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

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.

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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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The Peter Attia Drive - March 03, 2020

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

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