Ye shall not tempt the LORD your God. — Deuteronomy 6:16 Ye shall do no unrighteousness in judgment, in meteyard, in weight, or in measure. — Leviticus 9:35 With what measure ye mete, it shall be measured to you again. — Matthew 7:2
Octogenarian with severe AS [aortic stenosis] for two years clinically followed as asymptomatic. Rising NT-proBNP but says no symptoms. Can’t TMT [treadmill test] due to orthopedic issues. Post TAVR [transcatheter aortic valve replacement] “I feel 10 years younger. What a difference it made, wish we did it earlier.” Elderly slowing down and not complaining is real. (Twitter)
As man grows older and wiser, he is not in a hurry to complain. Uncorrupted man knows of his finitude. He is grateful for a good life he lived and good health he enjoys. In all of history, amongst all the peoples, an eighty-year-old man who has nothing to complain about would be considered blessed beyond measure. Not today.
A Physician came upon a magic ball and a ruler.1 He looked into the magic ball and measured the heart structures of the old man’s heart. He compared the measurements to the Average Statistical Man’s and grew discontent.2 The average numbers were statistically linked to dire outcomes and wasteful expenses.3 The numbers were off to warrant a diagnosis of the narrowing of a heart valve that prevents the blood from flowing normally. Physician’s anxiety of all the Statistically Average Things That Could Go Wrong In A Population compelled him to compile a Replacement Valve Menu to prevent all of the things that may never go wrong in this particular man.4
A woman in her seventies with a history of obesity (BMI in the 30s), hypertension, dyslipidemia, breast cancer status post resection/chemotherapy/radiation went for a routine appointment to a cardiologist.5 She had no complaints. The cardiologist reviewed her records. In comparison to the imaging study of the heart from five years ago, the condition and measurements of the aortic valve changed. The cardiologist asked probing questions and discovered that the patient was “short of breath on exertion”.6 He updated the five-year-old diagnosis from mild aortic stenosis to symptomatic severe aortic stenosis.7 He recommended replacing the aging heart valve to prevent changes in the heart tissues and function that accompanies aortic stenosis. The patient “selected a bioprosthetic valve” and scheduled a surgery.8 In preparation for transcatheter aortic valve replacement, another imaging study was done to obtain accurate measurements for the procedure. It showed “concern for coronary obstruction” and structural peculiarities that warranted having the heart valve replaced by cutting into the patient’s chest. The patient was instructed on the benefits and risks of the procedure that included a two-percent risk of major organ failure, stroke, and death, amongst other complications.9
The day before the surgery the woman was moving bags of dirt and planting a garden.10 The following day, a cardiac surgeon replaced the aortic valve early in the morning. The surgery went well.11 By the middle of the day the patient had to be opened up because she was not doing well. By midnight, the woman died three times, was dead for almost an hour, and a cardiac surgeon was doing an open heart massage, while transferring the patient to a specialty hospital. Her family was called to come say goodbye to her.12 The probability of her surviving the surgery that went well was estimated at three percent.13
After a three-week coma, a bewildered patient awoke in the world of the living. She could not eat or drink, was wetting and soiling herself, unable to turn in bed, get out of bed, or walk. Miraculously, her senses were spared. She knows who she is and recognizes her husband and children. The husband breaks down crying from time to time. The woman is serenely disturbed. The last memory she has is the day she planted flowers and tomatoes. Now she is severely incapacitated. She is very grateful to the cardiac surgeon for saving her life.
It is cost effective and quality assuring to replace a mechanic with an artificially intelligent robot to cure statistical probabilities.14 It is easy to treat a disease algorithmically. In classical medicine, a physician attended to a suffering patient. If you are careful to notice, there are two parts to this idea - a physician and a suffering patient. A suffering patient consists of two philosophical concepts - suffering and a patient. A patient is neither a number nor a Guinea pig. A patient is man that comes and belongs to some people, some place, some time. What constitutes suffering is not set in stone. Notice that an algorithm does not attend to a disease, a measurement, a prognosis, imagination of the future, or personal anxiety of the unknown.
Medicine is not an exact science. At its foundations, medicine is a philosophical discipline. It is a deliberation if this man in front of you is a patient; if so, why; if he is suffering; who brings it up or finds out about suffering; and if there is good reason to proceed with treatment of a condition that acquired the name of a heart valve disease, an underdiagnosed, costly, debilitating, and lethal condition.15
The reality of a patient and her health are ambiguous philosophical concepts of some proportionate relation to the physical reality of her living body and questionable correlation to the representation of this body by the means of imaging technology, measurement technique, and their interpretation as compared to the average statistical body.16 As we age, we slow down and accommodate physiological and structural changes that result from routine use or abuse of our bodies. It does not inherently mean that we are unwell/unwhole/unhealthy in any way or need to be cured of anything. To argue that replacement of all the used or abused body parts will result in the miracle of health and youth is to deny the physical reality of bodies of men that have limits.17
The deceiving confidence that we derive from the optimistic statistics about the achievements of modern medicine are inapplicable to the inherent uncertainty that each man in front of us presents. Sane scientific endeavor would reflect this reality, not create and foster the delusion of control of our finitude. Misunderstanding of the scientific knowledge and misapplication of technology leads to indiscriminate algorithmic treatment of populations that harms individual patients who do not understand what they agree to. In the quest for abstract population health and longevity, the very real body and life of the patient were destroyed forever. Such careless disregard for the sacredness of the body-and-life of man is inexcusable.
The Proto-Indo-European root *med from which the word medicine arose means “take appropriate measures”. The ancient meaning of the word measure had to do with moderation and proportional relation of parts, not arithmetic and abstract numbers.18 Our desire for certainty, power, control, objectivity, order, law, and truth manifests in the ritual of measuring.19 In Numbers We Trust. A number is an idol of our own creation. Our ability to measure physiological changes in our bodies as we age does not mean that we must do something about it.
A man is rich in proportion to the number of things which he can afford to let alone.
— Henry David Thoreau, Walden
We create many diseases today with the tools that we have. We invent diseases through philosophy and technology. A disease is neither an illness nor a fact of physical reality.
We establish norms by measuring something in a population, cutting off extremes, then averaging out the middle. Man made of averages would not be viable.
Porter, Theodore. The Rise in Statistical Thinking, 1820-1900.
We connect some biometrical parameters to some other body functions, then attempt to fix these parameters in a delusion it would improve function. Much of evidence-based medicine is the enterprise of population doctoring in this manner. It all ties into how little money it is fiscally prudent to spend on passive consumers of medical services and products.
Doing or not doing something is often a habit or a custom, not a scientific practice or philosophical discernment.
A routine visit to a doctor or a test “just in case” can turn your life upside down.
If a patient has no complaints, it is hard to say definitively if it is prudent to look for trouble with this particular patient.
You can study how a diagnosis comes to be and what treatments are recommended for some abstract patient of no relation to the man in front of you in 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease. Those who work in this area can probably enlighten you about the ongoing changes to these guidelines, which often entail narrowing the range of normal parameters.
One wonders how a patient can select a heart valve as if it were an item on the tapas restaurant menu.
Nobody understands statistics. Such reporting of adverse outcomes creates a cognitive distortion that this procedure is not very dangerous.
One wonders how to correlate “shortness of breath on exertion” with fairly strenuous activity and the results of medical testing and situate it in the broader understanding of what it means to be well now and in general for this particular patient, taking into consideration patient’s age and general state of health.
Did the patient sweat before he died? Yes. Very good!
Experiments on patients affect everyone in the family. The ordeal affects the well-being of more than the patient.
Again, such statistical reporting is odd. You either die or you do not. In this case, the patient lived. It is a miracle.
It is not a coincidence physicians are replaced by operators of computers and robots.
There are many websites that market TAVR to patients and healthcare providers by “creating awareness”. It is hard to say if this is unambiguously good or bad.
Few are trained to understand that a patient is not a broken car.
When you start pushing beyond limits, things go wrong.
Data is killing us. It is not true that the world is made of numbers or that everything can or should be measured.
Check out popular science and academic literature on the philosophy and history of measurement.
Having recently been poked and prodded and imaged (for some baseline testing tied to familial history), I can see why it is hard for the average person to get off the medical testing treadmill. It took a simple question to my MD to hit pause: so, what sort of testing would that specialist want to do?
MD responded with "well I suppose I can have a conversation first to see if you even need to have an appointment. "
Dude, you do that. In the meantime, I will modify some aspects of my lifestyle but I refuse to panic over test results in an asymptomatic body. (I think this is exactly what perplexes the MD - that I am mostly non-plussed about the familial history thing.)
"Physician’s anxiety of all the Statistically Average Things That Could Go Wrong In A Population compelled him to compile a Replacement Valve Menu to prevent all of the things that may never go wrong in this particular man."
In a nutshell!