Welcome to a special bonus episode of the Peter Atia Qualies, a member exclusive podcast. The Qualies is just a shorthand slang for qualification round, which is something you do prior to the race, just much quicker. The Qualies highlight the best of the questions, topics, and tactics that are discussed in previous episodes of the drive. So if you enjoy the Qualies, you can access dozens more of them through our membership program.
Without further delay, I hope you enjoy today's quality. I want you to give us a quick or reasonably quick primer on other things that tend to confuse patients such as calcium scores versus CT angiograms, and I even want to touch on Heartflow in a minute because that comes back to it. So I think the listeners know what a Calistair score is in CT angiogram is, but just give us the quickest sense of that, because what I'm much more interested in is what do the results tell us? As a cardiologist practicing in 2019, I struggle with the question of whether I'm going to help you or hurt you, that I feel this tremendous sense of uncertainty about whether I should be as aggressive as I can, picking up every rock and looking under everything, and trying to optimize to the best of my extent, my ability, versus whether that may be the best thing I can do is leave you alone.
And you've probably seen examples too where I remember against a cardiology fellow, maybe even as a resident, where somebody would come in from an outside hospital sick as shit, just absolutely on death's door, and all we did was just turn out everything and the patient got better because they were just over-managed. And I think I struggle a little bit with this sort of where I want to be in that spectrum and how aggressive I should be in looking for say a cult coronary disease, which I think is a question you get a lot and I get a lot. One of the major reasons somebody comes to see me as a preventive cardiologist is they say, I'm going to die of a heart attack and what's my risk of dying from a heart attack? Or my brother died of a heart attack at 44, which I do, and I still don't have an answer about how aggressive I should be and try to understand it.
A lot of these tests we'll talk about, I think, to feed into that. And I think ultimately what we're missing, and I hope we can eventually refine it and make it better, is a good way to predict disease risk in these chronic diseases, these common chronic diseases like cardiovascular disease, metabolic disease that we just don't now yet have the tools to be able to say, you know, Peter, well, your risk is X, Y, or Z, and so therefore we should do this or this in terms of prevention, understanding that there's going to be risk in each one of these things that we do and maybe risk in even part of the process of getting from here to here point a point B. So I'm glad you brought that up because it illustrates the challenge that frankly can't be explained or rationalized or described on Twitter, not that pick on Twitter, but just to, so there's this idea which you've said, which is I don't know sometimes how aggressive to be or not to be. And what you're really saying is at the individual level with you as my patient sitting in front of me, I don't know how aggressive to be or not to be.
You're not asking the question on average. And yet what tool are you given to guide you? You are given a tool called a clinical trial, which is by its very nature, all about averages. And so therein lies the mismatch of what I've described as medicine 2.0.
When I say describe me, I'm writing about it in this book. I'm working on that hopefully I'll have finished by the time I'm alive, not alive. And the idea is it's not a poo poo clinical trials, it's just to acknowledge that clinical trials give us great information on averages and the larger and more robust the trial generally more heterogeneous the data. But you've asked a question that comes down to judgment.
You know what it means to be aggressive and you know what it means to be conservative and you have, you know what the corners of that box look like. What you're asking is I could have two people in front of me that superficially look similar, but actually one of them is probably going to have a better outcome if I behave aggressively and the other one might have a better outcome if I behave conservatively. It's the challenge to figure out which ones which if you're a hammer and everything's a nail, even if you're acting as a hammer and nail in accordance with clinical trials, I suspect you were still acting in a very blunt manner. 100%.
But I'm also talking about these areas and I think prevention is a great example that are sort of outside the boundary of what's been studied or is likely to be studied in the context of a clinical trial. I mean, there's not going to be a clinical trial to answer a lot of the questions that I have about how to manage my patients. And I feel the same way. I mean, prevention is not really amenable to this idea of medicine 2.0 which is clinical trial, average outcome, short duration, simple intervention, easy to measure outcome.
It's the economic thing. You're a company and you want to get your product to market whether that product is a stand or a drug or whatever it is. And the best way to do that economically is the shortage amount of time. And so you want to take the sickest people.
So these trials, I mean, I joke that like a prevention trial, all kinds of trials that I want to do would take 50 or 60 years. How do you convince somebody about to be 50? I wouldn't want to start a trial that I'm not going to see the answer from the result from. So it's unsettling to me.
And again, I think you just have to be remained humblest. I've tried to and hope that your patients, your human patients have some patients that were going to be wrong. There are litne of examples like LBLA was something I didn't pay attention to until the past few years. So somebody came to see me with a corner, a calcium scan, 10 years ago, I would say, I wish I didn't have this information, but I never ordered one before, 78 years ago.
So there are lots of examples of things that I didn't use to do that. I've now incorporated into my practice. And I'm doing so without that safety belt of evidence basis that we're used to, right? There's not going to be an orbiter like trial to help me decide whether I should be aggressive with living, lowering in a 35 year old.
That's not going to happen with primary prevention. So we have a mutual patient in whom that's exactly the type of question that's being asked, right? Yeah. And there's a term.
And I know all these cute little terms and I never know who to attribute them to, but we talk about evidence-based medicine versus evidence-informed medicine. To me, the latter just makes much more sense because these decisions that you have to make virtually every day, and I feel like I'm in the same situation, virtually nothing that I do can I point to the orbiter or courage equivalent. It just doesn't exist. And certainly not if you really want to discretinize it, every single thing is a variation on a theme that stems from some clinical trial.
But if you really wanted to be a skeptic, you would say, no, that's not the exact same patient and that's not the exact same situation. And therefore, you can pop yourself out of doing anything. And I'm super fond of saying that being a preventive cardiologist is no one's to feel sorry if we have the best job in the world, but it's difficult in that we only know success by the absence of failure. So there's no one who's going to come to me tomorrow and say, gosh, Ethan, thank you for the fact that I'm 46 and that I did not have a heart attack again this year.
It just doesn't happen. That's a great way to explain it. The other way around, like, I've had a few patients- But this is Northropetic surgeon, for example. That's right.
You break your leg, you fix it. Or an interventional cardiologist, right? You show up in the cath lab with that STEM-E. You know what you did.
The outcome is clear. The outcome is not that clear in prevention unless there's failure. So those examples, and I've had a few recently, I've been public about them on Twitter that are treatment failures, but maybe not personal failures. In fact, I don't think I've managed the patients incorrectly, but the fact is they had events while they were in my care.
Those live with you for a long time. So then the question is, under your race guard, the question is, is your reaction to that to then have a tendency to want to oversteer. So because I have these anecdotes, these very profound anecdotes of young people who've had terrifyingly scary outcomes, and I was not as aggressive as I could have been, but probably still following the sort of guidelines, is that going to guide me as a physician to be more aggressive in the future? And again, we're not going to have clinical trial data to help us here.
This is all art and judgment. The subtitle of my book, I'm hoping if the publisher lets me is going to be called the Science and Art of longevity. There's a title to it, but that's the subtitle. And I'm insistent upon that order because normally you say it in the reverse the art and science of whatever, but it's the science and art.
You're informed by science, but in the end, this still comes down to an art. Well, it is the art of the science, too, as you said, right? I mean, it is sort of how do you put this? And then there's the whole other layer, which is how do you communicate it with your patients?
And how do you include them as a partner in making these decisions? I hope you enjoyed today's special bonus episode of the quality. New episodes of the qualities are released Tuesday through Friday, each week, and are published exclusively on our private member only podcast. If you're interested in hearing more as well as receiving all of the other member exclusive benefits, you can visit pteratiamd.com forward slash subscribe.
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