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Healthy skepticism needed in modern-day cardiology
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It seems to me that there is more controversy in cardiology these days than ever.
This may be a fairly limited statement of opinion, since I have been a physician-in-training for just over five years, but it is based on the lessons I learned as a fellow at a private institution, perennial attendee of the American Heart Association and American College of Cardiology scientific meetings, and as a fellow representative at this year’s ACC Congressional meeting.
From the rofecoxib (Vioxx, Merck) lawsuit to the drug-eluting stent mania, the controversy continued at the AHA meeting last month with focus on negative late-breaking trials for chronic total occlusions recanalization (OAT), a heated debate over noninferiority trials (ACUITY) and discussion about implantable cardioverter defibrillator appropriateness and utilization. Most of us are looking for the scientific truth, while others have vested interest in the truth.
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Navigating disparate realities
My fellowship is sponsored by a private academic hospital where the mission is an environment in which academia and the private sector can flourish together. Fellows can learn from an eclectic mix of practice patterns that include minimalist empirical styles, evidence-driven practice and reimbursement-driven test ordering. There is often a double-edged sense of disdain for evidence-based medicine in that guidelines cannot serve as substitutes for real-world scenarios and practicality. Concordant with this thought, we often see different results between strict randomized controlled trials and real-world registries, like recent DES literature would suggest. Cost-effectiveness in many of our minds is at other people’s cost. This understanding of disparate realities has been a tremendous strength to my training perspective.
On the other hand, I learned that at a private institution, all new prospective faculty must be approved by a board of private physicians. As we looked to expand and replace faculty in our department, I learned from candid conversations with private physicians that the best candidate for the job, from the fellows perspective, may be particularly undesirable to the current private sector. An expertise in a particular procedure or subspeciality may threaten the existing referral base of practicing physicians, and therefore an endorsement for hire would cease to exist.
If there was not such a discrepancy between the financial reimbursement of a pure academician and the private practictioner, would industry be as pervasive in evidence-based medicine?
It is reality that the majority of scientific literature published is industry-sponsored and in an article published in JAMA last year, those that are sponsored by industry are more likely to be positive. All of the physicians that run trials have an incentive to deliver results and we must interpret these findings cautiously and constructively.
If patient care was the priority, would noninferiority trials exist? Why would a company spend time and money on a trial that demonstrates that a study drug is only 10% to 25% worse than the current practice standard? If an investigator cannot deliver the desired results, then he or she must spin it in such a way, or use underpowered subgroup analysis to demonstrate some original message.
One of my mentors told me that the trials are not getting better, the trialists are just getting smarter. For this reason, I put more emphasis as a fellow completing my training into registry data and negative superiority-design trials.
Money Matters
I recently wrote a summary on my eye-opening experience in Washington at the ACC Legislative Conference. The fact is that for most of the issues we lobbied, it came down to capital preservation. The constant threat of Medicare cutbacks on reimbursement and the fight to preserve in-office imaging dominated the discussion among legislative aides. Medicine is a business, after all, and why I thought otherwise supports a naivety during training.
Lastly, political power, if not through numbers, is gained by financially supporting local legislator campaigns. In a fight about money, the wealthiest have the best chance of winning.
My experiences as a clinical fellow have gone far beyond a traditional cardiology curriculum and I am grateful for many diverse opportunities.
In addition, to have the unique opportunity to voice my random and heart-felt thoughts in this column has been invaluable. As we age and accumulate experiences, many of us become grumpy or “bitter.” However, I believe that a better understanding of the forces at play in our world should really make us have a better grip on reality and the rules of the game. A sense of healthy skepticism is imperative in life and medicine.
Roderick Tung, MD, is a fellow at Cedars-Sinai and is a member of Cardiology Today’s Fellows Advisory Board. This is his last regular column and the editors are grateful for his contributions. Starting in January, Juan Rivera, MD, a fellow at Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, will continue the Fellows Forum column.