Hey everyone… it’s Medicine Mondays. I hope everyone had a Happy Easter weekend. It’s kind of ironic, that I’m posting late about “Why Does Medicine Move So Slowly?” I was supposed to post more about The House Buying Itch, but I wasn’t able to talk to my colleagues about their experiences with buying houses as residents. Rather than push out an unfinished post, I decided to switch gears, with plan to return to The House Buying Itch later.

Stock Photo from: Pixabay

What do you mean?

You might be thinking about long wait times, or the need to wait for labs, or imaging studies. That might be another post.

What I am actually talking about is how slow the field of medicine is to implement new things.

Here is an example from my time as a medical student back in 2006. Remember my astute neurology attending? The one who told me to be a neuroradiologist because I “wasn’t a neurologist”? I remember being on rotation with her when a new article came out in New England Journal of Medicine (NEJM). I was actually able to find the article because I remember the content:

Clopidogrel and Aspirin versus Aspirin Alone for the Prevention of Atherothrombotic Events

From the article:

An “atherothrombotic” process is described as “atherothrombotic disorders of the coronary, cerebrovascular, and peripheral arterial circulation are the leading cause of death and disability in the world.”

Essentially, it was an elegantly created trial to evaluate whether this patient population should receive aspirin, plavix, or both. At the time that this article came out, everyone at my hospital (and most other places, I think) had orders of aspirin and clopidogrel (Plavix) .

When I say “elegantly created trial”, this is what I mean:

“The Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial was a prospective, multicenter, randomized, double-blind, placebo-controlled study of the efficacy and safety of clopidogrel plus aspirin as compared with aspirin alone in patients at high risk for a cardiovascular event.” (excerpt, emphasis mine)

It was:

• prospective
• multicenter
• randomized
• double-blind
• placebo-controlled

Try to remember back to your Biostatistics class. This study is pretty much as good as it gets.

Ok, so what did the article say?

“In summary, the combination of clopidogrel plus aspirin was not significantly more effective than aspirin alone in reducing the rate of myocardial infarction, stroke, or death from cardiovascular causes among patients with stable cardiovascular disease or multiple cardiovascular risk factors. Furthermore, the risk of moderate-to-severe bleeding was increased. Our findings do not support the use of dual antiplatelet therapy across the broad population tested. There was a potential benefit in symptomatic patients (those with established vascular disease); this finding requires further study. Data on mortality rates suggest that dual antiplatelet therapy should not be used in patients without a history of established vascular disease.” (excerpt, emphasis mine)

The TL;DR is that you should give just aspirin, not aspirin and clopidogrel (Plavix) in patients without a history of established vascular disease. Giving both was not significantly more effective than aspirin alone, while it increased risk of moderate-to-severe bleeding.

So what did your attending do?

She is/was an excellent neurologist. Once this article came out, she did her best to get the word out to everyone in the hospital. She told all the residents, all the attendings, everyone  about it. Unfortunately, it’s difficult to change the status quo. Despite her best efforts to change inform everyone to change from “aspirin and plavix” to “just aspirin”, it was tough to change “the way it was”.

Even months later, getting everyone to switch over to “just aspirin” still hadn’t happened.

…? But why?

Well, this is kind of hard to explain, but bare with me.

There is always some new treatment or new protocol that just came out or is coming out. This was just one example. It’s hard to decide whether this new treatment or new protocol will be “the one”. So, in general, we tend to stick to what has worked. In my opinion, doctors are basically late adopters on the Product Adoption Curve.

Also, it’s sometimes difficult to discern just how well the trial/study was performed/researched. You may have a new article come out and be 100% behind it and switch over the whole hospital to this new protocol, only to have a new article come out 2 months later contradicting that article… leading to problems.

For example, for the study I linked above, there is a follow-up article that came out in 2013:

Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack

“In conclusion, our study shows that among patients with high-risk TIA or minor ischemic stroke who are initially seen within 24 hours after symptom onset, treatment with clopidogrel plus aspirin for 21 days, followed by clopidogrel alone for a total of 90 days, is superior to aspirin alone in reducing the risk of subsequent stroke events. The combination of clopidogrel with aspirin did not cause more hemorrhagic events in this patient population than aspirin alone.” (excerpt, emphasis mine)

The TL;DR of this article is that in certain cases, using dual platelet therapy (aspirin + clopidogrel (Plavix)) for 21 days and then clopidogrel (Plavix) alone was better.

So how long did it take for hospitals to switch over from aspirin and clopidogrel (Plavix) to just aspirin?

I don’t know. However, you can understand the dilemma that we physicians face. With all this new information coming out all the time, how do we know what we should implement into our practice? Who will tell us? Most likely, you will hear about it from a colleague. In fact, you may need to hear it a few different times before you implement it in your day to day practice.

The reason for this is because we want to make sure that this is the new standard to follow before we make any sweeping changes.

Can we speed things up?

Maybe.

Remember that medicine isn’t a startup:

From Quotlr

If Theranos taught us anything, that doesn’t work for medicine. When health and lives are at stake, you can’t just “wing it”. Everything must be peer-reviewed, tested, re-tested before it is implemented. I guess the real question is:

Does it really need to take so long?

If you look at Twitter, you’ll see a hotbed of new things happening on the daily. My Twitter Feed is full of new research and people doing new things and pushing for people to adopt new technologies, new treatments, new protocols, etc. However, without a driving force behind them, I think it is difficult to make any substantial change.

This is for good reason of course. Rushing head first into a new treatment or new protocol without the proper safeguards in place may potentially cause disastrous results.

The real problem is identifying the changes that make the biggest impact with the least risk and implementing them as soon as possible.

Here’s a radiology example:

If you’re a radiologist, you know the Fleischner Society guidelines regarding pulmonary nodules. This original research and guidelines came out in 2005. I can’t pinpoint exactly, but it became pretty widespread by  2008 or 2009 when I was radiology resident. However, even with that, I would still receive reports which did not use the Fleischner criteria.

However, the Fleischner Society criteria updated its guidelines on March 13, 2017. The changes are pretty significant, as the previous guidelines used <4 mm, 4-6 mm, 6-8 mm, and > 8 mm. The new guidelines use < 6 mm, 6-8 mm, and > 8 mm. It also gives additional guidelines of “subsolid nodules”, which did not previously exist.

To be honest, this should change how every radiologist practices on a daily basis. Unfortunately, I think it will take another 3-5 years before this gains wide spread usage. In the meantime we will see confusion between different radiologists quoting different Fleischner criteria. In my own practice, I try to specify:

According to the new Fleischner Criteria Guidelines of March 13, 2017:

I do this in order to try to avoid confusion, as well as spread awareness in my reports.

My question to my readers is:

What do you need in order to make a change to the way you practice medicine?

Does it need to be from a reputable journal? From a colleague? From both? Or…?

What do you need in order to make a change?

TL;DR

Medicine Moves So Slowly…

We are late adopters on the Product Adoption Curve (of Medicine).

But…. it’s for good reason.

Can we speed this up a bit?

How? What does it take for you to make a change to your day-to-day practice?

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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