Last 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 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 really 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. But that’s not how it turned out.
The Widowmaker is a documentary about the development of a medical screening methodology called coronary calcium scoring, in parallel with the invention, development of the coronary stent and the growth in its use by cardiologists. The name is based on a nickname for the anterior interventricular branch of left coronary artery, which is intended to grab your attention, rather than to describe the content, but poetic license probably bridges the gap. 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 (emphasis mine):
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 (who is, in fact, channeling Patrick Forbes, the writer/director of The Widowmaker), and also according to Vliegenthar, et al (the authors of the above-referenced study), there are individuals for whom the checking of risk-factors, like weight, age, cholesterol, etc. will not predict their coming heart attack. The movie 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.
It’s probable that your doctor works with you and chooses tests, treatment, and other actions based on what he assesses as your risk, using profile types that take into account such factors as your age, weight, smoking, high blood pressure, family history, etc. If you don’t match a certain risk profile, then the chance that you will suffer the relevant problems is considered acceptably small.
But there’s a problem with that.
Low-probability of risk isn’t zero probability of risk, and therefore, there are some number of people who will have the problem, even when their risk profile indicates that their risk is acceptable. These people have names, addresses, families and are 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 acceptable-number-of-guys who is going to have the unlikely heart attack, based on his risk profile, probably has a doctor who’s doing the same risk assessments for him.
Consider the Cardio Vascular Disease Risk Calculator at the National Institutes of Health web site. Below the calculator is information about what “good” numbers would be for each of the calculator’s fields. I entered all “good” numbers, and my age, 53. According to the calculator there would be a 3% chance that a person with “good” numbers would have a heart attack within 10 years. In other words, out of each 100 53 year old, non-smoking men who have “good” numbers for blood pressure and cholesterol, 3 will have heart attacks within the next 10 years. Using 2010 census data to estimate that there are roughly 2 million 53 year-old males in the US right now, that 3% is equivalent to about 60,000 heart attacks, or an average of 16 unexpected heart attacks per day, over the next 10 years, just among 53 year-old males. (edit: I need to adjust this, since not 100% of 53 year-old males have good numbers)
The Widowmaker tends to paint the opposition to routine 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 most mainstream-media-apparent expression of stent value in improving patient outcomes, the COURAGE Trial * , suggests that medical treatment, such as statin drug therapy, is as effective as stents in treating coronary heart disease. Unfortunately, statins have their own detractors.
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 pooh-poohing and brushing-aside by doctors who seem to want to play down coronary CT scans for any purpose, often without completing their argument, leaving us to simply accept, “because a doctor says so”.
I think that doing what your doctor tells you to do is probably a good rule to follow, but if you assume that doctors speak candidly, without restraints from management, litigation risk, and frustration at the endless barrage of patients who misapprehended something they read on WebMD, you would be doing so, perhaps, at your peril.
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? I admit that I am 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.
Society, that construct of which we are participants, creators, and victims, should seek to promote public health, and better probabilities for more of us, but it never seeks to monitor and manage the health and welfare of each of its persons. Even democracy, for all the marketing it has enjoyed in popular culture, will never be an inclusive model. The police protect economic stability, rather than people. Broadband Internet initiatives serve people who happen to be near statistically-important parts of statistically-important cities. Free shipping promotions on e-commerce sites are great unless you live in Hawaii or Alaska. If your needs are not the needs of a majority, they aren’t a priority. The knack of living long and well, especially for those of us who are counted in the little slivers of the pie-charts of acceptableness, is to manage it ourselves.
Perhaps the salient point in all of this, the point that can negate the value of this inquiry, is in the question asked by one of the detractors in the movie (I paraphrase) “So you find out that you have significant coronary plaque. Then what?” Some of us will have a hereditary predisposition that has decided our fates for us. Some of us will be unable to bear the thought of life without potato chips. Some of us will get stents, and/or statins. Some of us will adopt a healthy lifestyle, and some of us will drop dead. But none of us, without surgical procedures, will encounter a determination of whether what we did helped or hurt us, cardiovascularly. It’s primarily speculation.
Still, I’m willing to accept that our culture —
- which paints itself as epicurean, but is in fact simply hedonistic,
- whose participants eat for convenience, rather than for nutrition, and
- who have come to equate “freedom” with the absence of accountability
may not do its best to promote personal health.
Mind you, it’s probably among the most survivable cultures in history. The post-smallpox, post-cholera, post-polio, world we enjoy is, by 1910 standards, astonishingly low-risk. But that’s due to the effects of applied public health, not individual health. One can’t really predict and prevent heart attacks, but one can manage weight, blood pressure, and refrain from using tobacco, among other things.
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-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, if any, coronary calcium score detractors who go so far as to say “don’t ever get one under any circumstances”. The argument is more aptly paraphrased as “it has no value if you’re not in a 50% or 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 pay for one yourself.
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 has the proit-motive to 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. It appeals to the techno-fascinated nerd boy in me, as well as my lust-for measurement engineering side. 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. CT scanners are to be found in pretty much any modern radiology provider, but the cardiac program probably requires that the scanner be equipped with a program to image the heart at rest between beats, by taking the EKG as input. I speculate that adding that capability to a CT scanner isn’t cheap, since nothing is in the world of high medical tech. (Reference the cost of CT scanner maintenance training from GE.)
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/controlled 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-of-denial is lasting.
The substrate of personal health is outlook. One can’t act to live longer when one feels as though one is already beyond help, but as I said, this is a speculative undertaking. Your lot in life is largely what you declare it to be. The whole “count your blessings/stop and smell the roses” thing, as trite as it seems, could be the key to long life. You count yourself lucky, or you count yourself out.
Despite my readiness to wax Pagliacci-esque over the news when my calcium score came, my score turns out to be zero. This is, of course, encouraging/disappointing, and it doesn’t mean I will live longer, but perhaps makes several other modern-day causes of death budge into the foreground of my personal health inquiry. Still — outlook is the way to go, as well as perhaps a few celebratory potato chips.