Qualy #121 - The "art" of longevity: the challenge of preventative medicine and understanding risk
This Qualies episode, featuring insights from Dr. Ethan Weiss, explores the profound challenges in preventive cardiology. It highlights the difficulty physicians face in determining aggressive versus conservative patient management due to the limitations of clinical trials for individual care and the absence of clear outcomes in prevention.
Deep Dive Analysis
8 Topic Outline
The Cardiologist's Dilemma in Preventive Care
Challenges in Individual Disease Risk Prediction
Limitations of Clinical Trials for Individual Patient Management
Economic Barriers to Long-Term Prevention Trials
Adopting New Tools Without Robust Clinical Evidence
Evidence-Based vs. Evidence-Informed Medicine
Measuring Success in Preventive Cardiology
The Art and Science of Longevity Medicine
4 Key Concepts
Medicine 2.0
This concept describes a medical approach heavily reliant on clinical trials, which provide information based on averages, often for short durations, simple interventions, and easily measurable outcomes. This model, while useful for product development, often creates a mismatch when applied to the complex, individualized, and long-term nature of preventive patient care.
Evidence-Based Medicine
This approach to medical decision-making strictly adheres to the results of robust clinical trials and established scientific evidence. It emphasizes making choices that have been proven effective and safe through rigorous study.
Evidence-Informed Medicine
This approach acknowledges that while scientific evidence from clinical trials is crucial, many real-world patient situations lack direct, perfectly matched trial data. It involves using available evidence as a guide, combined with clinical judgment, patient values, and the physician's expertise to make individualized decisions, especially in areas like prevention.
Success in Preventive Cardiology
Unlike fields with clear, immediate outcomes (e.g., fixing a broken leg), success in preventive cardiology is often defined by the absence of failure. Physicians know they are successful when patients do not experience adverse events like heart attacks, making it difficult to quantify or receive direct positive feedback.
5 Questions Answered
The main challenge is determining the appropriate level of aggressiveness in intervention for individual patients, as there's often uncertainty about whether extensive investigation and treatment will ultimately help or harm, given the lack of perfect predictive tools for chronic diseases.
Clinical trials provide data on averages across large populations and are typically designed for short durations and simple interventions, which doesn't always translate directly to the complex, long-term, and individualized nature of preventive care, especially when economic factors favor shorter, sicker patient trials.
Evidence-based medicine strictly adheres to clinical trial data, while evidence-informed medicine uses available scientific evidence as a guide but also incorporates clinical judgment, patient context, and physician expertise, especially when direct trial data is lacking for a specific patient's unique situation.
Success in preventive cardiology is often known by the absence of failure, meaning patients don't experience adverse events like heart attacks, rather than by a clear, positive, and immediately observable outcome, which makes it a challenging field.
Physicians must rely on a combination of available evidence, clinical judgment, and the 'art' of medicine, acknowledging the potential for 'oversteering' based on individual anecdotes, as direct trial data for many primary prevention questions is often lacking due to the long timeframes required for such studies.
3 Actionable Insights
1. Longevity: Science and Art
Adopt the mindset that longevity is informed by science but ultimately comes down to an art, requiring individual judgment and personalized application of knowledge rather than just strict adherence to scientific data. This helps in navigating complex health decisions.
2. Adopt Evidence-Informed Mindset
Understand that medical decisions, especially in prevention, often rely on ’evidence-informed medicine’ rather than strictly ’evidence-based medicine.’ Clinical trials provide averages, but individual patient situations require judgment beyond direct trial applicability, helping in evaluating personalized medical advice.
3. Partner in Healthcare Decisions
Actively seek to be a partner with your healthcare provider in making decisions about your treatment and prevention strategies. This collaborative approach is essential for navigating complex medical choices, as effective communication and shared decision-making are crucial.
5 Key Quotes
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, you know, trying to optimize to the best of my extent, my ability versus whether that maybe the best thing I can do is leave you alone.
Ethan Weiss
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 are still acting in a very blunt manner.
Peter Attia
I'm doing so without that like safety belt of, of evidence basis that we're used to, right?
Ethan Weiss
being a preventive cardiologist is no one should feel sorry for me. I have the best job in the world, but, but it's difficult in that we only know success by the absence of failure.
Peter Attia
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.
Peter Attia