Up to Speed: The Cholesterol Mess
The only thing doctors like more than hearing themselves wax poetic on the intricacies, centrality, and difficulties of medical work is to give a major theatrical mea culpa where all can see – on the front page of The New York Times perhaps. A place where all can read, hear, and bear witness.
The latest entry in this long list of hyperbolic apologies revolves around an online calculator for determining cardiovascular (heart attack and stroke) risk and, by extension, the possible need for intervention. Let’s get up to speed.
The Calculator Doesn’t Work
According to The New York Times, a brand new web-based calculator designed to allow doctors and patients to quickly determine who have real risk has a fatal flaw—the model used to build the calculator utilized 1990s data, not a modern cohort. The older group smoked more, had more strokes and heart attacks and in all ways was inferior, resulting in a skewing of the data.
The story is that that the American Heart Association and the American College of Cardiologists—august, drab, conservative groups both—decided to update their recommendations on who needs possible statin or other therapy to curb cardiovascular risk. To accomplish this, they did what plodding professional societies always do: they put together a group of hyper-opinionated experts into a room to discuss the issues and reach a consensus. (Author’s note: I have been in such a room on several occasions, and I will say without question that the ambient level of maturity most closely resembles that of a high school student council meeting early in the school year before everyone has given up hope.)
Two Doctors Blew the Whistle
Not surprisingly the product was not the greatest. Two members of the reviewing body, Drs. Nancy Cook and Stephen Ridker—both international experts on the subject—found that their suggestions had been ignored. And so they did what academics do when they are aggrieved: they wrote an article in a medical journal. The Lancet has not yet made the piece available, but in it, the authors lay out, in apparently convincing fashion, the worrisome limitations of the current guidelines, to wit: the calculator inflate—sometimes by a factor of two—a person’s risk, funneling ever more people into the group recommended to take statins.
But It’s Probably Not a Conspiracy
Which should make any veteran paranoid about professional motives quite paranoid about professional motives. Was the calculator created only to pump up sales of the already multi-billion-dollar statin market? To scare the crap out of people at no risk and motivate them off their couch and into the local drug store to join the hooked generation? I suspect not; though one can never underestimate the motives and potential from that fertile nexus of needy doctors and runaway Pharma cash, it seems more like decent people trying hard and swinging and missing than a systematic plot against America.
Plus you have the usual good-cop-bad-cop sides of every academic debate—staid, underwhelmed authorities driving the boat for too long surrounded by flustered insurgents who speak in ever more shrill tones: “it’s stunning!” and “a real disaster” and “something is terribly wrong” and et cetera.
What’s Next? Another Calculator
Make no mistake: the purveyors of the guidelines seem to have screwed up. It is likely that groups will go back to the drawing board with even more antipathy and derision towards each other and, against all odds, improve the product. This is the natural history of all guidelines, all advice, all new anything— Broadway plays out of town for a few months; baseball has spring training; businesses toy with test markets: everyone—other than Healthcare.gov—knows you never get it right the first time out. So perhaps we could all calm down and let this work itself out.