EDITOR'S PAGE
The Informed Patient
Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology*
* Address correspondence to: Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112 (Email: ademaria{at}acc.org).
I was scanning a long list of new e-mails recently when one caught my eye. It was from a VIP patient who had led one of the largest organizations in the State and is well known and admired for his intellectual accomplishments. The e-mail described an article he had just read in the magazine Business Week entitled "Do Cholesterol Drugs Do Any Good?" (1). The article, which he thoughtfully attached, correctly assuming that I had not read it myself, represented a relatively scholarly, if somewhat one-sided, presentation of the pros and cons of using statins in patients without overt heart disease. It quoted authorities and cited literature to argue that the number needed to treat (NNT) for a single patient to benefit was too high for the potential side effects and expense of the medication. It alluded to potential conflict of interest on the part of pharmaceutical companies and physician panels, including the U.S. National Cholesterol Education Program, who recommend cholesterol reduction with statin therapy. The e-mail indicated that, based on this article, my patient had decided to discontinue his statin.
Several days later while driving to work and listening to National Public Radio (NPR), I came upon a program discussing the tendency of physicians to treat the "numbers." They discussed bone density measurements for osteoporosis, glucose levels for diabetes, and (of course) cholesterol values for cardiovascular disease as being laboratory numbers that were often treated by physicians without unequivocal evidence of benefit and with some risk of side effects. Again, this was a relatively scholarly presentation from a credible source, although clearly a program with a definite viewpoint and agenda. I have no idea how many patients, or potential patients, were influenced to take action by this program, or even to discuss it with their physician.
These two recent experiences provided a number of thoughts. With regard to my specific patient, we had a long conversation about the data supporting the benefit of lowering serum cholesterol and the efficacy of statins. We discussed absolute versus relative risk reduction, an issue addressed in detail in Business Week (1), and the concept of NNT. Among other things, I pointed out to him the many things in every day life that incorporate an NNT concept, such as airbags in automobiles. I was impressed at the level of sophistication of our discussion, and in the depth of detail involved in determining how this patient would ultimately be managed.
In a broader sense, however, these experiences stimulated me to think of the medical information available to our patients and how it affects their health care decisions. It is obvious that there is a large amount of medical information in the print media, on television, and especially on the Internet. This can be of great value, informing patients of beneficial lifestyle choices and empowering them to make intelligent health care decisions. However, the quality and accuracy of the information can vary greatly, from unfounded claims to evidence-based and data-driven presentations. The ability of individual patients to understand this information and intelligently incorporate it into their own health care is also very heterogeneous. Some patients have an appropriate background to fully comprehend the information, while others must rely on interpretation by someone more knowledgeable. Regardless of the nature of the information, or the status of the patient who receives it, it is clear that our patients are receiving a great deal of medical information that is impacting their health care decisions and the management they receive. It is equally obvious that it is incumbent upon us as physicians to deal with the transmission of information to patients to prevent harm and ensure that it is of maximal benefit.
In dealing with this flow of information, it seems apparent that physicians have to be as aware of what is being presented to our patients. We are all familiar, of course, with the headline stories in the media regarding breaking trials. We often first learn of these trials through questions from our patients, before we have even had a chance to examine the study results ourselves. However, there is also a great deal of less sensational information being presented to patients, such as the Business Week (1) and NPR pieces I discussed. In light of this, I have begun to scan the media and Internet as much as possible to keep up with what my patients are reading. While most of the best informed patients actually bring articles to me to read, it is a definite advantage to have read and considered the material beforehand. Although this presents a burden to very busy physicians who are already struggling to keep up with their medical journals, it makes a favorable impression and is appreciated by the patients.
In an effort to address the issue of medical information for patients, the American College of Cardiology (ACC) has initiated a Web site called CardioSmart. Its objective is to improve outcomes by empowering patients with or at risk of cardiovascular disease by means of web-based educational and informational resources and health management tools. This program recognizes the need and desire for patients to have more medical information available to them. It exploits the potential to improve their health by providing data to educate patients about actions that will be of benefit and those that are detrimental. Since all of the information will be evidence based and evaluated by experts, CardioSmart will provide an alternative to sources that offer poorly validated or frankly erroneous recommendations. Hopefully, CardioSmart will facilitate our interaction with patients to pursue guideline-based management.
CardioSmart will provide a number of valuable features. Tools will be available for patients to calculate their own risk of cardiovascular disease. The site will provide objective updates on breaking health care news stories. A dictionary of cardiovascular terms will be available, as well as the opportunity for patients to blog and interact with each other. A forum entitled "Ask the Cardiologist" will enable patients to know the answers to some of the most commonly asked questions about heart disease. Finally, CardioSmart will provide a venue for patients to track and chart important cardiovascular parameters such as heart rate, blood pressure, serum chemistries, and so on.
It is now abundantly clear that the transmission of medical information to the public is of great importance to physicians. Patients seek this information; it can be of value to them in choosing healthy lifestyles and it can affect medical decisions. It is important, therefore, that the information be accurate, unbiased, and understandable. As is true of so many health-related things, we physicians are in the best position to oversee this transmission of information and to ensure that it is done optimally. The ACC has already taken a proactive step in this direction in initiating CardioSmart, a Web site that will be of great value to our patients and to ourselves as we advise them. It will be of increasing importance for physicians to stay abreast of what is being presented to our patients so that we can reinforce the accurate information, rebut any that is erroneous, and interpret that which is equivocal. I’m afraid that Reader’s Digest may soon be as important to read as JACC for cardiovascular specialists.
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- Carey J. Do cholesterol drugs do any good?. Business Week. 2008. pp. 52-59January 17.
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