Demystifying Medicine One Month at a Time

President 43: Paragon or Patsy?

In case you missed it, former President George W. Bush had a stent placed in one of the arteries that feeds his heart.

The 67 year-old came through the procedure with flying colors, we are told. Stents are tiny metal mesh tubes that get inserted into clogged arteries, essentially to prop them open.PresidentialSeal

Bush, heretofore thought to be in excellent shape, seems an unlikely candidate for the procedure. We hear tale of him riding his bike, running, controlling his weight, avoiding tobacco and alcohol, and having a low cholesterol. His stress level is remarkably lower than just a few years ago. In terms of heredity, his longevity seems assured: his parents are both alive and near 90.

If he were my patient, I would not have ordered a “stress test”; the “pre-test probability” of finding coronary disease was extremely low. It’s not just because I’m a minimalist. I would be following the best available scientific evidence on the issue.

Of course, in the real world we don’t all follow the wisdom of the sages. He is a former President, after all. If I were his doctor, I’d work toward immortality for him, too.

Here’s the thing: stents don’t help us live longer. They are merely a form of symptom control for angina–that weird word that means chest pain caused by narrowing of the coronary arteries. And Mr. Bush had no symptoms! One non-indicated test (the stress test) begat another (a CT scan of his heart arteries)…and so on through to a risky and costly procedure of dubious value in his case.

Stents cost more than the alternative. They’re no better in terms of outcome than medical management, our term for using effective pills that provide the same amount of disease-specific longevity. Most importantly, having a stent placed involves real risk: (low, very fast voice) bleeding, kidney failure, infection, abnormal heart rhythm, tearing the blood vessel.

Daily pills, you say? Yuck. But having a stent placed also requires at least one additional daily pill. So no real trade off there.

Luckily for Mr. Bush, we live in a place where free enterprise is a core value. Yes, even in health care. Especially in health care, where there’s inherent information asymmetry between buyers and sellers. We doctors are free to peddle our wares; is it surprising that paying customers sometimes get a touch more than they need? “Just to be on the safe side,” we rationalize. Yet in medicine, doing more than necessary is the opposite of safe.

It’s human nature to want to do more. Fighting human nature is an uphill battle.


  1. Dr Jones

    Amazingly clear eyed exposure of why and when we use too much medical care, using a powerful example. If it happened to former president Bush, it could happen to you!

  2. bill ruddy

    Thanks John, I forwarded a copy to my brother Shaun. You don’t mind taking on the big guys.

  3. Mavis Miller

    My mantra “Just because you can doesn’t mean you should.”

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