 Did you ever wonder if the food you eat has a direct effect on your health, well-being, and longevity? Well, I'm here to end that mystery. You are the food you eat. Welcome to the Nutrition Facts Podcast. I'm your host, Dr. Michael Greger. Today, it's part three in our series on the coronary procedure known as stents. It probably comes as no surprise, but over and over, studies have shown that doctors tend to make different clinical decisions for patients based on how much they will get personally paid. In 2007, we learned from the courage trial that angioplasty and stents don't reduce the risk of death or heart attack, but patients didn't seem to get the memo. Only 1% realized that there was no mortality or heart attack benefit, perhaps because cardiologists failed to happen to mention this little fact. I mean, one can imagine that if patients actually understood all they were getting was symptomatic relief, then they'd be less likely to go under the knife. But then, 10 years later, the orbiter trial was published showing even the promise of symptom relief was an illusion. The implications are profound and far-reaching. First and foremost, the results showed unequivocally that there are no benefits to angioplasty and stents for stable heart disease. So, basically, patients would be risking harm for no benefit whatsoever. So, it's hard to imagine a scenario where a fully informed patient would choose an invasive procedure for nothing. So, is the orbiter trial the last nail in the coffin for stents in non-emergency situations? In that editorial, the Journal of Cardiovascular Revascularization Medicine disagreed, pointing to the broad angina relief that occurred in both arms. In other words, stents helped, even if the fake operation without stents helped just as much. So, hey, if I give a patient a stent and they are benefiting from the placebo effect, well, who am I to interfere with that benefit of this quote-unquote therapy? Well, why not do fake surgeries? I mean, stent placement can go for like $40,000. It'd be cheaper to just fake the whole thing. But the reason we shouldn't keep electively stenting people is because there's a body count. During stent placement, 2% of patients develop bleeding or blood vessel damage, and another 1% die or have a heart attack or a stroke. And then, because you're having something stuck in your chest, 3% of patients have a bleeding event from the blood thinners you have to be on where the blood thinners don't work and the stent clots off and causes a heart attack. Why are they still done? Well, we don't just have no evidence of benefit, but in many cases explicit evidence of no benefit. One of the sources of resistance may be all the financial gain. These procedures make a lot of money for hospitals. Don't expect them to be promoting a lifestyle changes anytime soon. Nor will physicians quickly abandon the practice. That seems to make sense and supports their income. Is it that simple? I mean, is it that famous Upton Sinclair quote on how difficult it is to get a man to understand something when his salary depends on his not understanding it? Think that's just cynicism? Let's ask doctors themselves. Thousands of physicians were surveyed, and 70% believe that physicians provide unnecessary procedures when they profit from them. That's what doctors themselves believe, and the data bears this up. Doctors have been shown to make different clinical decisions for patients based on how much they get paid. For example, when choosing which chemotherapy to treat breast cancer, increasing a physician's margin by 10% can yield up to a 177% increase in the likelihood of choosing one drug over another. That may be why cesarean sections are more likely to be performed in for-profit hospitals compared to non-profit hospitals. Operating on commission. Pay surgeons per procedure, and you can increase surgery rates 78%. Could that explain why we do 101% more angioplasties than any other rich countries? A study on physician financial incentives and treatment choices and heart attack management found that they do indeed respond to payments, and the response is quite large. Unconditionally, plans that pay physicians more for more invasive treatments seem to result in more invasive treatments. So it may actually be quite common for patients to receive different treatments based on whether the doctor is getting paid per procedure. One of my heroes, Dr. Akalbaal Asselstyn, who always tries to see the best in people, even he had to break down and admit that compensation may be playing a role after evidence surfaced that docs are running up millions doing unnecessary stent implants. Docs like Mark Middieye, who inserted 30 in a single day. That could be like a million dollars worth of billing. As a token of their gratitude, a sales rep from the stent company spent $2,000 to buy him a whole slow-smoked pig, peach cobbler, and all the fixes were the only developed country where healthcare is delivered like this. It explained that chief of cardiovascular medicine at the Cleveland Clinic, the economic incentives are just too strong. Finally, we look at how cardiologists can criminally game the system by telling a patient they have a much more serious, unstable disease than they really have. Fraud that results in unnecessary procedures, unnecessary costs, and unnecessary patient harm. The history of medicine abounds with false dogmas that were simply assumed, and later, sometimes much too long later, overcome. Like the Women's Health Initiative study, the show that giving women premarin hormone replacement therapy increased the risk of the number one killer of women heart disease, as well as breast cancer risk to boot. Millions of women stopped taking it, and the breast cancer rates came down. Another such reversal of established medical practice is angioplasty and stents for stable coronary artery disease, for which billions are spent on procedures shown unequivocally to offer no benefits. So why are cardiologists still doing them? Researchers did some focus groups and concluded that, although cardiologists may believe that they're benefiting their patients, this belief appears to be based on emotional and psychological factors, rather than on evidence. The sense of irrationality surrounding this practice is so strong that the phenomenon has been coined the oculostinotic reflex, like you see are narrowing and they stent it like they can't even help it. Since the procedure carries some risk, including death, there's an argument that stents should only be used for people who are actively having heart attacks in an emergency or unstable situation. Thankfully, there are now published appropriate use criteria in place to help guide cardiologists, and the good news is that now 82% of stents are reported to be performed in these emergency or unstable situations, so we can disregard that study that showed there's no benefit in stable patients, since now it's almost always done, just in unstable patients like it should be, or at least it's almost always reported that way. There are two ways a physician could comply with the rules. One is to do fewer unnecessary procedures, which is the whole point, but hey, where's the money in that? The other way to comply is to make unnecessary procedures seem necessary. Wait, are they implying that a doctor would try to game the system by telling a patient that they had much more serious unstable disease than they actually had, so they could carry out the procedure anyway? This is referred to up-coding. Another word for it would be fraud. Researchers found that some of that decline in inappropriate use may indeed be doctors falsely and intentionally misclassifying patients with stable angina as unstable angina, because as soon as those appropriate use criteria went into effect, all of a sudden there was suspiciously a 4-10-fold increase in the rates of stents for acute coronary syndromes like heart attacks. In New York, the proportion of stents labeled as acute, but performed as outpatient procedures increased 14-fold. There's no biologically plausible reason why that would happen, so they were unnecessary procedures, unnecessary cost, and unnecessary patient harm. Harm not only from the risk of getting an unnecessary stent, but also by lying to the patient by exaggerating how bad their heart disease is. At best, this practice damages the credibility of the profession, violates patient autonomy, and puts the patient at risk for complications, and at worst may cross the threshold into criminal activity. What's the solution? There could be like an independent review panel to protect patients, or we could simply remove the financial incentive to perform more procedures. How many other established standards of medical care are wrong? Who knows? Bloodletting with standard of care for thousands of years. Rigorous questioning of long-established practices is difficult. I mean, there are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products. Given this conundrum, it's possible that some entire medical subspecialties are based on little evidence. Ironically, in the case of heart stents, in the landmark courage trial that showed stents were useless for extending life, what did seem to determine longevity was how many risk factors they were able to control. Those that nailed all six by lowering their blood pressure, cholesterol, weight smoking, and improving their diets in activity had five times the survival of the subsequent 14 years than those who didn't. I mean, should we be surprised that angioplasty and stents failed to improve prognosis? I mean, after all, it does nothing to modify the underlying disease process itself. In other words, it doesn't treat the cause. Even if stents helped with symptoms beyond the placebo effect, it would still just be treating the symptoms and not the disease. And so, no wonder the disease continues to progress until the patient is disabled into death. Thus, Dr. Osselstyn wrote, The leading killer of men and women in Western civilization is being left untreated. What is instead being practiced is palliative cardiology, non-treatment of heart disease, leading to disease extension and frequently and eventually fatal outcome. Deaths by the plane load every week just regarded as unfortunate rather than a national preventable tragedy. It's as though in ignoring this dairy oil and animal product-based illness, we are wedded to provide futile attempts at temporary symptomatic relief rather than the cure. Thankfully, we are on the cusp of a seismic revolution in health, not another pill, a procedure, or operation, but instead treating the underlying cause of heart disease with whole food, plant-based nutrition. Perhaps the mightiest tool medicine has ever had in its toolbox. To get there, we need to fight a key nutrition deficiency in education. 90% of cardiologists, 90% reported receiving no or minimal nutrition education during their cardiology training, leaving fewer than one in 10 confident in their nutrition knowledge. So maybe it's a good thing that most spend three minutes or less discussing nutrition with their patients. Only one in five themselves even ate five servings of fruits and veggies a day. Thankfully, this life-saving information is slowly but surely getting out there. Medical education is focused on being the ambulance at the bottom of the cliff rather than a fence at the top. Money talks, very little money, promoting eating broccoli and going for a walk. It was so eager to see the citation they used for that and was so honored when I did. We would love it if you could share with us your stories about reinventing your health through evidence-based nutrition. Go to nutritionfacts.org slash testimonials. We may share it on our social media to help inspire others. To see any graphs, charts, graphics, images, studies mentioned here, please go to the Nutrition Facts podcast landing page. There you'll find all the detailed information you need plus links to all the sources we cite for each of these topics. For a vital, timely text and the pathogens that cause pandemics, you can order the e-book, audio book, or the hard copy of my second to latest book, How to Survive a Pandemic. For recipes, check out my latest, the How Not to Diet Cookbook. It's beautifully designed with more than 100 recipes for delicious and nutritious meals. And of course all proceeds I receive from the sales of my books go to charity. Nutritionfacts.org is a non-profit science-based public service where you can sign up for free daily updates and latest in nutrition research via bite-sized videos and articles. Everything on the website is free. There's no ads, no corporate sponsorship. It's strictly non-commercial. I'm not selling anything. I just put it up as a public service, as a labor of love, as a tribute to my grandmother whose own life was saved with evidence-based nutrition.