From the Dean: How science works (a lesson from cardiology)
Over the past few weeks, I’ve been updating, revising, and finalizing the presentation materials I’ll use starting this coming week when I’ll deliver a series of talks to our medical students on various aspects of cardiovascular pathophysiology, including valvular heart disease, coronary artery disease, pericardial and myocardial diseases, and other related topics. One of the neat changes we’ve made recently has been that to better integrate cardiac pathology into the talks, Dr. Susan Roe, clinical professor of pathology, has kindly agreed to join me in the presentations and we jointly teach the material.
As I’ve updated my slides recently, however, another aspect of this renewal process has been on my mind, and that is how some of the “truths” that I taught the medical students not that long ago no longer are true. Take the use of aspirin, for example. While aspirin has an important and enduring utility in patients with overt manifestations of coronary artery disease (CAD), its use in other patients who are at risk of CAD but are without clinical manifestations has become much more questionable. Following the accumulation of a lot of clinical trial data, it has become increasingly clear that the routine use of aspirin in most patients without manifest CAD likely is associated with more risk (especially of bleeding) than benefit. Accordingly, the routine use of aspirin in so-called primary prevention no longer is recommended for most patients.
But the challenge is how to explain this change in recommendations to clinicians, let alone to patients. After all, it had been well-established dogma to consider the use of low-dose aspirin in patients who might be at some risk of CAD in an effort to subvert subsequent events. But mounting data suggest the opposite – that the use of aspirin is more likely to cause a deleterious side-effect than a benefit.
Such a change in practice recommendations can be confusing to all. But in this (and most) cases, the change is the result of newer and better clinical data regarding safety and efficacy. After all, if we want to practice evidence-based medicine, we need the latest and best evidence upon which to base our recommendations. The issue is that sometimes – even frequently – newer and better data can indicate a different conclusion than was believed previously. When this occurs, we really do need to change our recommendations to patients – even though this often is not an easy discussion.
I can’t think of a good alternative, though. To cling to the processes of the past and to ignore new data clearly is not best practice. But trying to explain to patients why our recommendations now are different – often 180 degrees different as with the aspirin example – also is problematic. I think that the one constant in all of this is the importance of the provider-patient relationship. In this era of information overload, one result of the ever-present internet, I believe that the importance – and sanctity – of the personal interaction of provider and patient has never been greater.
In view of all this, I plan to spend some time in the coming weeks talking with students about the importance of practicing evidenced-based medicine, and also how the acquisition of new evidence may lead to a change – or even a repudiation – of what had been established dogma. But if we don’t continue to insist that we always let the best evidence available show us the path forward, we easily could regress to a fad-based healthcare culture that would not be in anyone’s best interest – especially that of the patient.
Joshua Wynne, MD, MBA, MPH
Vice President for Health Affairs, UND
Dean, UND School of Medicine & Health Sciences