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In Praise of Older Doctors: A Paean for Experience

      In his book, In Praise of Older Women: the Amorous Recollections of A.V., Stephen Vizinzcey avers that older women develop talents that more than make up for fading beauty and loss of innocence.
      • Vizinzcey S.
      In Praise of Older Women: The Amorous Recollections of A.V..
      However, the contemporary image of the doctor who quotes his or her experience is not one of beauty or innocence. Rather, it is one of arrogance, ignorance, and greed! However, I would like to suggest that experience endows doctors with enhanced capacity to apply the best evidence to individual patients. I will address 3 issues: clinical spectrum, the patient's own natural history trajectory, and patient choices.

      Clinical Spectrum

      It is self-evident that the prognosis of a common disease, such as coronary artery disease, must depend on the circumstances in which the patient is seen. Thus, there cannot be a common prognosis of coronary artery disease in asymptomatic subjects, those with stable coronary heart disease, those with acute coronary syndromes, and those in an intensive care unit with cardiogenic shock. This also is true of less common conditions. For example, Maron
      • Maron B.J.
      Hypertrophic cardiomyopathy: a systematic review.
      has emphasized the wide clinical and prognostic spectrum of the disease hypertrophic cardiomyopathy (HCM). This excellent clinical summary ignores the differing clinical contexts of this disease. Most patients with this condition seen in an office practice are asymptomatic and may even have a normal electrocardiogram. They have “a common disease with a good prognosis.”
      • Shapiro L.M.
      • Zezulka A.
      Hypertrophic cardiomyopathy: a common disease with a good prognosis. Five-year experience of a district general hospital.
      • McLeod C.J.
      • Ackerman M.J.
      • Nishimura R.A.
      • et al.
      Outcome of patients with hypertrophic cardiomyopathy and a normal electrocardiogram.
      • Sorajja P.
      • Nishimura R.A.
      • Gersh J.
      • et al.
      Outcome of mildly symptomatic or asymptomatic obstructive hypertrophic cardiomyopathy: a long-term follow-up study.
      A second context in which patients with HCM might be seen is as hospital inpatients for the evaluation of symptomatic HCM. The symptoms of such patients are usually related to the severity of the left ventricular outflow gradient. Such patients might require pharmacological therapy, failure of which might lead on to the need for interventional cardiology or cardiac surgery. The prognosis of patients with symptomatic HCM is often worse than their asymptomatic counterparts. The least common group with HCM is those who present with resuscitated cardiac arrest or syncope. Such patients tend to present to electrophysiologists, pediatric cardiologists, sports cardiologists, or to units with a special interest in HCM. Clear guidelines exist for their management, and most will require intervention such as an implantable cardioverter-defibrillator.
      • Zipes D.P.
      • Camm A.J.
      • Borggrefe M.
      • et al.
      European Hearth Rhythm Association; Hearth Rhythm Society
      ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death).
      There is often a recognized genetic basis for their predicament, but the management of their relatives, most of whom will be asymptomatic, is fraught with difficulty. The disease-based description
      • Maron B.J.
      Hypertrophic cardiomyopathy: a systematic review.
      should not discourage an office-based physician from giving a good prognosis to most asymptomatic patients with HCM. What you have seen yesterday, and again today, is highly predictive of what you are likely to see tomorrow.
      The experienced physician knows that a particular disease usually behaves in a predictable fashion. When variance from the normal pattern occurs, the physician is alerted to the possibility of complications for that disease, or that the course could be that of a different disease. Of course, a rare disease is much more likely to be recognized by an experienced physician who has seen that disease before.

      The Patient's Own Natural History Trajectory

      While it is possible to give a prognosis for a group of patients with a disease, it is impossible to give an accurate estimate of prognosis for an individual patient with that disease. For instance, an analysis of my practice data over a period of 25 years showed that patients with coronary heart disease and heart failure had an average life expectancy of 3.2 years. However, 14% of such patients lived 10 years or more (Figure 1). I believe that one should always offer an optimistic prognosis for patients with serious diseases, even if a good outlook is statistically unlikely—a good outcome can, and sometimes does, happen!
      • Jelinek M.
      • Santamaria J.
      Metamorphosis: the natural history of coronary heart disease. Sudden death is common. Unexpected death is not.
      Figure thumbnail gr1
      Figure 1Kaplan-Meier survival curve of 59 patients with coronary heart disease followed from their stabilization until their death.

      Patient Choices

      Experience is the basis whereby the global becomes local; the group results are applied to the individual; and the science behind medicine becomes only one of the factors in the art of treatment. By global, I mean conclusions based on evidence-based medicine. Individual patient quality-of-life issues and the optimal treatment of disease are not necessarily identical. Some years ago, I modified the Eysenck Personality Inventory
      • Eysenck H.J.
      • Eysenck S.B.G.
      Manual of the Eysenck Personality Questionnaire.
      to create a 4-quadrant clinical scenario relating disease outcomes and patient quality of life (Figure 2).
      • Jelinek M.
      Applying evidence based cardiology to the individual patients.
      All doctors who practice clinical medicine are keen to practice in quadrant 1, where lifesaving treatment is accompanied by improvement in the patient's quality of life.
      Figure thumbnail gr2
      Figure 2Relationship between treatment effects on prognosis (x-axis positive to right) and treatment effects on patient quality of life (y-axis, positive upwards).
      Many who practice preventive medicine work in quadrant 2, where the patient's disease treatment is pursued with some impairment of the quality of life. Examples of this include the taking of all recommended medication to increase life expectancy or reduce disease complication rates. The hardest recommendation is the use of warfarin anticoagulation to prevent cardioembolic stroke, particularly in the context of nonrheumatic atrial fibrillation. Clearly, stroke is a personal and community catastrophe. The use of oral anticoagulation has been shown to reduce the risk of stroke by about two thirds.
      • Hart R.G.
      • Pearce L.A.
      • Aguilar M.I.
      Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.
      Yet the successful use of warfarin demands that the patient have a steady lifestyle, an understanding of the need for frequent blood tests, and be reliable in the taking of medication. The elderly and frail older subject, who is most at risk of stroke, also is the least cognitively able to follow the demands of warfarin treatment and also is more prone to accidental falls with the attending risk of hemorrhage. Sometimes it is more dangerous to introduce warfarin to such a patient than to withhold it for safety reasons. Such a judgment—to treat or not to treat—is helped by clinical experience.
      Sometimes surgery is recommended for patients who are asymptomatic but at risk of developing serious manifestations of disease. A good example of such treatment is carotid endarterectomy for asymptomatic patients with >80% internal carotid artery narrowing. Randomized clinical trials have shown that, on average, carotid endarterectomy in asymptomatic patients results in fewer strokes over 5 years than does conservative care.
      • Rothwell P.M.
      • Mehta Z.
      • Howard S.C.
      • et al.
      Fro sub-groups to individuals: general principles and the example of carotid endarterectomy.
      The trouble with such surgery is that both the patient and the surgeon may be locked into a “lose-lose” scenario should the previously asymptomatic patient awake from the operation having had the stroke that the operation was designed to prevent.
      Procedural doctors offer patients with impaired quality of life procedures that might improve the quality of life if the procedure is successful. This is quadrant 4. In such cases, a bad outcome may not only involve the death of the patient, but might result in disability and worse quality of life than that which existed before the procedure. Treatments that make patients feel ill as well as that shorten their life are clearly bad treatments—quadrant 3.
      The common feature in treating patients whose conditions lie in quadrants 2 or 4 is that such patients and their doctors have choices. Not all patients are prepared to have treatment that might prolong their life if such treatment reduces their quality of life (quadrant 2). Conversely, patients may choose to take risks to improve their quality of life with interventions (quadrant 4). In these situations, individual patients negotiate their choices with their own medical practitioner. The patient's decision may well depend on the way the treatment choices are presented to the patient.
      • Devereaux P.J.
      • Anderson D.R.
      • Gardner M.J.
      • et al.
      Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study.
      In turn, this conversation between the physician and the patient is usually enhanced in the experienced physician.

      Conclusion

      Experience-based medicine has had bad press in recent years. In this article, I have tried to show that careful and knowledgeable review of the evidence tempered by experience may be more valid in a particular doctor's environment than that reported in the literature. Experience has shown that it is always possible to be optimistic in the management of prognostically significant disease, as good outcomes do occur sometimes, even if they are statistically unlikely. And experience helps in balancing questions of the quality of a patient's life with the best disease-based care when there is a potential conflict between these 2 parameters of management. But, ultimately, the purpose of this article is to rehabilitate experience as a basis of good clinical care. I hope that this stimulates others to develop the theme of good experience-based medicine.

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