Progress note 03/21/2016
William C. Roberts and “floating hearts.” Did Osler practice evidence-based medicine?
My favorite cardiology journal is the American Journal of Cardiology, mostly because its editor, William C. Roberts, publishes research articles and editorials that I can read, understand, and enjoy.
I’ve never met Roberts, but he seems like a very personable, old school, Southern gentleman. More importantly, as a dedicated academic cardiac pathologist who’s had an illustrious career and been at his trade for more than 60 years, I suspect he has directly examined, touched, and smelled more hearts than all currently practicing cardiologists combined.
Roberts is of the kind of clinician scientists I had in mind in my post on small data versus EBM when I described those who use their five senses. He just published a descriptive series of 146 hearts taken from autopsies and immersed in formaldehyde. The simple trick was to observe “floating hearts” as a measure of cardiac adiposity.
Roberts and his son had published a similar series in the early 1980’s, when they found that the pravalence of floating hearts was 5%. The prevalence is now about 50%! There is some correlation between heart weight and adiposity with BMI, but it is not very strong (Roberts has a couple of hypotheses about why that is). While there is no immediately obvious clinical importance to the findings, it is certainly a striking one and didn’t require anything fancy, beyond some powers of observation. It may seem like a triviality, but who knows? Sometimes breakthroughs happen after a series of trivialities are put together over time.
In a lengthy interview conducted by Bruce Fye, Roberts talks a bit about EBM. Here is what he said:
Fye:…Let me ask your views on the whole field of clinical trials. When you started at the NIH they were barely getting started and now, of course, clinical trials are the hottest news. What about them?
Roberts: That is tough.
Fye:It is not a yes or no answer, that is for sure.
Roberts: The investigators, unless they are the first or the last authors on the published article, do not necessarily advance their careers. The articles that I like most are the ones that allow a single patient to be fit easily into the data. When I can’t fit a single patient into the data it bothers me. It is often difficult to fit a single patient into many multicenter trials (…)
Fye:Did you read an article in the Annals of Internal Medicine about the practice of medicine by older physicians vs by younger physicians (7)? Their design was to look at a variety of studies going back about 25 years. Their conclusion was that the older doctors did not follow the guidelines as much as did the younger doctors. Therefore, younger physicians are probably providing higher-quality medical care than the older physicians. The editor chose to write an editorial that basically amplified the message and then they chose to create a page for patients based on this, and the bottom line was you should be aware that this study suggests that if you are seeing an older doctor you might not be receiving high-quality care. Of course, this thesis doesn’t apply to all physicians. In other words, this evidence-based medicine is a bit like religion, and it is unlike most religions that have taken centuries or thousands of years to get a critical mass of followers. This new religion came on the scene 15 years ago, and if you aren’t a part of that religion, you are a heathen. Do you have any thoughts about that?
Roberts: My son, Chuck (Charles Stewart), made a comment to me one time to the effect that Osler practiced evidence-based medicine. As Chuck mentioned, in terms of our thinking today, it is a bit arrogant to think we are practicing evidence-based medicine and nobody before us did. When I first became editor of AJC, I thought it was probably not a good idea to send manuscripts for review to young doctors, i.e., those <35 years old. It didn’t take long for me to realize that the best reviews often came from those under 35, probably because they had more time than did those >50 years old. As time goes along, we have to do more and more things, so certain things don’t get as much attention as earlier, although one might be a little more efficient in doing them.
I had a hip problem starting in 1983 and I was advised to have a hip replacement in 1984. I went to a female rheumatologist in 1983 and she said, “Don’t have a hip replacement until you can’t stand it any longer.” Now that was good advice, so I had the operation in 1997 because by then I could not walk from one of my offices to another at BUMC. Had the hip replacement been done in 1984, I would probably have had a second hip replacement in 1997. Personal pain makes for a better physician! Younger physicians have few pains. I think whether one keeps up in medicine or not is determined more by one’s interest in medicine than by the physician’s age.