 Hi, I'm Dr. Joe Rogers, president and CEO of the Texas Heart Institute, and I'm joined today by Dr. John Mandrola, who's just given a great grand rounds at the Texas Heart Institute. Dr. Mandrola is an electrophysiologist who, in addition to having a profound and prolific investigative career, also has an interesting social media presence, where I think that you've done something really interesting and special in medicine, and you've taken a really thoughtful approach and pushed us to look at data in a very critical way. I think you were described as a nihilist earlier today, and I think, and I appreciate you taking that approach and forcing us to think critically about the kind of information that we're looking at as we review clinical trials and make clinical decisions. Thank you for having me, and it's a real honor to be here at Texas Heart. Yes, I practiced for 10 years without really thinking too much about it, and then I started looking at things. And I wouldn't say that I'm nihilist because I practice and I think we help people. I just have been interested in taking a more skeptical, but not cynical, view of everything that we do. Yeah, I think one of the things that came up in the Q&A session today at the end of grand rounds, which really resonated with me, was this idea that no clinical trial is perfect. And I think that you even highlighted this, but Dr. Rosick's question about when you're looking at some of this data and there's crossover, for example, trying to integrate that into your interpretation, the accurate interpretation of a clinical trial can be really challenging. But it really resonated with me that it's impossible to do a perfect clinical trial. And so reading the literature critically is so important to come to the correct conclusion. The other challenge, of course, we have is that oftentimes, as you highlighted in those clinical trials, we spend years and years and millions of dollars trying to answer a clinical question. And then you end up with a data set and you go, this is imperfect. So how do you resolve that as you look at data? Number one, I think that evidence is what separates us from palm readers, right? We need evidence, but evidence in trials is really kind of a best case scenario because we find an average effect in a population, in an environment that's special. And then what we have to do is take that average effect and take it to the bedside. And this is why doctors are important because otherwise a robot could do it, right? You have to be able to take the data that's generated in a really special environment, gives us an average effect and apply it to our patients. And this is the art of medicine. I guess I would say that no trial is perfect, but some of the critics of trials will say, we don't need this because our patients are different. And I guess my answer to that would be that if you think your patient is different and the trial doesn't apply, then you kind of have to do another trial. And you kind of have to show that your idea that may be opposite of the trial really works. I would argue that, in fact, cardiology has been as good as any specialty in all of medicine at generating evidence to guide our clinical decision making and our thinking. I think the other thing that I found fascinating about your talk today and was the discussion about whether or not defibrillators were beneficial in patients with non-eschemic cardiomyopathy. And you kind of walked us through the evidence that went back decades, you know, where the evidence in that subpopulation, which was maybe not even the primary population of the clinical trial, suggested that there may not be benefit all the way up to the Danish study. And the other thing that struck me was how much background therapy has changed in that time. You almost have to keep asking the same question because the patient population and the therapies that we use today are so very different. You could make the same argument about the ischemia trials in PCI, right? That the background therapy is so good now and it's changed and evolved and we know how to use it more effectively that maybe there's less benefit from percutaneous revascularization. Absolutely agree. Number one, cardiology has been exemplary. We have done so many trials and we have so much evidence. But yet I think I can cite a study that shows that only 25% of our Class 1 recommendations come from trials. So we still there's still a lot of evidence to be had. But that said, I think the hurdle that cardiology faces going forward is that we have made such good progress and that the reason why the reason why defibrillators are not shown to be beneficial and non-eschemics is because background therapy is so good. We fight against our own progress. That incremental progress is really hard. Yeah. Again, I just wanted to thank you very much for taking the time to come up. It was a wonderful grand round. So I think you made all of us think a little bit differently and we'll think a little bit harder about the evidence. I think you also stimulated us to be really mindful about going backwards and looking at the cumulative body of knowledge that has developed around a particular question. So again, thank you. We really enjoyed having you. Thanks for having me. We appreciate it.