PRETTY regularly, I receive an urgent call from a distraught friend or friend of a brother. “Zeke, Mom was at home and her heart stopped. The E.M.T.s are rushing her to XYZ hospital in Miami. Can you help me find the best cardiologist there for her?” “Get me the best cardiologist” is our natural response to any heart problem. Unfortunately, it is probably wrong. Surprisingly, the right question is almost its exact opposite: At which hospital are all the famous, senior cardiologists away? One of the more surprising — and genuinely scary — research papers published recently appeared in JAMA Internal Medicine. It examined 10 years of data involving tens of thousands of hospital admissions. It found that patients with acute, life-threatening cardiac conditions didbetter when the senior cardiologists were out of town. And this was at the best hospitals in the United States, our academic teaching hospitals. As the article concludes, high-risk patients with heart failure and cardiac arrest, hospitalized in teaching hospitals, had lower 30-day mortality when cardiologists were away from the hospital attending national cardiology meetings. And the differences were not trivial — mortality decreased by about a third for some patients when those top doctors were away. Truly shocking and counterintuitive: Not having the country’s famous senior heart doctors caring for you might increase your chance of surviving a cardiac arrest. The researchers did interesting checks to be sure the results were valid. They noted that there was no difference in mortality from heart conditions when physicians were attending the cancer or orthopedic meetings, presumably because the oncologists and orthopedic surgeons, not cardiologists, attended those meetings and don’t care for patients with heart problems. And when the cardiologists were at their national meetings, there were no changes in mortality from nonheart conditions such as hip fractures. Overall for all heart conditions examined, patients cared for at the teaching hospitals did significantly better than those cared for in community hospitals. So choosing a teaching hospital, when possible, makes a difference. It is not clear why having senior cardiologists around actually seems to increase mortality for patients with life-threatening heart problems. One possible explanation is that while senior cardiologists are great researchers, the junior physicians — recently out of training — may actually be more adept clinically. Another potential explanation suggested by the data is that senior cardiologists try more interventions. When the cardiologists were around, patients in cardiac arrest, for example, were significantly more likely to get interventions, like stents, to open up their coronary blood vessels. This is not the only recent finding that suggests that more care can produce worse health outcomes. A study from Israel of elderly patients with multiple health problems but still living in the community tried discontinuing medicines to see if patients got better. Not unusual for these types of elderly patients, on average, they were taking more than seven medications. In a systematic, data-driven fashion, the researchers discontinued almost five drugs per patient for more than 90 percent of the patients. In only 2 percent of cases did the drugs have to be restarted. No patients had serious side effects and no patients died from stopping the drugs. Instead, almost all of the patients reported improvements in health, not to mention the saving of drug money. We — both physicians and patients — usually think more treatment means better treatment. We often forget that every test and treatment can go wrong, produce side effects or lead to additional interventions that themselves can go wrong. We have learned this lesson with treatments like antibiotics for simple medical problems from sore throats to ear infections. Despite often repeating the mantra “First, do no harm,” doctors have difficulty with doing less — even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery. There are potential policy solutions. One would require that doctors provide patients with data about a procedure, including its rate of success, complications and the like, before every major intervention. A solution for overmedication, especially in older people, would be to require that doctors attempt to discontinue medications at least once a year. One thing patients can do is ask four simple questions when doctors are proposing an intervention, whether an X-ray, genetic test or surgery. First, what difference will it make? Will the test results change our approach to treatment? Second, how much improvement in terms of prolongation of life, reduction in risk of a heart attack or other problem is the treatment actually going to make? Third, how likely and severe are the side effects? And fourth, is the hospital a teaching hospital? The JAMA Internal Medicine study found that mortality was higher overall at nonteaching hospitals. It is surprising how uncomfortable some physicians get when you ask these questions. No one likes to be second-guessed or have to justify their decisions. But studies show that when patients are systematically given information about benefits and risks they tend to consent to fewer interventions and feel more informed about their decisions. So when your mother is being rushed to the hospital, it might be best not to seek the most famous senior doctor, but to ask those four questions. Source
