How Medicine, Money and Mindset are Costing Lives | Warrick Bishop | TEDxUniversityofMississippi
The speaker, a cardiologist, argues that the medical field must shift from reactive treatment to proactive prevention by adopting advanced imaging like cardiac CT, which allows for precise risk stratification beyond simple population probability calculations. The evidence for this is the speaker's personal experience of underestimating a man's risk in 2003 versus the current ability to visualize plaque buildup, and the tragic statistic that heart attacks kill 9 million people annually, disproportionately affecting those under 65. ## Speakers & Context - Unnamed cardiologist. - Gave presentation after being involved in the roadside resuscitation of a man in his early 50s who suffered a heart attack during a fun run. - Found discrepancy between his initial risk assessment in 2003 and the man's subsequent health crisis. ## Theses & Positions - Cardiology practice must improve by moving beyond simple risk calculators to use detailed, individualized assessment methods. - The fundamental error in past practice is conflating *population-based probability* (the risk rate for a group) with *individual actuality* (the actual event likelihood for one person). - The process of modern medicine, constrained by inertia, money, and the focus on advanced treatment, prevents the routine adoption of superior preventative tools like cardiac CT. - The medical approach needs a shift from the *cure-based mentality* (which pays) to valuing prevention, which is crucial for public health. - Change requires sustained community advocacy, modeling the historical necessity for therapies like x-ray usage for tuberculosis. ## Concepts & Definitions - **Population-based probability:** The rate of an event occurring in a larger group with specific characteristics (e.g., 6 out of 100 men). - **Individual actuality:** Whether an event will happen to a single person (either 0% or 100%). - **Cardiac CT imaging:** A technology allowing visualization of the heart and the health of arteries, compared to a "mammogram for the heart." - **Inertia in medicine:** The resistance encountered when trying to implement new, better practices due to existing constraints and processes. - **Prevent vs. Treat:** A dichotomy where the financial system favors treating existing illness over funding prevention. ## Mechanisms & Processes - **Improved Risk Stratification:** Using cardiac CT to visualize plaque build-up, allowing clinicians to "hone in on our true high-risk individuals" who can then be proactively treated to mitigate risk. - **Clinical Trial Obstacle:** The inability to test cardiac CT-guided therapy in a randomized controlled trial (RCT) due to ethical concerns (a patient in a non-treatment group might be uncomfortable knowing their artery has a problem). - **Observational Data Use:** Advocating for the use of large amounts of observational data (like those supporting the link between smoking and heart health) when RCTs are ethically impossible. - **Advocacy model:** The need for an organized group (like the choir in the example) to approach government bodies to mandate the adoption of new, beneficial treatments for the broader community. ## Timeline & Sequence - **18 months prior to the talk:** Speaker gave a "clean bill of health" to the man, stating his 5-year heart attack risk was only 6% based on available data. - **Event date (Approx.):** The presentation takes place when the speaker revisits the case. - **Historical context (2003):** The speaker made the initial assessment using available risk calculators. - **Present:** Cardiac CT imaging is available, providing a much clearer diagnostic picture than 2003 allowed. ## Named Entities - **Mississipi, Louisiana, and Arkansas:** States used to contextualize the sheer number of annual heart attack deaths in the US. - **Elvis:** Famous figure whose death was noted at age 42. - **Boeing max 7:** Aircraft model mentioned regarding a plane crash. ## Numbers & Data - **Age of first assessment:** Early 50s (the patient). - **Initial Risk Calculation:** 6% chance of a heart attack in the next five years. - **Annual Heart Attack Deaths (Western World):** 9 million people. - **Annual Heart Attack Deaths (US):** 640,000 people. - **Cardiac CT ability:** Allows for quantification of plaque issues on the left and right sides of arteries. - **Mortality Impact:** Heart attack is cited as a cause of death that "destroys families" and "takes away loved ones." ## Examples & Cases - **The Fun Run Patient:** Initial 2003 assessment giving a low risk (6%) was proven wrong by the patient's subsequent cardiac event 18 months later. - **The Choir:** Used as an analogy for a highly selective group whose health could be analyzed precisely (arteries) in a way the general public cannot yet be, demonstrating the power of advanced imaging. - **Tuberculosis Treatment:** A therapeutic strategy that proved effective in the field but was never tested in a randomized control trial. - **Air Safety Analogy:** The speaker notes that we don't need randomized trials to prove parachutes work, suggesting similar common-sense evidence should apply to heart health. ## Tools, Tech & Products - **Risk Calculator:** The standard (but flawed) tool used for estimating general heart attack risk. - **Cardiac CT imaging:** Technology that allows visualization of arteries, described as a "mammogram for the heart." - **X-ray:** Mentioned as a tool that aided in eradicating tuberculosis. ## References Cited - Guidelines at the time of the 2003 assessment (local and international guidelines). ## Trade-offs & Alternatives - **Population Probability vs. Individual Actuality:** The primary contrast between the statistical tool and precise clinical assessment. - **Cure-based vs. Prevention-based medicine:** The economic tension where treating established illness is profitable, while proactive prevention is not paid for. ## Counterarguments & Caveats - The ethical difficulty in running a randomized controlled trial for cardiac CT-guided therapy, as withholding the diagnostic finding from the non-treatment group would be ethically questionable. ## Methodology - The speaker uses personal anecdotal evidence (the man at the fun run) to establish the failure of generalized risk modeling. - Compares this failure to the robust, established science of public health (like TB eradication) where evidence was gathered outside of formal RCT structures. - Calls for a shift in methodology from waiting for crisis to proactive screening and intervention. ## Conclusions & Recommendations - The conversation must shift from *inertia to momentum* by bringing pragmatism to process. - **Recommendation:** Advocating for the systematic use of cardiac CT imaging to improve individual risk stratification and drive preventative care. - Call to action: Audiences are urged to "share this conversation" to build momentum for change. ## Implications & Consequences - Failing to act means allowing the high death toll (9 million/year in Western world) to continue, especially impacting people under 65 who are otherwise capable of contributing. - Over-reliance on treating illness creates a profitable, but ultimately harmful, "huge business" model for medicine. ## Verbatim Moments - *"I'd said to him look your risk of a heart attack in the next five years is only 6%."* - *"I just don't know who it's going to be because what I didn't really get that clearly back in 2003 was the difference between population based probability and that's the rate of event in a particular population with particular characteristics and actually that's what the risk factor calculator tells us vers individual actuality."* - *"think mammogram for the heart"* - *"it's caught by the constraints and processes of medicine the influence of money and the human mindset when it comes to medicine"* - *"The irony of this discussion of course is that the very risk calculator which is our current gold standard for evaluating risk has never been assessed by double-blind randomized control trial itself"* - *"we need to move from inertia to momentum"* - *"it's time to act and do something"*