I sat alone in our bedroom on my computer taking a test. It was a maintenance of certification (MOC) examination. This was a part of maintaining my board certification in advanced heart failure (AHF) and transplant cardiology. For medical board exam questions, the typical format is a patient scenario complete with a medical history and pertinent physical exam, laboratory, and imaging findings. From there they ask you a multiple-choice question. Of course, for each question there is only one “right” or “best” answer. The rest are wrong.
I thought about this as I worked through question after question. We make many decisions every single day of our lives. Is real life like one giant multiple-choice test? Is there really only one “best” answer? I don’t think so.
Let me explain my thinking: On a test there are multiple wrong answers and only one correct (or best) answer. In life, however, there are generally multiple reasonable choices you can make. What do you have for dinner? Which pair of shoes should you buy? Where do you go on vacation? There are likely multiple good and acceptable choices. We can debate even bigger questions like, “What career do you select?”, “Should I begin a relationship with this person?”, or “Should I take this job?”
As I continued to answer one question after another on the examination, it occurred to me that the practice of medicine also is not like the board exam. For any given medical problem, you often can order one of a few tests to try to find out what is going on with your patient. There are multiple reasonable ways to come up with the answer. You also often have a few different ways in which you can treat your patient and have them get better. Usually there is not just one correct answer, but instead several acceptable answers.
On my exam it was not so. Should I pick A, B, C, or D? One answer was right. All the others were wrong.
Why the difference?
On one level it is because our bodies have an amazing tendency to adapt, cope, heal and recover. Many times, our patients get better regardless of what we do. In fact, I am convinced there are times when our patients get better in spite of what we do.
I have an ancestor who was involved in treating George Washington on his death bed. Washington’s throat had swollen with an infection, and he struggled to breath. My ancestor argued that they needed to stop bleeding him and that he needed an experimental new technique called a tracheostomy. He was vetoed by the senior physicians. The senior physicians drained more blood from him, he became weaker, and he died.[1]
In those days, doctors would in good conscience practice bleeding believing it would drain “evil humours” from their patients. They would also apply noxious plasters or give emetics (medicines to make the patient vomit). In Washington’s case they even applied a salve of dried beetles to his throat. Thinking about it now it seems clear they were adding insult to injury. These practices developed however because sometimes the doctors did these things (bleeding, plasters, emetics) and the patients got better. The truth of the matter is that the patients were getting better despite the treatments rather than because of them.
The 20th century brought the scientific method to medicine along with randomized blinded controlled trials. We are fortunate for the incredible growth in science and technology. We now have a growing armamentarium of treatments that do work. Using the scientific method, we have been able to develop, test and prove that treatments help people get better. We are able to say that our patients now get well because of the treatments we apply.
Mostly.
Science has taught us and continues to teach us that there are times when we don’t need to do anything. In those circumstances patients will get better without us doing anything. Medical science has also taught us to look at each treatment critically. Just because a patient takes a treatment and gets better doesn’t mean that the treatment made them better. It could be that they would have recovered with or without the treatment.
For example, the COURAGE trial randomized patients with significant but stable coronary artery disease to medical therapy plus stenting vs just taking medicines alone. Surprisingly the patients who didn’t get the coronary stents did just as well as those who did. This trial has changed how we treat our patients. Stents are very powerful and effective for patients who are having a heart attack or for relieving symptoms of angina. But for stable patients, treating with medicines alone can be just as effective.
The value of critical thinking and scientific testing has been evident over the past 2 years with a variety of COVID treatments. Science generally starts with an observation that something was done, and patients got better. Often there is a theoretical basis to a treatment, it is tried, and patients get better. This was what happened with hydroxychloroquine and ivermectin. There was a theoretical basis that would suggest that they should work. On an observational basis, when they were given to patients the patients got better. But did they get better because of the medicines or in spite of the medicines? Ultimately multiple randomized controlled trials failed to show benefit. These treatments are no longer favored by the experts.
In life we also face a daily collection of multiple-choice questions. For most of these questions more than one of the choices would be just fine. We make our best judgment, give our answer and move on. Things turn out okay. Perhaps it was because of the choice we made. Perhaps it would have turned out well either way.
But what if things don’t work out okay (in life or in medicine)? What if my patient doesn’t get better? What if despite the tests that I order, I cannot find a cause for their symptoms. What if despite the treatments that I prescribe the patient fails to get better? What should I do then?
This is where I will reveal a secret.
Sometimes medicine (and life) is indeed like the board exam. Sometimes it really does matter which choice you make. Sometimes you do need to be very smart. You need to be able to see through what look like multiple reasonable choices to find that one that is correct (best). Sometimes the practice of medicine is hard and not forgiving. Sometimes one answer is correct, and all the others are indeed wrong.
As a patient most of the time almost any physician can help you. But there are times when it really does matter which doctor you see. There are times when the doctor you are seeing may not have seen your problem before or may not know how to sort through what is going on. Sometimes there just are not any answers. In those times it might be that medical science doesn’t have an answer or you have a bad disease for which there are no good treatments. But it also might be possible that there are answers and that another doctor (especially someone with specialized knowledge on your condition) might have an idea of what to do.
If you get sick, get treated and then get better, all is good. But if you don’t get better (or you get worse) you might benefit from a specialist or a second opinion. I know that this all seems very obvious. The problem is that it doesn’t always happen.
In my previous blog I stated 4 lessons that have been important for me to learn in life:
- Sometimes I think I am right, and I am wrong.
- Sometimes I think I can do something on my own, but I really need the help of a professional (someone with more training and experience than me.)
- Sometimes I think I know everything, but it turns out that there are things that I don’t know I don’t know.
- Sometimes I think I know a lot about something and yet there are others with a deeper knowledge on the subject than me.
These 4 lessons have driven a lot of the focus of my career. Let me explain.
The advance of medical knowledge has been tremendous. Last year there were 21,793 articles published on the topic of heart failure alone. There is no way that I could read each and every one of those articles. I have strategies that I use to remain current (reading key journals, medical twitter, scientific meetings, etc…) but that is just in the field of heart failure. If I consider the rest of cardiology, it becomes daunting (interventional cardiology, electrophysiology, cardiac imaging, preventive cardiology, structural heart, adult congenital, etc…) The amount of information that is available is enormous. We have been forced to come up with strategies to cope with this.
The answer has been the development of subspecialization within the specialty of cardiology. Let me make that clear:
- Within medicine we have the specialty of internal medicine.
- Within internal medicine we have the subspecialty of cardiology.
- Within cardiology we have developed multiple subspecialties (or I suppose we could call them sub-sub-specialties!)
- Even within heart failure we have experts that focus more strongly in one area or the other. This is being done out of necessity. No matter how smart a physician is, there is just no good way for them to know or keep up on everything.
- Within cardiology we have developed multiple subspecialties (or I suppose we could call them sub-sub-specialties!)
- Within internal medicine we have the subspecialty of cardiology.
Fortunately, most of the time, life is not a multiple-choice question with only one answer. Normally we can treat patients following accepted standards of care, our past training and our experience and they get better. Sometimes they don’t. When that happens, we get help. Our system of specialization and sub-specialization and sub-sub-specialization is the tool that we use to do this.
I was fortunate to live through the birth of the subspecialty of advanced heart failure (AHF). I can remember going to the leadership of my cardiology group 15 years ago to ask that we create a dedicated inpatient rounding service to manage complex heart failure patients. This service would be where we would take care of the patients who had not responded to standard treatments or who had high risk features. The group listened and the AHF service was born. The service quickly became a tremendous success. It turns out that within heart failure, with its high mortality, there was a strong need for AHF as a distinct subspecialty. As referring physicians began to see us coming up with new answers or solutions for their patients, the referral volumes steadily grew. What happened for us locally also happened around the country and the AHF subspecialty was born.
Over the past dozen years, we have been blessed to recruit and retain some incredible talent. In addition to the 2 of us who started our AHF subspecialty service 14 years ago, we now have 6 other well trained and experienced AHF cardiologists. At the same time, subspecialization has developed throughout and within all areas of our cardiovascular medicine division (interventional, electrophysiology, imaging, prevention, structural, congenital, etc.)
This brings me to another new term: “advanced cardiac disease (ACD)”. ACD is defined as conditions in which patients fail to improve with standard treatment, or for which standard treatments are high risk for adverse outcomes. ACD patients are the ones who benefit from subspecialist physicians and advanced therapies.
We can divide the world into: 1. Not board exam like (more than one choice is okay) and 2. Board exam like (harder, complex). Patients with ACD are living in world # 2. For these patients, there may be only one correct answer. They need the breadth and depth of knowledge that subspecialization brings.
The data shows that the population with ACD is growing. There are a lot of factors driving this including an aging population as well as increasing complexity of treatment and diagnostic options. To meet this need we have had to build out not just multiple layers of focused specialized experts but also team-based care strategies to allow us to benefit from each other’s knowledge.
The problem is that the focus, time and energy that is needed to do all of this is not practical in all locations. In other words, there is a lot of work to do that involves every day, normal life medicine (and cardiology). It just doesn’t make sense for every center to have a full-time subspecialist in all of the areas of medicine (or cardiology). For this reason, we have focused on hub and spoke models. This means that we have collaborative and cooperative relationships so that most patients are managed near their home, but for those with advanced cardiac disease, the care is shifted to the hub where the full breadth of subspecialty teams are available.
I know this blog post may be getting a bit long, but it is a complex explanation of what has been driving my career and recent changes. In October 2018, I was diagnosed with cancer. I had surgery, followed by radiation and chemotherapy. I had a prolonged recovery. When I returned, I realized to my delight that the team was strong and did very well without me. On my return, I came back with adrenal insufficiency and problems with reduced energy. I was forced to ask a simple question, “If I can’t do everything, where would I want to spend the energy I do have?” I have spent the past 3 years working on and implementing the answer to that question.
When I started in cardiology, patients needed the specialty of AHF which didn’t yet exist. We created it and it has been a really good thing. Now that it exists, some patients with ACD get to subspecialized care but some don’t. A lot depends on where they live or come to seek care. This realization led to my answer to my question: If I can’t do everything, I want to deliver AHF care to patients who otherwise wouldn’t have access to it.
Practically speaking this means that I have stepped down as section chief and medical director and shifted my focus to outreach clinic locations. My vision is to demonstrate the value of my specialty (advanced heart failure) to the clinicians and patients throughout a broader region. I want to open up access to patients who might not be willing to drive to us. I want to demonstrate value to clinicians who might not in the past have thought to refer to us. If a patient with heart failure gets treated and gets better, that is excellent. If they don’t get better or they get worse, then I want to see them (or have one of my AHF colleagues see them.) I also hope to be able to be a tool that other physicians can use to tap into the network of sub-specialization that has developed at the Meijer Heart Center in Grand Rapids.
Let me be frank about this: I am not smart enough to be able to manage every patient that has failed standard therapy who is referred to me. What I do have is a heartfelt understanding of the 4 lessons (see above) and access to a variety of really smart people who I hope can give the answers our patients need.
What am I trying to say?
First, if you or your loved one has a medical problem that is not getting better, I would encourage you to push to get a 2nd opinion. “All doctors are good until you get sick,” one doctor taught me. I might rephrase that to say that in most of medicine (and in most of life) multiple options are acceptable and people do just fine (they get better). Sometimes they don’t. That is when they need expert help.
Second, know that sometimes in life things are hard. There are times when life is like the really hard test question for which you are not sure of the answer. What do you do then?
Don’t give up being a seeker. Remember the 4 lessons from my prior blog. Just because the people you have asked don’t have an answer doesn’t mean that an answer doesn’t exist. Ask questions, read, and seek. PRAY. Seek out a professional. If the professional doesn’t help, get a second opinion. It is a good thing to keep pushing for answers even if you are not sure where or how to find them.
Finally, understand that most of life is not the “one answer” is correct multiple-choice test. I find that comforting. It takes the stress off me as I live my day-to-day life to know that in general, I have multiple good and acceptable options to choose from. If I am given a choice, often A, B, C, or D might all be good answers and perhaps B or C might each be potential best choices. I don’t have to be perfect in everything and in every choice.
For the maintenance of certification examination, I have volunteered to be a part of a pilot program to develop the examination questions. This meant that I volunteered to take the exam not once, but four times. I took a break to write this blog. After I wrote this, I went back to do the examination one more time. Sometimes finding the right answer was easy. Other questions were quite challenging. As a worked through the questions, I thought how happy I am that much of life is not like answering these questions. Usually more than one answer is acceptable. I also was happy to think about what has happened during my career with subspecialization. I thought about how I don’t have to know everything every day. I thought about our community of experts where I can turn for help in the times when the world becomes a board exam.
Hmm. B or C? It is clearly not A or D. Is it B or C? Oh, I guess I am just going to have to go with my gut and pick one of them. “Let it be” is what the song says, so let’s go with “letter B!” On to the next question!
[1] https://washingtonpapers.org/resources/articles/illness/
