced appraisal). He spoke for about 20 minutes, sharing anecdotes of amazing improvements in quality of life metrics and cardiovascular outcomes, during which time my mind was racing, evaluating strategies to politely excuse myself.
At one point I caught myself rolling my eyes, and at least had the self-awareness to feel guilty, but it only lasted a minute. I did eventually excuse myself, but not in the polite manner I’d hoped. I was brusque and abrupt when I thanked him and left, but I just had to get away.
Heavy is the Head
I think arrogance is a helmet—Difficult to wear for long, but sometimes helpful in the short term. Physicians can effectively wear a bit of arrogance like armor, to help appear and feel authoritative when we’re just not there yet. But balance is key.
“As a surgeon you have to have a controlled arrogance. If it's uncontrolled, you kill people, but you have to be pretty arrogant to saw through a person's chest, take out their heart and believe you can fix it.”—Dr. Mehmet Oz
But I couldn’t balance it. That clumsy helmet blocked my view of things, limiting the information I took in. I don’t know how many years it would have taken me on my own to realize that I needed a humility check—But that, and a million other wonderful reasons, is what Moms are for—She brought me down to Earth over chicken and broccoli at a Chinese restaurant. And I’m forever grateful for that.
I only saw truly again once I took off that stupid headgear, and when I did, I realized that I’d just walked a dangerous path. My mind went right to the arrogant cardiologist who dismissed that my father’s end-stage heart failure could have been caused by Lyme—I’d never want to be anything even remotely like him. Good riddance to that dumb hat.
Whereas arrogance may be like armor, humility is like a pair of old shoes. Although comfortable, it may feel like they don’t offer the protection of the helmet, but that’s an illusion. As I’ve gotten older, I’ve realized that I never needed being protected in the first place.
And so it’s with humbled eyes that I’ve watched, at first hopeful, then disappointed, and now jaded, as doctor after doctor—Over the past 25 years—Has only recommended interventions to my patients which are profitable to either pharmaceutical companies or hospitals.
Turf War
If this sounds outlandish, take a look at what happened with CT coronary artery calcium scores. Despite compelling evidence from 2004 that these tests can non-invasively detect coronary artery disease that leads to heart attacks when stress tests often fail to do so, they were not embraced by cardiology medical societies until the data became too overwhelming, in my opinion embarrassingly so, to ignore.
From NBC:
“Among the 1,119 patients who had normal stress tests, 56 percent had calcium scores greater than 100, and 31 percent of patients had scores greater than 400…Calcium scores of zero are the "best" scores. Patients with calcium scores from 100 to 400 are at increased risk for cardiac events such as heart attacks, while patients with scores above 400 have the highest risk for a heart attack.”
A calcium score greater than 400 carries a risk of heart attack or stroke of more than 20% within 10 years—A clarion call which requires action to save lives, but which would have been completely missed in about one third of normal nuclear stress tests.
Here’s the study to which the NBC piece is referencing:
“Of 1,119 normal MPS [myocardial perfusion single-photon emission computed tomography, also known as a nuclear stress test] patients, CAC [coronary artery calcium] scores were >0, >or=100, and >or=400 in 78%, 56%, and 31%, respectively…low CAC scores appear to obviate the need for subsequent noninvasive testing. Normal MPS patients, however, frequently have extensive atherosclerosis by CAC criteria. These findings imply a potential role for applying CAC screening after [I put this in bold because in the article it was italicized for emphasis, and this quote is already italicized] MPS among patients manifesting normal MPS.”
This study found that 31% of patients with normal nuclear stress tests had extensive coronary artery disease as diagnosed by calcium scores. And yet, even though the authors state that a low calcium score removes the need for further non-invasive testing, they still advise that calcium scores be done after nuclear stress testing. They even emphasize the word “after”—Why? Could it be due to a medical turf war, with seriously ill patients caught in the crossfire?
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