Last week, when former President George W. Bush underwent stent surgery, the procedure was declared a great success. What is surprising is that not everyone in the mainstream media applauded.
From Bloomberg News “Former President George W. Bush’s decision to allow doctors to use a stent to clear a blocked heart artery, performed absent symptoms, is reviving a national debate on the best way to treat early cardiac concerns.
“The discussions have been ongoing since 2007, when the trial known as Courage first found that less costly drug therapy averted heart attacks, hospitalizations and deaths just as well as stents in patients with chest pain. The results were confirmed two years later in a second large trial.
“The debate has centered on both the cost of stenting, which can run as high as $50,000 at some hospitals, and its side effects, which can include excess bleeding, blood clots and, rarely, death. Opponents say the overuse of procedures like stenting for unproven benefit has helped keep U.S. medical care on pace to surpass $3.1 trillion next year, according to the U.S. Centers for Medicare and Medicaid Services.
“’This is really American medicine at its worst,’” said Steven Nissen, head of cardiology at the Cleveland Clinic in Ohio . . . ‘It’s one of the reasons we spend so much on health care and we don’t get a lot for it. In this circumstance, the stent doesn’t prolong life, it doesn’t prevent heart attacks and it’s hard to make a patient who has no symptoms feel better’” . . .
“’Stents are lifesaving when patients are in the midst of a heart attack’ added Chet Rihal, an interventional cardiologist at the Mayo Clinic in Rochester, Minnesota . . . ‘They allow immediate and sustained blood flow that help a patient recover. For those who aren’t suffering a heart attack, the benefits are less clear . . . While stents may be used in patients with clear chest pain, there’s no evidence that they prevent future heart attacks.’ A review of eight studies published last year in JAMA Internal Medicine also found no differences.
“Two large-scale clinical trials completed within the last seven years have shown that drug therapy works just as well as stents in preventing cardiac complications. (The three major U.S. heart associations changed their guidelines in 2011 in an effort to reduce excess treatment. )
[This is important. The major U.S. heart associations have absolutely no vested interest in recommending fewer procedures. When they say “Do Less,” everyone should listen–mm. ]
“In Bush’s case,” Freddy Ford, the former president’s spokesman told Bloomberg, ‘he underwent the procedure without any symptoms after a stress test during his annual physical turned up signs of an electrical abnormality on an EKG . . .
“Paul Chan, an associate professor at the Mid-America Heart Institute in Kansas City, Missouri, questioned why Bush would have undergone a stress test at all if he didn’t have symptoms. While it’s fairly common practice for doctors to put older patients through such tests even without chest pain, Chan said, there’s no evidence showing it’s beneficial. . ..
“The reality is that we don’t know if we can change the trajectory of disease in people who don’t have symptoms, are doing fine and are physically active . . . There’s no evidence treatment will help them live longer, feel better, or have fewer heart attacks.”
The Dallas Morning News had a very different take on Bush’s operation.
From the Dallas Morning News: “Former President George W. Bush’s unexpected surgery Tuesday to clear artery blockage in his heart served as a reminder that even the fittest and most health-conscious must be watchful of cardiovascular disease.
[Translation: Even if you’re fit and healthy, you should worry. You may need surgery tomorrow.]
The Dallas paper continued: “Doctors discovered on Monday the blocked artery during Bush’s annual physical examination at the Cooper Clinic in Dallas. The famously fit 67-year-old then had a stent implanted in his heart Tuesday at Texas Health Presbyterian Hospital.
“The health scare. . . came as a surprise, given that Bush is an exercise fanatic who showed no outward symptoms of distress. . . .
“About 600,000 Americans die each year from heart disease, according to the Centers for Disease Control and Prevention . . . many people, like Bush, show none of the common symptoms, such as tightness in the chest and shortness of breath.
“The blockage typically builds up slowly over many years, causing heart disease to sometimes become a silent killer. Experts said that highlights the need for those with risk factors to get periodic screenings.
“’It’s very important for the public to understand that it’s not necessarily pain,’ [that signals a need for stenting] said Dr. Gaurav Gupta, an interventional cardiologist at Methodist Dallas Medical Center.”
[In other words, you shouldn’t wait for “symptoms” before scheduling surgery.
Forget about ‘listening” to your body. The folks who run the testing facilities will tell you what you need to do. Just go for the screenings—as often as possible–and they’ll let you know when you should sign up for the procedure.]
The Dallas Morning News concludes:
“Hundreds of thousands of Americans receive stents each year. And the relatively simple procedure can have a lasting impact: experts said that fewer than 10 percent of patients with stents see re-blockage in the first year.
[Great. What happens to that 10 percent? And what happens after the first year?]
The Dallas Morning News story is based on the notion that more care is always better care. This late twentieth-century view of medicine assumes that you can never be too careful. Even if you feel healthy, you should go for screening. Your doctor may be able to find something.
TIME, like the Dallas Morning News (and many other publications) stuck with the traditional script, hailing the procedure as one of the mircales of modern medicine:
“Doctors discovered the blockage during Bush’s routine physical, and recommended a stent to keep the artery open.
“That advice has become increasingly popular in recent years to treat chest pain and angina, thanks to advances in stent technology and the fact that the hour-long procedure is less invasive than bypass surgery . . . the devices are also being recommended in more patients like Bush, who show early signs of heart blockages . . . “:
A Changing Medical Culture?
By contrast, Bloomberg expressed a growing awareness that over-testing may lead to over-diagnosis—and over-treatment. (For background on how stenting has been overused in recent years, see this HealthBeat post
Health care reform aims is to squeeze some of the waste out of our health care system by reducing overtreatment. But that will require a change in our medical culture: both physicians and patients must begin to realize that, as California governor Jerry Brown tried to tell us back in 1974: “Less is more.”
For years, Americans have resisted this idea. Until very recently we tended to think that “Plenty” is never enough. Whether we were talking about the size of a restaurant meal, a McMansion or a car, “More” was always better
But in the past decade attitudes have been changing –and nowhere is this cultural change more important than in medicine.
Five years ago, if a former president underwent heart surgery that appeared successful, I very much doubt that we would have read anything like the Bloomberg story in the mainstream media.
But today, more and more doctors have been speaking out about the excesses. And some in the media are printing their objections. Regarding Bush’s operation, USA Today quoted Nissen, saying that “Bush ‘got the classical thing that happens to VIP patients, when they get so-called executive physicals and they get a lot of tests that aren’t indicated.’”
Meanwhile CNN reported that a 2006 medical examination revealed that Bush had no signs of hypertension or other modifiable risk factors and that he had a “low” to “very low” coronary artery disease risk profile.
This reflects a critical change in how some reporters cover medical care. Healthcare reform is beginning to open minds. Rather than simply interviewing the doctors who treated former president Bush, the Bloomberg reporter sought second opinions from leading medical experts. Not only that, he assumed that his readers would be interested in what skeptics had to say. (Ten years ago, I can imagine an editor saying: “Our readers don’t want to hear this.”)