How Medicine, Money and Mindset are Costing Lives | Warrick Bishop | TEDxUniversityofMississippi
URL: https://www.youtube.com/watch?v=w1flxZfAVpQ Video ID: w1flxZfAVpQ ============================================================ [Music] [Applause] as a cardiologist I've spent my entire career looking after people's hearts but they got turned upside down in 2005 when by complete chance I was involved in the roadside resuscitation of a man in his early 50s who was participating in a fun run that man had a heart attack and dropped dead by the side of the road fortunately we got his heart beating again and he did fine but I found out several days later I'd seemed a very same man some 18 months earlier and I'd given him a clean bill of health shocked I went back and looked at the notes to try and understand what had happened it turned out that by local and international guidelines at the time I've done everything right for him I'd put all these details for a risk calculator and I'd said to him look your risk of a heart attack in the next five years is only 6% in fact you get a Green thermometer you should be fine I sent him on his merry way I don't need to be standing over his dead body some 18 months later clearly something is wrong here in my remaining time what I'd like to share with you is the filing of my assessment back in 2003 how we can do better and why we're not doing as well as we should so when I said to this man back in 2003 look your risk of a heart attack in the next five years is 6% I misrepresented the facts what I should have said to this man was based on your characteristics what this risk calculator is telling me is if I take 100 men with the same characteristics and follow those 100 men for five years that six of those men 6% will have a heart attack 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 because the individual won't have an event ie 0% or will have an event 100% think fun runner well let me introduce you to the 50 year old male 100 voice choir and I'm somewhat embarrassed to say that the choir master had a slightly better understanding of this than I did back in 2003 and he said okay guys I've spoken at the dock and he says about six of you will have a heart attack in the next five years could I just ask that it's not all the tenants but we can be more precise we can actually take that choir and we can put them through a process we can look at the health of their arteries in recent years and this wasn't available in 2003 we've now had the progression and the widespread availability of cardiac CT imaging which allows us to look into the heart and get a feel for the health of someone's arteries think mammogram for the heart allowing us to start to see what's going on on the left hand side healthy arteries on the right hand side clearly a problem and we can quantify that problem we can start to hone in on our true high-risk individuals and why is that helpful because if we can find the high risk individuals we can treat them we can mitigate their risk weak or induce heart attack and we can save lives well why aren't we doing it what why isn't it happening all the time maybe you haven't heard of it and for how would I come all the way from Australia to talk about it well it turns out that cardiac CT imaging sits in a perfect storm of inertia it's caught by the constraints and processes of medicine the influence of money and the human mindset when it comes to medicine modern medicine dictates the highest levels of evidence to inform our treatment strategies that make sense but let's think about cardiac CT and the Jim being asked does cardiac CT guided therapy improve outcome so we take our group of people we scan them we put some people in the treatment group after randomization and some in a non treatment group now if you're following me how would you be if you are in the non treatment group but you'd been scanned and something was found in your arteries you would probably be just a bit uncomfortable with that in fact you wouldn't be told because there would have been a blinded study so you hopefully didn't go in the study in the first place and I can tell you a doctor like me wouldn't want to put my patients in something like that and there is an an ethics committee in the world that would allow that particular study to proceed which is a good thing so we may never actually get the highest level of evidence to support this particular therapy and the question we want to ask so if we can't get the highest level of evidence what's next well we can use observational data let's step outside of medicine momentarily and I think we'd all agree that we don't need to randomize people to parachute or no parachute and push them out of a plane to test the hypothesis two parachutes work DUII well what about medicine is there a precedent in medicine and when we know smoking is bad but there's never actually been randomized trials to tell us it is it's all observational data we know it's not good for us because it's overwhelming observational data but we're talking about x-ray today we know that we used the x-ray to help us eradicate tuberculosis and you know that strategy that therapeutic strategy which just about did its job was never tested in a randomized control trial we just did it because it worked 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 and yet we have tens of thousands of observational data sets clearly demonstrating to us that if there's a lot of plaque or stuff in your arteries you're at higher risk if there's not Europe low risk and we can use that information to bring precision to an individual's risk stratification unfortunately or fortunately depending where you stand US doctors get paid a lot more money to wait till you're sick and try and fix you up good for us not so good for you but the whole process of being ill is hugely expensive devices therapies things we insert it means that researchers driven towards cure based mentality and infect your local hospital of course it doesn't make any money if you will it only makes money when you're sick unfortunately medicine is huge business and prevention just doesn't pay and while that's the case we're going to have a lot of trouble with medicine actually receiving the priority and the attention it truly deserves for your best benefit the mind sits interesting and I'm talking about a different way of evaluating risk but already there's an established way set up by organizations institutions and individuals over a period of time or to shift that we have to recognize that change always pushes back so we need to be open and understanding of how we can facilitate that but one of the interesting things to me is that the human mind set almost seems programmed to respond to emergency we're not programmed to prevention I mean what child in their right mind asks for a safety manual for Christmas now on a firetruck and what young man checks out the seat belts when really he wants to know how fast does that cargo and even adults even our leaders confronted with decade's worth of scientific data we'll wait until a crisis to actually act no we need to take a leaf from the ancient Chinese who recognized that superior doctors prevent the disease mediocre doctors treat the disease before ever been an inferior doctors treat the full-blown disease and this is the process of taking something to government and getting it out to the community just try and imagine momentarily a group of people suffering with a particular cancer and a new therapy becomes available that get organized they approach the government to access to get access for the community for that treatment and it's brought out to the community well if we think about cardiac CT who are the advocacy group because there's six men in that choir who don't know they should be advocating to look after their own lives because nothing's happened to them yet there is an organization of doctors who work both locally and internationally advocating the cause because I understand the benefit of benefit of it and interestingly this technology is standard practice for NASA astronauts and presidents of the United States but not for you and me what does that say one of the other things that I find intriguing is we almost seem to treat differently a life depending on how it's lost and that's probably partly to do with the media I think we'd all be aware of the plane crash last year and if yoga I was a Boeing max 7 flight 257 people died it was front-page news around the world yet heart attack kills more men and women and women in the Western world than anything else we're talking nine million people per annum to put that into some sort of local context that's the states of Mississippi Louisiana and Arkansas their entire populations dispatched each year with this condition in the United States we're talking six hundred and forty thousand people per annum that's one in four deaths and by the time I finished presenting 10 to 15 people will have had a heart attack and died but they're just statistics but this one grabs me 20 percent of these individuals are 65 years of age or younger these are people who are not ready to die these are people who still have plenty of life to live and plenty of life to give Gary was 53 years of agent could have been one of those statistics but I can tell you he's a father of three heart attack destroys families it takes away loved ones it devastates communities I mean for goodness sake it took Elvis of 42 years of age today it's a joke you can laugh about that I mean it's a tragedy but it's a mid-major we need we need to move from inertia to momentum it's time to bring pragmatism to process it's time to truly value prevention / cure and it's time to change the way we think about heart attack my presentation today is the beginning of a conference conversation on a continuum of change which includes education implementation and realization for a better world for less deaths from heart attack for those here and if anyone sees this on video my hope is that I've informed and encouraged you to share this conversation because the more we share this conversation the greater the chance we can drive the change we can shift the inertia from the bottom up because it's taking too long from the top down it's not okay anymore to just wish upon a star and hope everything will be okay it's time to draw a line in the sand it's time to act and do something put your hand up if you feel comfortable to share what I've shared with you tonight with your family your loved ones your community to make a difference please do that please make a difference please save a life please go and do something positive about this we can stop heart attack thank you so much your attention a gent I genuinely wish you all good health and don't die from a heart attack good night [Applause] [Music]