On Tuesday night, I faced the cord-cutter’s dilemma: having consumed all 6 seasons of the Sopranos from Amazon Prime, which I had been grazing upon since March, I needed something new to watch. This is the moment when cord-cutting most resembles the old channel-surfing model, where one pokes around and finds something that one had not previously encountered. It provides the joy of the hunt, and it can yield new information, despite the best efforts of Netflix, Amazon, etc to make sure that what you watch today resembles what you watched yesterday.
A source of new input, not surprisingly, tends to be the “newly-added” list, which on Tuesday featured a new movie called “The Widowmaker” prominently.
From the description, it wasn’t entirely clear whether the movie was a documentary, or a fiction, but it was compelling enough. “Starring: Gillian Anderson” it said. Although I’ve never been an X-Files fan, I tend to enjoy the projects that she chooses. Maybe it was fiction. I craved escape, and if it was a documentary, I would just back out and try something else, I thought. That’s not how it turned out.
It is a documentary about the development of a medical screening methodology called cardiac calcium scoring, in parallel with the of cardiac stent and the growth use by cardiologists. It’s obviously designed to lead you to a viewpoint, and much of what is said is compelling, but it has the tone of something that, although reasonably well composed, needs to be verified by other means. To that end, I submit that my take-away from The Widowmaker pretty much matches the abstract from a study I found on PubMed at the National Institutes Of Health:
[Computed tomography coronary artery calcium scoring: review of evidence base and cost-effectiveness in cardiovascular risk prediction.; Vliegenthart R, Morris PB., Department of Radiology, University of Groningen/University Medical Center Groningen, Center for Medical Imaging-North East Netherlands, The Netherlands. firstname.lastname@example.org]
The entire abstract reads:
Cardiovascular risk factor-scoring algorithms may fall short in identifying asymptomatic individuals who will subsequently suffer a coronary event. It is generally thought that evaluation of the extent of the atherosclerotic plaque and total plaque burden can improve cardiovascular risk stratification. In the last decade, there has been an increasing interest in coronary calcium scoring by computed tomography. By determining the calcium score, an estimate of the total amount of coronary plaque is obtained. Numerous studies have shown that the calcium score predicts coronary heart disease. Recently, the calcium score was shown to improve risk stratification beyond cardiovascular risk factors, especially in those individuals deemed to be at intermediate risk. So far, only limited data exist on the cost-effectiveness of coronary calcium scoring in asymptomatic populations.
According to Ms. Anderson, and also to Vliegenthar, et al (the authors of the above-referenced study), there are individuals for whom risk-factor checking, like weight, age, cholesterol will not predict their coming heart attack. Ms. Anderson (who is, in fact, channeling Patrick Forbes, the writer/director of The Widowmaker) goes on to say that EKG, or even a cardiac stress test (which includes an EKG) does not serve to detect impending “coronary events” in some patients, many of whom show no risk factors anyway, so they may not have had such tests.
The Widowmaker paints the opposition to coronary calcium scoring as cardiac-stent-obsessed robber barons, who are promoting the application of expensive stents into patients for whom the stents have no benefit. The movie also asserts that hospitals have prevented bankruptcy by the revenue that stenting provides. In the movie, as well as on the wide internet, there is a certain amount of that poo-pooing and hand-waving by doctors who seem to want to play down coronary CT scans for any purpose, many times without completing their argument, leaving us to simply accept, “because a doctor says so”.
So if profit-motivated health care service providers are in it for the money, why are the insurance providers reluctant to reduce the need for a $30,000 stent by paying for a $200 coronary scan? There are missing pieces in that inquiry, but in the movie it’s stated that they recognize that their customers don’t stay with an insurance company for more than a few years, and that screening would only benefit their competitors.
So, it’s probable that your doctor works with you and chooses tests, remedies other actions based on what he sees as your risk. If you don’t possess a certain risk profile, the probability of risk for things that risk profile is designed to predict is considered acceptable. Except that there’s a problem with that. Low-probability of risk involves some number of actual people in the small group for whom the risk is realized. People with names, spouses, children, and people, who — no delicate way to put this — might be You. Somewhere, a guy who’s sporting the realized risk, that is, one of the guys who is going to have the unlikely heart attack, which is unlikely based on his risk profile, probably has a doctor who’s doing the same risk assessments for him.
If profit and competitive edge determine the course of health care, then who’s looking after the individual? (Hint: it’s someone in the mirror. Or your wife. At least your wife, anyways)
Humans are terrible at conceptualizing meaning of risk probability. We live in fear of killer asteroids, while blithely tailgating on the freeway and eating french fries.
Watching The Widowmaker, even though I see the need to question the veracity of something that’s obviously a “hearts and minds” pitch, has had an immediate effect on my daily habits. My FitBit One is currently preparing for shipment from Amazon. Even without it, the Android FitBit App tracks my activity, logs my calories, and graphs my weight (entered manually), and I have to admit that I want FitBit, inexplicably, to be proud of me. The occurrence of boredom-or-anxiety-snacking in my diet has ceased. My waistline has been pushing the limits of my wardrobe this last year or more, and just the consideration of my own risk factors has given me a long-sought handle on the problem.
There are few coronary calcium score detractors who go so far as to say “don’t ever have one under any circumstances”. The argument is more aptly paraphrased as “it has no value if you’re not in a 50% 0r higher risk group”. Meaning that even if you haven’t been told that you need one, there really isn’t anyone who’d object if you wanted to have one.
Question is: who would offer such things in a world where the scan is largely not used? Or put differently, in a profit-motive-based health care industry, who would offer cardiac CT scanning? Well, stand-alone radiology service providers, of course.
Although I don’t presume to have invented Recreational Radiology as a pastime, I do see the allure. I called Ko’olau Radiology on Thursday, after a day of hesitation. I expected to be told that there would be an appointment available in 3 or 4 weeks, but the lady said “any time starting tomorrow morning is fine, cost is $418″. After that declaration, I found the view from the precipice atop my warm, cozy denial bracing. A mere 19 hours later, I was inside the GE Lightspeed CT scanner, with my arms over my head, and EKG pads on my chest.
The results will arrive in the mail. A benefit of Recreational Radiology is that I get all the results, without omission, and no doctor can keep them from me. I chose, at no extra cost, to share them with my GP, and with my aviation medical examiner (who is a cardiologist), primarily because I want them to be included in both medical records, and secondly because no matter what either doctor thinks of it, I will have exposed him to it. I may benefit by my own test, others may benefit from my doctors’ exposure.
The pending results have the potential to be the most valuable medical results I had ever received, the one that delivers The News. Or it could lack any worthwhile guidance. The crux is, perhaps, “conclusive results are bad, inconclusive results are less bad.”
I felt that it was important to blog this during the blessed interval between having the test and getting the results. When you think about it, the best course of action really doesn’t depend on my coronary calcium score. I am 53 years old, about 50 pounds overweight, with treated high blood pressure. I have serious doubts that most doctors would have discouraged any cardiac screening test, based on my risk profile.
Of course, Denial is waiting, just beyond the firelight, to creep back in. Hopefully the re-calibration is lasting.
Having just finished 6 seasons of the Sopranos, and being a fan of the late (of a heart attack), great James Gandolfini, I hereby toast to his memory with the immortal words of his own Tony Soprano:
I know that every day is a gift, but why does it always have to be socks?
But then again my own saying is –
Thank God for flat tires.
Your charmed life, where such things as flat tires, or losing your cell phone are representative of serious problems, is a fantasy life, one that you will wish you had back after some unforeseen thing takes it away.