My 81-year-old patient came in several weeks ago and disclosed that he had stopped taking his aspirin after watching a news report on television. “They said I didn’t need it anymore,” he told me. I gently informed him that this news didn’t apply to him.
He was responding to a recent study in the New England Journal of Medicine, which showed that aspirin failed to prevent heart attacks in healthy people who were randomly assigned to receive aspirin versus placebo for nearly five years. Aspirin also caused more bleeding than placebo. The study enrolled over 19,000 participants, and the unexpected results attracted major media coverage. After seeing the piece featured on CNN, my patient decided to stop.
However, the new study wasn’t relevant to my patient. The study enrolled healthy people; my patient already had coronary artery disease. And decades of studies have shown that aspirin considerably lowers the risk of heart attack in people with his condition. Current guidelines, therefore, recommend lifetime aspirin for anyone with a diagnosis of coronary artery disease, and my patient would never have been eligible for the new study.
My patient’s confusion was understandable given the nearly continuous deluge of new medical information in popular media. The CNN headline had simply stated: “With daily low-dose aspirin use, risks may outweigh benefits for older adults.” While the New England Journal of Medicine study focused on primary prevention (treating to prevent disease onset), his scenario was one of secondary prevention (treating to prevent worsening of an existing disease).
Understanding these nuances often requires reading the medical literature and being able to differentiate populations studied, treatments used and outcomes measured. As another example, a study recently presented at the American Heart Association Scientific Sessions demonstrated that prescription fish oil reduced the risk of major cardiac events. After many negative trials using fish oil, patients are now faced with a new study showing benefit.
Given how easily our patients may be confused by such information, it’s remarkable that a growing chorus of physician leaders and technology executives predict that the future of medicine will involve patients being able to diagnose and manage many conditions entirely on their own, thanks to their increased access to information. A New York Times contributor even offered the advice: “Skip your annual physical,” in light of studies failing to show specific, measurable benefits to yearly physician visits. These promoters of technology-enabled self-diagnosis and management aim to “disrupt” the longstanding physician-patient relationship in the name of promoting patient autonomy (and, for technology companies, profit).
Here’s the problem: many patients are nothing like the people dispensing this advice. This is particularly true among older adults, who represent a rapidly growing segment of the U.S. population. In my geriatric cardiology practice, the majority of people are over age 75; my oldest patient is over 100. Age-related syndromes such as cognitive impairment, hearing impairment and visual impairment are all common in this age group.
Recent estimates indicate that one in five Americans over age 75 has cognitive impairment, which increases to one in three over age 85. Cognitive impairment can interfere with the performance of complex tasks, including understanding medical information related to diagnosis and treatment. Vision and hearing impairments may worsen these problems by limiting patients’ abilities to interact with the external world. Further, many older patients are socially isolated and lack care partners to help them make medical decisions.
The enthusiasm for technology-facilitated self-diagnosis and management, therefore, runs into the reality of an aging society. Explaining medical recommendations to our older patients is the antithesis of an algorithm or search engine result. Our conversations are individualized, time-consuming, and need to take into account each patient’s unique impairments, care preferences, and social context. Americans in the “oldest old” category (85 years of age or older) represent the fastest growing segment of the U.S. population (their number is expected to triple by 2050), and we will, therefore, need to have more of these conversations, not less.
Good medicine is fundamentally about good relationships, particularly with our older patients. In designing the future of health care we need to take this into account. While technology might facilitate interactions — for example, through remote “virtual” physician visits that obviate the need to drive for hours to a clinic — health care for older adults by necessity will remain a fundamentally human endeavor. And we need to invest in human resources — including training geriatric physicians and nurses, strengthening home health services and supporting family caregivers.
For my own patient, after I explained at-length the benefits of aspirin in his condition, he agreed to restart it. The future of health care for older adults will require more conversations like this, which will be facilitated but not replaced by technology. Maybe not a very disruptive idea — just common sense.
John A. Dodson is a cardiologist.
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