From the Dean: Maybe/it depends
Susan and I recently “attended” (virtually) the annual meeting of the American College of Cardiology (called ACC22) that was held in Washington, D.C., from April 2-4. It was a hybrid event, with a moderate number of in-person attendees and a fair number online (like Susan and me). I spent a total of 18 hours participating over the three days, and except for a higher-than-expected number of technical glitches, the experience overall was a positive one. Yes, I missed the chance to network and re-connect with colleagues and friends in the cardiology community. But from a learning standpoint, it was a productive use of our time.
It’s clear that a lot has changed in cardiology, even over the past year or two. Much of the practice of cardiology uses so-called guidelines that are promulgated by our professional societies (in cardiology, most commonly the ACC in conjunction with the American Heart Association). While the various guidelines do not stipulate what care should be given, they are useful in showing what are considered best practices in a wide variety of situations. The guidelines are organized into recommendations that broadly might be characterized as “yes,” “no,” and “maybe/it depends.”
Things get interesting when a given guideline recommendation moves from one category to another as subsequent guidelines are published and then popularized at meetings such as ACC22. Such was the case this year, and I’ll give you a few examples regarding aspirin use. First, consider the situation of a patient with a mechanical heart valve replacement. These patients all require anticoagulation (thinning of the blood) with a drug called warfarin. But for decades the guidelines also specified the concomitant use of low-dose aspirin. Well, no more! Concomitant aspirin has moved from a “yes” recommendation to “maybe/it depends,” meaning there no longer is a best practice obligation (as it was before) to use both agents. The same thing is true in patients on warfarin who’ve had a prior coronary stent. The use of low-dose aspirin in this setting also moved from “yes” to “maybe/it depends.”
The patient-care challenge is how to explain our shifting recommendations to an individual patient. Especially in this age of “alternate facts,” patients often are confused and uncertain as to what to do when our advice changes. So why do guidelines evolve and change over time? There are two main reasons, I think. First, new and better data often become available as a result of recently completed clinical trials. Second, many of the guidelines are not based on multiple rigorous randomized clinical trials (the best sort of evidence), but rather by consensus statements by experts in the field trying to arrive at as definitive a statement as might be possible in the absence of hard data. But those opinions may change over time. Take the aspirin and the heart valve example, where no new clinical trial data have become available recently to influence the discussion. Rather, the guideline authors likely were influenced by the emerging general perception that over the years we’ve overestimated the value of low-dose aspirin and underestimated its risk. Thus, in the absence of recent rigorous trial data showing benefit (the original data suggesting aspirin’s benefit are decades old), it’s likely that the expert opinion consensus conclusion moderated the prior “yes” determination to the “maybe/it depends” one.
But how do I maintain credibility with my patient with a mechanical heart valve when I have to modify my recommendation and change what I told the patient previously? After all, the worst thing that might happen is for the patient to then disregard all my recommendations, stop the warfarin too, and likely experience a catastrophic outcome! So how do we try to ensure that the patient does the right thing, since just educating – talking to the patient – probably isn’t enough?
I think I got at least part of the answer when I took my car in for service on Tuesday. What does car service have to do with this? Well, the service that I received was based on a prior discussion with the lead service representative at the auto repair firm, someone who I have been dealing with for over 15 years. And what was the critical issue involved in the discussion? Trust. I trust his judgement and recommendations. So too for discussions with patients. The message about patient care has to come to the patient from a trusted messenger. Health care providers can be that trusted messenger, but we have to devote time and effort to do so. All of us providing health care services really need to spend less time preaching and more time listening and discussing. By doing so, it’s my hope that my patients will better accept the changing advice that I’m giving them and be active partners in striving to optimize their own health and minimize disease.
Joshua Wynne, MD, MBA, MPH
Vice President for Health Affairs, UND
Dean, UND School of Medicine & Health Sciences
