The Peter Attia Drive - March 03, 2020


Qualy #121 - The ＂art＂ of longevity： the challenge of preventative medicine and understanding risk


Episode Stats

Length

10 minutes

Words per Minute

198.58041

Word Count

2,061

Sentence Count

91


Summary

In this bonus episode, Dr. Peter Atiyah, a cardiologist from the University of Toronto, joins Dr. Kelly to discuss how to answer the question, "How aggressive should I be in treating a patient with a chronic disease?"


Transcript

00:00:00.000 Welcome to a special bonus episode of the Peter Atiyah Qualies, a member exclusive podcast.
00:00:16.100 The Qualies is just a shorthand slang for qualification round, which is something you
00:00:20.120 do prior to the race, just much quicker. The Qualies highlight the best of the questions,
00:00:25.320 topics, and tactics that are discussed in previous episodes of The Drive.
00:00:30.000 So if you enjoy the Qualies, you can access dozens more of them through our membership
00:00:33.520 program. Without further delay, I hope you enjoy today's Qualies.
00:00:40.400 I want you to give us a quick or reasonably quick primer on other things that tend to
00:00:47.300 confuse patients, such as calcium scores versus CT angiograms. And I even want to touch on heart
00:00:53.160 flow in a minute because that comes back to it. So I think the listeners know what a calcium
00:00:57.220 score is in a CT angiogram is. But so just give this the quickest sense of that, because
00:01:00.980 I'm what I'm much more interested in is what do the results tell us?
00:01:04.820 As a cardiologist practicing in 2019, I struggle with the question of whether I'm going to help
00:01:09.820 you or hurt you, that I feel this tremendous sense of uncertainty about whether I should
00:01:15.480 be as aggressive as I can, picking up every rock and looking under everything and, you know,
00:01:20.740 trying to optimize to the best of my extent, my ability versus whether that maybe the best
00:01:27.840 thing I can do is leave you alone. And you've probably seen examples too, where, I mean,
00:01:32.040 I remember again, as a cardiology fellow, maybe even as a resident where, you know, somebody would
00:01:35.800 come in from an outside hospital sick as shit, just absolutely on death's door. And all we did was just
00:01:40.700 turn off everything and the patient got better because they were just over managed. And I think
00:01:45.200 I struggle a little bit with this sort of where I want to be in that spectrum and how aggressive I
00:01:51.520 should be in looking for, say, a cult coronary disease, which I think is a question you get
00:01:55.940 a lot and I get a lot, right? One of the major reasons somebody comes to see me as a preventive
00:02:00.500 cardiologist is they say, am I going to die of a heart attack? And, you know, what's my risk of dying
00:02:04.980 from a heart attack? Or my brother died of a heart attack at 44, what should I do? And I still don't
00:02:11.440 have an answer about how aggressive I should be in trying to understand it. But a lot of these tests
00:02:16.900 we'll talk about, I think, feed into that. And I think ultimately what we're missing, and I hope we
00:02:22.220 can eventually refine it and make it better, is a good way to predict disease risk in these chronic
00:02:28.540 diseases, these common chronic diseases like cardiovascular disease, metabolic disease, that we
00:02:32.620 just don't now yet have the tools to be able to say, you know, Peter, well, your risk is X, Y, or Z.
00:02:40.420 And so therefore we should do this or this or this in terms of prevention, understanding that
00:02:45.080 there's going to be risk in each one of these things that we do. And there may be risk in even
00:02:48.580 part of the process of getting from here to here, point A to point B. So I'm glad you brought that up
00:02:53.240 because it illustrates the challenge that frankly can't be explained or rationalized or described
00:03:00.380 on Twitter, not to pick on Twitter, but just to, so there's this idea which you've said, which is,
00:03:05.680 I don't know sometimes how aggressive to be or not to be. And what you're really saying is,
00:03:10.180 at the individual level with you as my patient sitting in front of me, I don't know how aggressive
00:03:15.780 to be or not to be. You're not asking the question on average. And yet, what tool are you given to
00:03:22.060 guide you? You are given a tool called a clinical trial, which is by its very nature, all about
00:03:28.640 averages. And so therein lies the mismatch of what I've described as medicine 2.0. When I say
00:03:35.500 described, meaning I'm writing about it in this book I'm working on that hopefully I'll have finished by
00:03:39.280 the time I'm alive or not alive. And the idea is, it's not to poo-poo clinical trials, it's just to
00:03:46.380 acknowledge that clinical trials give us great information on averages. And the larger and more
00:03:51.020 robust the trial, generally the more heterogeneous the data. But you've asked a question that comes
00:03:57.580 down to judgment. You know what it means to be aggressive, and you know what it means to be
00:04:02.180 conservative, and you have, you know what the corners of that box look like. What you're asking is,
00:04:07.680 I could have two people in front of me that superficially look similar, but actually one of
00:04:13.380 them is probably going to have a better outcome if I behave aggressively, and the other one might
00:04:17.360 have a better outcome if I behave conservatively. It's the challenge to figure out which one's which.
00:04:22.520 If you're a hammer and everything's a nail, even if you're acting as a hammer and nail in accordance
00:04:28.460 with clinical trials, I suspect you are still acting in a very blunt manner.
00:04:33.160 A hundred percent. But I'm also talking about these areas, and I think prevention is a great
00:04:38.800 example, that are sort of outside the boundary of what's been studied or is likely to be studied
00:04:44.000 in the context of a clinical trial, right? I mean, there's not going to be a clinical trial
00:04:47.660 to answer a lot of the questions that I have about how to manage my patients.
00:04:51.300 And I feel the same way. I mean, prevention is not really amenable to this idea of medicine 2.0,
00:04:57.220 which is clinical trial, average outcome, short duration, simple intervention, easy to measure
00:05:05.280 outcome. It's the economic thing. I mean, you're a company and you want to get your product to market,
00:05:10.820 whether that product is a stent or a drug or whatever it is. And the best way to do that
00:05:15.020 economically is the shortest amount of time. And so you want to take the sickest people. So
00:05:18.280 these trials, I mean, I joke that like a prevention trial, all kinds of trials that I want to do would
00:05:22.900 take 50 or 60 years. How do you convince somebody I'm about to be 50? I wouldn't want to start a
00:05:27.900 trial that I'm not going to see the answer from, the result from. So it's unsettling to me. And
00:05:33.060 again, I think you just have to be, remain humble as I've tried to, and hope that your patients,
00:05:37.980 your human patients have some patients that were going to be wrong. There are a litany of examples
00:05:42.660 like LP little a was something I didn't pay attention to until the past few years. Coronary calcium
00:05:47.720 scans. If somebody came to see me with a coronary calcium scan 10 years ago, I would say, I wish I
00:05:52.920 didn't have this information, but I never ordered one before seven to eight years ago. So there are
00:05:57.680 lots of examples of things that I didn't use to do that I've now incorporated into my practice.
00:06:01.760 And I'm doing so without that like safety belt of, of evidence basis that we're used to, right?
00:06:07.740 There's not going to be a orbital like trial to help me decide whether I should be aggressive with
00:06:13.540 lipid lowering in a 35 year old. That's not going to happen with primary prevention. So
00:06:18.280 we have a mutual patient in whom that's exactly the type of question that's being asked, right?
00:06:22.880 Yeah. And there's a term and I, I know all these cute little terms and I never know who to attribute
00:06:27.540 them to, but we talk about evidence-based medicine versus evidence informed medicine. And to me,
00:06:32.960 the latter just makes much more sense because these decisions that you have to make
00:06:37.820 virtually every day. And I feel like I'm in the same situation, virtually nothing that I do. Can I
00:06:45.120 point to the orbita or courage equivalent? I mean, it just doesn't exist. And certainly not, if you
00:06:51.660 really wanted to scrutinize it, every single thing is a variation on a theme that stems from some
00:06:57.800 clinical trial. But if you really wanted to be a skeptic, you would say, nope, that's not the exact
00:07:02.400 same patient and that's not the exact same situation. And therefore you can talk yourself
00:07:07.320 out of doing anything. And I'm super fond of saying that being a preventive cardiologist is
00:07:13.880 no one should feel sorry for me. I have the best job in the world, but, but it's difficult in that
00:07:18.020 we only know success by the absence of failure. So there's no one who's going to come to me tomorrow
00:07:23.820 and say, gosh, Ethan, thank you for the fact that I I'm 46, that I did not have a heart attack again
00:07:29.720 this year. It just doesn't happen. Right. That's a great way to explain it. Whereas the other way
00:07:33.780 around, like I've had a few patients, if you're an orthopedic surgeon, for example, that's right.
00:07:37.680 You break your leg, you fix it or an interventional cardiologist, right? You show up in the cath lab
00:07:42.200 with a STEMI, you know what you did. The outcome is clear. The outcome is not that clear in prevention
00:07:46.820 unless there's failure. So those examples, and I've had a few recently, I've been public about them
00:07:52.720 on Twitter that are treatment failures, but maybe not personal failures. In fact,
00:07:57.900 I don't think I managed the patients incorrectly, but the fact is they had events while they were
00:08:04.200 under my care. Those live with you for a long time. And so then the question is, I know you're
00:08:07.780 a race car driver. The question is, is your reaction to that to then have a tendency to want to oversteer?
00:08:13.160 So because I have these anecdotes, these very profound anecdotes of young people who've had
00:08:18.080 terrifyingly scary outcomes. And, you know, I was not as aggressive as I could have been,
00:08:24.060 but probably still following the sort of guidelines. Is that going to guide me as a physician to be
00:08:29.140 more aggressive in the future? And again, we're not going to have clinical trial data to help us
00:08:33.780 here. This is all art and judgment. The subtitle of my book, I'm hoping if the publisher lets me
00:08:39.540 is going to be called the science and art of longevity. There's a title to it, but that's the
00:08:44.120 subtitle. And I'm insistent upon that order because normally you say it in the reverse, the art and
00:08:48.680 science of whatever, but it's the science and art. You're informed by science, but in the end,
00:08:53.760 this still comes down to an art. Well, it is the art of the science too, as you said, right? I mean,
00:08:58.000 it is sort of how do you put this? And then there's the whole other layer, which is how do
00:09:01.100 you communicate it with your patients? And how do you include them as a partner in making these
00:09:06.660 decisions? Hope you enjoyed today's special bonus episode of the Quali. New episodes of the Qualis
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