The Peter Attia Drive - Qualy #121 - The “art” of longevity: the challenge of preventative medicine and understanding risk

Episode Date: March 3, 2020

Today's episode of The Qualys is from podcast #52 – Ethan Weiss, M.D.: A masterclass in cardiovascular disease and growth hormone – two topics that are surprising interrelated.   The Qualys is a subscriber-exclusive podcast, released Tuesday through Friday, and published exclusively on our private, subscriber-only podcast feed. Qualys is short-hand for “qualifying round,” which are typically the fastest laps driven in a race car—done before the race to determine starting position on the grid for race day. The Qualys are short (i.e., “fast”), typically less than ten minutes, and highlight the best questions, topics, and tactics discussed on The Drive. Occasionally, we will also release an episode on the main podcast feed for non-subscribers, which is what you are listening to now. Learn more: https://peterattiamd.com/podcast/qualys/   Subscribe to receive access to all episodes of The Qualys (and other exclusive subscriber-only content): https://peterattiamd.com/subscribe/  Connect with Peter on Facebook.com/PeterAttiaMD | Twitter.com/PeterAttiaMD | Instagram.com/PeterAttiaMD

Welcome to a special bonus episode of the Peter Atia Qualies, a member exclusive podcast. The Qualies is just a shorthand slang for Qualification Round, which is something you do prior to the race, just much quicker. The Qualies highlight the best of the questions, topics and tactics that are discussed in previous episodes of the drive. So if you enjoy the quality, you can access dozens more of them through our membership program. Without further delay, I hope you enjoy today's quality. I want you to give us a quick or reasonably quick primer on other things that tend to confuse patients such as calcium scores versus CT angiograms.

And I even want to touch on heart flow in a minute because that comes back to it. So I think the listeners know what a calcium score is in a CT angiogram is. But so just give this the quickest sense of that because I'm what I'm much more interested in is what do the results tell us? As a cardiologist practicing in 2019, I struggle with the question of whether I'm going to help you or her 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 trying to optimize to the best of my extent, my ability versus whether that may be the best thing I can do is leave you alone.

And you've probably seen examples too, where I remember, again, as a cardiology fellow, maybe even as a resident where somebody would come in for an outside hospital sick, it just absolutely on death's door, and all we did was just turn off everything and the patient got better, because they were just overmanaged. And I think I struggle a little bit with this sort of where I want to be in that spectrum

and how aggressive I should be in looking for say a cult coronary disease, which I think is a question you get a lot and I get a lot. One of the major reasons somebody comes to see me as a preventive cardiologist is they say, I'm going to die of a heart attack. And you know, what's my risk of dying from a heart attack? Or, my brother died of a heart attack at 44, what should I do? And I still don't have an answer about how aggressive I should be

and trying to understand it. But a lot of these tests will talk about, I think, feet into that. And I think, ultimately, what we're missing, and I hope we can eventually refine it and make it better, is a good way to predict disease risk in these chronic diseases, these common chronic diseases, like cardiovascular disease, metabolic disease, that we just don't now yet have the tools to be able to say, you know, Peter,

well, your risk is x, y, or z. And so therefore we should do this or this or this in terms of prevention, understanding that there's going to be risk in each one of these things that we do, and there may be risk in even part of the process of getting from here to here. Point A to point B. So I'm glad you brought that up because it illustrates the challenge that frankly can't be explained or rationalized or described on Twitter. Not that pick on Twitter, but just to... so there's this idea, which you've said, which is, I don't know sometimes how aggressive to be or not to be, and what you're really saying is

at the individual level with you as my patient sitting in front of me, I don't know how aggressive to be or not to be. You're not asking the question on average. And yet, what tool are you given to guide you? You are given a tool called the clinical trial, which is by its very nature, all about averages. And so therein lies the mismatch of what I've described as medicine 2.0. When I say describe meaning, I'm writing about it in this book.

I'm working on that. Hopefully I'll have finished by the time I'm alive or not alive. And the idea is it's not to poo poo clinical trials. It's just to acknowledge that clinical trials give us great information on averages and the larger and more robust the trial, generally the more heterogeneous, the data. But you've asked a question that comes down to judgment.

You know what it means to be aggressive and you know what it means to be conservative and you know what the corners of that box look like. What you're asking is, I could have two people in front of me that superficially look similar, but actually one of them is probably going to have a better outcome if I behave aggressively, and the other one might have a better outcome if I behave conservatively, it's the challenge to figure out which ones which. 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. A hundred percent, but I'm also talking about these areas, and I think prevention is a great example that are sort of outside the boundary of what's been studied or is likely to be studied in the context of a clinical trial, or is likely to be studied in the context

of a clinical trial, right? I mean, there's not gonna be a clinical trial to answer a lot of the questions that I have about how to manage my patients. And I feel the same way. I mean, prevention is not really amenable to this idea of medicine 2.0, which is clinical trial, average outcome, short duration,

simple intervention, easy to measure outcome. It's the economic thing. I mean, you're a company and you want to get your product to market, whether that product is a standard or a drug or whatever it is. And the best way to do that economically is the shortest amount of time. And so you want to take the sickest people. So these trials, I mean, I joke that like a prevention trial, those kinds of trials that I want to do would take 50 or 60 years.

How do you convince somebody I'm about to be 50? I wouldn't want to start a trial that I would not going to see the answer from, the result from. So it's unsettling to me. And again, I think you just have to remain humble as I've tried to and hope that your patients, your human patients have some patients

that we're going to be wrong. There are litany of examples like L.P. Little A was something that I didn't pay attention to until the past few years. Corner calcium scan, if somebody came to see me with a corner calcium scan 10 years ago, I would say, I wish I didn't have this information, but I never hoarded one before 70 years ago. So there are lots of examples of things that I didn't use to do that. I've now incorporated it into my practice. And I'm doing so without that safety belt incorporated into my practice. And I'm doing so without that safety belt of evidence basis that we're used to, right?

There's not gonna be a orbital trial to help me decide whether I should be aggressive with lipid lowering in a 35 year old. That's not gonna happen with primary prevention. So we have a mutual patient in whom that's exactly the type of question that's being asked, right? Yeah, and there's a term and I know all these little terms, and I never know who to attribute them to,

but we talk about evidence-based medicine versus evidence-informed medicine. And to me, the latter just makes much more sense. Because these decisions that you have to make virtually every day, and I feel like I'm in the same situation, virtually nothing that I do can I point to the orbita or courage equivalent. It just doesn't exist. And certainly not, if you really wanted to scrutinize it, every single thing is a variation on a theme that stems from some clinical trial. But if you really wanted to be a skeptic, you would say, nope, that's not the exact same

patient and that's not the exact same situation. And therefore, you can talk yourself out of doing anything. And I'm super fond of saying that being a preventive cardiologist is no one should feel sorry for me. I have the best job in the world, but it's difficult in that we only know success by the absence of failure. So there's no one who's going to come to me tomorrow and say, gosh, Ethan, thank you for the fact that I'm 46 that I did not have a heart attack in this year.

It just doesn't happen, right? That's a great way to explain it. Whereas the other way around, like I've had a few patients, if you're an orthopedic surgeon, for example, that's right. You break your leg, you fix it. Or an interventional cardiologist, right? You show up in the cath lab with a stem,

you know what you did. The outcome is clear. The outcome is not that clear in prevention unless there's failure. So those examples and I've had a few recently and I've been public about them on Twitter that are treatment failures, but maybe not personal failures. In fact, I don't think I'd manage the patients incorrectly, but the fact is they had events while they were under my care, those lived with you for a long time. So then the question is, I know you're a race car driver, the question is, is your reaction to that to then have a tendency to want to oversteer. So because I have these anecdotes, these very profound anecdotes of young people who have had terrifyingly scary outcomes, and I was not as aggressive as I could have been, but probably still following the sort of guidelines.

Is that going to guide me as a physician to be more aggressive in the future? And again, we're not going to have clinical trial data to help us here. This is all art and judgment. The subtitle of my book, I'm hoping if the publisher lets me is going to be called the Science and Art of Long Jeviti. 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. You're informed by science, but in the end, this

still comes down to an art. Well, it is the art of the science, too, as you said, right? I mean, it is sort of how do you put this, and then there's the whole other layer, which is how do you communicate it with your patients, and how do you include them as a partner in making these decisions. Hope you enjoyed today's special bonus episode of the QALE. New episodes of the QALEs are released Tuesday through Friday each week and are published exclusively on our private member-only podcast feed. If you're interested in hearing more, as well as receiving all of the other member-exclusive benefits, you can visit peteratia-md.com forward slash subscribe. This podcast is for general informational purposes only, and does not constitute the practice of medicine, nursing, or other professional health care services, including the giving

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