Evidence based medicine: Go beyond the headlines and dig into the data

Labor Day weekend, a young man in his early 50s came into our hospital.

He had multi-vessel coronary artery disease. I sent him in for surgery. Every one of his vessels was blocked. The surgeon came to me and said he couldn’t find enough veins to bypass all the occlusions.

There was an artery in the back of the heart, and he didn’t have any veins left to work with. Let’s sit tight, I said. We have four other vessels by-passed, let’s see if that is enough before we go too far. Later we see the vessel in the back of the heart is not working well, the heart of is not moving well.

His lungs are increasingly congestive. He is experiencing mitral valve regurgitation. This is a problem, but I’m not going to take him back and tear the bypasses out to get to the mitral valve. Why don’t we use more adrenaline drugs, I ask. But he gets worse.

I say to my colleague, let’s use a balloon. Here I am talking about intra-aortic balloon counter-pulsation (IABC). If what he is suffering from is more complicated, nothing will change. But if he improves that will tell us that it’s most likely this last vessel and we can find a solution.

Within an hour or so the man becomes much more alert and energetic. He can come off some of the adrenaline drugs. That told us the mitral valve problem and the back vessel needed to be addressed if he was going to come through. We took him down to cath lab, looked at the other bypasses, the one vessel in the back had 90 percent narrowing. We stented it.

In three to four hours, we removed the intra-aortic balloon pump (IABP). The mitral regurgitation went to mild and then to moderate. He came out of it.

We see variations on this continuously in hospital cardiology departments across the world. A patient is moving toward shock, through any number of routes. We insert an IABP. The situation reverses, giving the patient the opportunity to recover or giving us the opportunity to find the right solution.

This man’s situation sticks with me because he came in on the first weekend after a study called Shock II was presented at the European Society of Cardiology conference in Munich, Germany. It was heralded in many cardiology trade and industry outlets, as well as a few blogs, as showing that IABC is no better than the standard of care, and that we may be seeing the end of it as a tool for physicians like me.

Evidence based medicine is more than skipping to the conclusion page, thinking you know what the study says, and taking your marching orders from that. Good doctors know that.

IABC is one of many tools that we know works. We see it work in cases like the one I had that weekend. We have data that shows it works. We almost never have enough on why and how.

Fortunately cardiologists understand this and rumors of IABC’s demise have been greatly exaggerated, with apologies to Mark Twain. While I have no concern over the future of IABC, I do worry that some day we will run away with just pieces of a great study like this one – and it was a well done study – without taking the adequate time to debate it and understand it, potentially arriving at the wrong conclusion, like not placing that balloon that day. We may arrive at a day when too many sweeping conclusions are made and not enough questions are asked.

What is healthy is when we step away from the headlines and really get into the data and ask how can it make us better physicians for our patients. This does happen today. Take a look at this group of doctors discussing the study in a TCTMD webcast funded by the Cardiovascular Research Foundation. This is a great conversation to watch if you want to learn more about Shock II and understand what its implications are for patients like mine, and what they are not.

I don’t have an answer for how we – doctors, journalists, people that care about good medicine – do a better job reporting and talking about studies on important therapies, but I do think that we need to find new ways to have more of a conversation, and less of a dash to make a headline conclusion that’s off the mark. We need to help get out the right news and conclusions on critical data, not necessarily the fastest, and many times not the simplest.

Marc Cohen is Director, Division of Cardiology, Newark Beth Israel Medical Center and Professor of Medicine, Mount Sinai School of Medicine.

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  • http://twitter.com/sandeolson Sande Olson

    Great post Marc. This is a great example of why diagnostic machines of the future will work with physicians but not replace them (Vinod Khosla’s comment that technology will replace 80% of what doctors do)

  • drgg

    great article. I am not a cardiologist but it is unbelievable that the conference in germany would say IABC is no better than standard of care. My question is why do you think their thinking gets so skewed? Does this really have to do with IABC or saving money or is it just ignorance? It is baffling. Thank you for sharing.

  • Meryl Steinberg

    Always ask: who paid for the study? Can a company that makes billions off a conclusion on a drug be trusted to run the trials without bias? Can we be certain that the researchers are not paid by the people profiting? Until we know where the money is, can we be sure that the “evidence” is reliable? It has been uncovered time and time again that this is the case. We need to fund truly independent testing. Surely with the billions that are made, we can find a way to do that by making the companies fund an independent agency. Open to other ideas but as it stands right now, I distrust “evidence-based” medicine.

  • http://www.facebook.com/suzie.siegel Suzie Siegel

    I’m a sarcoma survivor. When people talk about “evidence-based medicine,” I always ask: What do we think is sufficient evidence? Most of our drugs are used off-label because of the difficulty of getting enough patients and funding for clinical trials.

  • sleemd

    Great article! Evidence-based guidelines are to help guide decisions, not make them . . . there will always be a need for doctor to apply the guidelines and to make sure that all factors are accounted for. After all, these are people we treat.