"We are losing the battle for the hearts and minds of our patients": The seeds of our health care mess
July 30, 2017
“We are losing the battle for the hearts and minds of our patients,” states Dr. Steve Nissen, a noted Cleveland Clinic cardiologist, exasperated that too many patients are listening to the internet instead of their doctors. But as a primary care physician I perceive his sentiment through a different lens: too many people are listening to their doctors who feed them deceptive information and who don’t respect their values and wishes, and that is leading them down precarious roads. This crisis is no more apparent than in Dr. Nissen’s field of cardiology.
Dr. Nissen points to a recent study that suggests that people who stop statins due to side effects are at much higher risk for bad outcomes than people who continue taking the drugs. After 4 years, out of 1000 people who stopped the statins, 17 more had some form of cardiovascular event (not all of which were serious or life threatening) than people who continued the statin, as shown in the BRCT above. To Dr. Nissen, whose studies are sponsored by companies that manufacture statins, these numbers are alarming. To many real patients, though, they are not.
Recently I saw a 70-year-old patient with a very high cholesterol. She was healthy and fit and had few risk factors for heart disease. Still, her cardiologist hounded her about taking a statin, insinuating imminent harm. We did a test proving she had no plaque on her arteries, and she had a normal stress test, but his push for the statin did not abate. Finally, the patient, on her own, started a strict vegan diet and her cholesterol dropped by over 150 points. “Why didn’t he talk to me about diet?” my patient asked me. “He just insisted I be on that drug.” In fact, with no plaque, my patient’s risk of heart disease is about 1.5/1000, whether she is on a statin or not, and that risk is not impacted by her cholesterol level. Diet and exercise are the most important determinants of her health. It is true that people with high risk of heart disease—those who have had heart attacks or have a lot of risk factors—do benefit from statins, but even they have only 45 fewer heart events in 5 years when compared to 1000 people who don’t take statins. That means that in 5 years, 955/1000 high risk people don’t benefit. And in people with low risk, like my 70-year-old patient, statin benefit is tiny if it occurs at all. Despite Dr. Nissen’s outrage, to many of my patients, those numbers are insignificant, especially if they have side effects from the drugs. Of course, Dr. Nissen poo-poos the side effects, but the pharmaceutical-sponsored studies he runs are very cleaver at minimizing adverse drug reactions, while other studies show that they are indeed very common among certain groups of people. I see them every day in my practice of elderly people, and I have experienced them myself; they are not the internet-driven delusions that Dr. Nissen insinuates they are.
Patients are intelligent enough to make reasonable health care decisions without being called deluded or misinformed, if they are given accurate information, something rarely occurring in the media, pharmaceutical ads, or from their doctors. A study of 13,000 doctors showed that only about 10% of them understood the actual risks and benefits of medical interventions, most consistently over-estimating the benefit. So much of what cardiologists perceive to be dogma has at best questionable efficacy, and at worse can cause side effects and higher death rates, from statins, to stress tests, to blood thinners, to stents, to aggressive lowering of blood pressure. No wonder that in 2008 cardiologists were costing the health care system $100 billion more per year than they were in 1999, without any reduction in heart attacks or death.
Rather than preach to patients without providing them with accurate information, rather than stating that certain interventions are necessary and life-saving and then labeling any skeptics of their medical dogma as denialists, doctors like Dr. Nissen should look in the mirror and see who is at fault for our high-cost, low-value health care system that squanders a trillion dollars every year on unnecessary care. Dr. Joel Stein from University of Wisconsin, who supports Nissen’s position, states about patients who listen to those questioning the utility of statins, “There is a special place in hell for people who use fear tactics and misinformation to promote [their products and positions]. I am not sure why Americans are so susceptible to these charlatans.” I am not sure either, except to doctors like me, who do listen to patients and allow them to make their own health care decisions, the charlatans are quite different than those to whom Dr. Stein is referring.