Getting the right answer

I have noted in the past that I dedicate a significant amount of time every day to reading. I have selected a series of informational websites that send me medical updates on a daily basis. These updates are related to specific topics that I select, each time I register for such a website. I do find this an effective way to stay abreast of general medical information as well as the latest news.

Over the last couple of days, I came across a number of articles dealing with a specific issue in heart disease. More specifically, I read a number of articles speaking to the significance of a special test, called Troponin, when assessing a patient in the emergency room.

Just within this group of articles I reviewed, there were discrepancies in the authors’ conclusions about how to best manage patients with acute chest pain. It is fairly easy to expand the review on the topic of Troponin, by doing a simple search on Google. Very quickly, I was impressed by the tremendous amount of research that has been published on this topic just in the last few months.

One of the references was to a textbook that includes a series of discussions on various topics specifically related to handling chest pain in the emergency room. In the course of a few pages, multiple physicians related their personal experiences with the handling of such cases. It is by no means facetious, but in one case, despite the fact that three of the discussants did not suspect a heart attack in the given patient, they all agreed that the patient would likely end up having an angiogram, to see if in fact there was a blockage in the arteries to the heart.

The textbook itself was published in 2012. It’s fair to say that the information in it was up-to-date as far as 2011. This however was already almost 5 years old. With the amount of research pouring in on a daily basis, especially on major topics like chest pain in the emergency room, one could argue that such an “old” book is too out of date, and as such is more wrong than right. This is equivalent to the statement that medical students hear, usually in their very first class. Even 30 years ago, I was told that the majority of what I will learn during my four years of medical school, will change dramatically by the time I complete my studies, and definitely my residency.

I should point out that, since its implementation, Troponin is a test that has been critical in the improvement of assessing chest pain patients in the emergency room. Even so, in a paper I read just today, the authors concluded that elevated levels of Troponin were not related to an acute heart attack in approximately 80% of cases. That is not a mistype. In only 20% of cases, the test [which is now touted as critical in the assessment of chest pain patients], is actually associated with a heart attack.

In the last 20 years, the whole concept of evidence-based medicine was thought to be the new and best way to treat patients. Rather than rely on the independent opinion of one or a few doctors, the key was to amass as much information from the world wide archive of medical research, before rendering a diagnosis. It is only relatively recently, when Internet access is so widespread, that it is practical for physicians to readily keep up on their specific field. Basically, while research-based medical advice should be the standard for all clinical practice, it just doesn’t happen that way.

There is too much to know. I personally find myself horribly overwhelmed by the amounts of information that I read. Basically, my hope is that when faced with a particular clinical issue, some nerve cell in my brain will spark, reminding me that I read an article about the specific issue. Based on this article, I can then begin to more effectively search the topic, spend a reasonable amount of time researching it, and then try as best as I can to provide a practical and reasonable diagnosis and further advice.

All of this assumes that the research that I am reading is reliable.. Of late, a large number of papers have been retracted due to all-out fraud in the way that they were submitted for publication. Although this particular incident was related to a certain geographical area, fraud within the research world is a frightening and horrible event that happens more often than we realize.

Even the way in which the FDA may assess a particular medication can be clouded by the noble desire to release potentially life-saving medications to the public. If a patient understands that a medication has only been proven to have some effect in a lab environment, and the patient still wants to take the chance of using it, one could easily argue that this is the patient’s prerogative. But this is one of these slippery slope situations where medications that have minimal, at best, proof of effectiveness will immediately become widely used. This will be nothing short of human experimentation, and there should be no doubt that people will die due to this practice.

In the midst of all this chaos, I do believe we are on the right track. I recently saw a demonstration of a computerized advice system that asked a number of questions related to a cancer that a patient had, and then demonstrated from the published research, what the chances of survival were when one type of treatment was compared to another. This empowerment of the patient, and doctor, based on research, is groundbreaking. It is hoped that as more and more people have their data added to the collection of research information, we will eventually manage to get the right answer when asking our medical questions.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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