You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


Are doctors over-servicing? Are millions of people worldwide receiving stents with no benefit? Are all patients providing their “informed consent” for surgery? “It’s a divisive area within the specialty because it threatens a lot of cardiologists’ incomes,” says one doctor. Coronary stents are a multi-billion-dollar market, a market which is rapidly expanding. Investigative reporter and medical science specialist, Maryanne Demasi, investigates.

Since their introduction in the mid 1980s, coronary stents have proven to be life saving in emergency situations such as in the event of a heart attack.

More recently however, stents are increasingly being used in non-emergency situations such as “angina”, where people experience chest pain or shortness of breath when climbing up stairs.

The procedure involves inserting the stent — a wire mesh scaffold — inside an artery, to widen up the space inside the vessel and restore blood flow (see picture).

The rationale for using stents in people with angina is that opening up a blocked artery (due to plaque accumulation) will alleviate chest pain.

But a new study has cast significant doubt on the value of using stents to treat angina, leading some doctors to believe that millions of people are receiving stents, with little benefit.

Are stents for angina unnecessary? I investigate the ongoing controversy where millions of dollars and reputations are at stake.

A costly business

The coronary stent market is expected to reach $US15.2 billion by 2024. In Australia, approximately 28,131 procedures involving stents were performed last financial year, up from 21,472 a decade earlier — a 31 per cent increase.

According to NSW Health, the average cost of an angiogram and insertion of a coronary stent is $16,900 so we now spend an additional $112 million a year on this procedure. Undoubtedly, stenting is big business.

Stenting makes sense – doesn’t it?

Intuitively, stenting a blocked artery makes sense. Here’s a common scenario:

A patient has chest pain. The doctor discovers a blocked artery during an angiogram. While the patient is awake on the table (but mildly sedated), the doctor shows the patient the blockage and decides to use a stent to open up the artery. The patient is hugely relieved because their blocked artery has been “fixed” and they thank the doctor for saving their life.

A US survey published in Annals of Internal Medicine showed that 88 per cent of people receiving a stent believed it would reduce their risk of a future heart attack or stroke.

But Dr Aseem Malhotra, a cardiologist who has performed hundreds of stent procedures and currently works as a consultant for the National Health Service (NHS) in London, says this is a common misunderstanding.

“Stenting a narrowed artery does not prevent heart attacks, strokes, nor does it prolong life in people with angina,” says Dr Malhotra. If they are told otherwise, it’s simply untrue for the vast majority of people”.

Dr Jason Kaplan, a Sydney based cardiologist from Macquarie University Hospital agrees. “The majority of patients who get a stent for stable angina think, ‘oh, I was lucky they found the blockage before anything [bad] happened’…. but it’s not always the case,” says Dr Kaplan.

In 2007, a seminal study published in the New England Journal of Medicine (COURAGE trial) showed that a stent in people with angina failed to reduce their risk of heart attack or stroke, nor did it prolong their life. The results rocked the cardiology community.

“We were shocked actually. We were surprised because we were stenting patients with the idea that it would reduce major cardiovascular events,” said interventional cardiologist Dr Rasha Al-Lamee, of the Imperial College Healthcare NHS Trust.

“Initially, we saw a drop in the number of procedures being performed but it eventually went back up again because our patients would tell us that they felt better after the procedure,” says Dr Al-Lamee.

What should have been a game-changing trial, was eventually abandoned by cardiologists who continued to put stents in people with the belief that, at least, it helped treat angina symptoms like chest pain. But, this had never been properly tested — until now.

A coalition of researchers at Imperial College in London, led by Dr Al-Lamee, conducted a unique clinical trial to find out.

“The study was the first of its kind where we wanted to see whether the relief of symptoms that our patients report was due to the therapeutic effect of the stent or whether it was due to placebo,” said lead researcher Dr Al-Lamee of Imperial College in London.

The ORBITA trial analysed two hundred people with angina who had an artery showing at least a 70 per cent blockage. Participants were given either a stent or a “sham” procedure (the equivalent of a surgical placebo) on top of their usual angina medications. To overcome any bias, neither the patients nor the researchers knew who was given a stent or placebo.

Six weeks later, the participants were put through their paces and assessed on a variety of measures including exercise and symptoms relief. The results of this landmark study reverberated across the cardiology community.

“Surprisingly for all of us, after 6 weeks there was no significant difference between the two groups when assessing capacity to exercise or symptoms of chest pain,” said Dr Al-Lamee.

Essentially, the coronary stent did not prove superior to placebo. “However, we did find the patients who had the stents showed improved ischemia. That is, the blood flow to the heart of these patients did improve,” said Dr Al-Lamee.

Dr Al-Lamee says it’s still not clear whether stenting a vessel and restoring blood flow has any significant benefit for the patient. A more definitive study, called ISCHEMIA, will be completed later this year.

How can unblocking an artery not make a difference?

“The narrowing happens so gradually that there is enough time for the heart to grow collateral blood vessels to compensate for the narrowed vessel,” says Dr Malhotra.

Another reason why stenting may not reduce the risk of a future heart attack is because stents are usually implanted in arteries where the narrowing is over 70 per cent.

However, most cardiac events occur at sites on the coronary artery where there is less than 70 per cent narrowing. So it is highly likely that doctors are stenting areas that would never have caused any harm.

ORBITA has cardiologists divided

Some cardiologists dismissed the trial saying it was too small to consider making any changes to current practice. Also, the follow up of six weeks wasn’t long enough to see any beneficial outcomes.

Others said that, in their experience, patients often want to have a stent, instead of taking angina medications for chest pain, which come with side effects like fatigue, dizziness and palpitations.

Conversely, other cardiologists have claimed the study is the ‘last nail in the coffin’ for using stents to relieve chest pain. “This is mind-blowing,” said cardiologist and Lown Institute president, Dr. Vikas Saini. “For cardiologists, this is like saying that penicillin doesn’t work for infections.”

Dr Al-Lamee believes the truth probably lies somewhere in the middle.

What are the risks?

According to TheNNT.com, one in 50 people who receive a stent for angina experience a serious complication such as death, stroke, heart attack, arrhythmia or haemorrhage. Hence, in the absence of benefit, the risks of receiving a stent for angina become paramount — especially if the procedure is unnecessary.

“I have no doubt that people have died during a stenting procedure, or have had a heart attack or stroke, who should probably never have undergone a procedure in the first place,” says Dr Malhotra — “or at the very least, have changed their decision to have the procedure done if they were told it wasn’t going to improve their prognosis”.

“Some patients prefer to have the stent put in, knowing about the risks because they don’t want to be on the anti-anginal medications for the rest of their lives and are willing to take the risk,” says Dr Al-Lamee.

Incentive to stent?

The Australian Medicare system is a government funded “fee-for-service” system. While it is highly regarded, this system is also vulnerable to “over-servicing” where doctors may provide unnecessary or inappropriate medical therapies.

A recent article in The Lancet said more needed to be done to address inappropriate medicine, which included deliberate over-servicing by doctors for their own financial gain.

Dr Malhotra is a member of the Academy of Medical Royal Colleges Choosing Wisely Steering Group campaigning to wind back the harms of unnecessary procedures and medicines.

“It’s a system failure that incentivises doctors to do more procedures, and their decision to stent a patient will be biased and unjust at times,” says Dr Malhotra.

A small US survey, published in the Annals of Internal Medicine claimed that 43 per cent of cardiologists would still implant a coronary stent, knowing that it had no benefit for the patient.

“I believe most doctors want to practice in an ethical way but I have no doubt that there is a small minority of cardiologists who are practicing unethical medicine,” says Dr Malhotra.

For example, a US cardiologist admitted to ordering US$19 million worth of unnecessary investigations and procedures, leaving many patients with false diagnoses of artery disease and angina. Unnecessary stenting for stable coronary artery disease has been estimated to cost the US healthcare system $US2.4 billion.

“Ultimately, I don’t think Australia’s fee-for-service model is in the patient’s best interest as it rewards doctors for doing procedures and interventions, where sometimes, not doing the procedure is the best thing for the patient,” says Dr Kaplan. “It’s a divisive area within the specialty because it threatens a lot of cardiologists’ income”.

Patient consent

This raises concerns about whether people are giving “informed consent” when accepting medical procedures. Transparent discussions about the risks and benefits of a procedure can change people’s decisions about whether or not to accept a medical therapy.

For example, one study published in JAMA Internal Medicine, showed that people were 20 per cent less likely to receive a stent when they were told explicitly that a stent would not reduce their risk of a heart attack. Hence, it was estimated that 20 per cent fewer stenting procedures in the US could represent a potential saving of $864 million in one year.

In 2014, Dr Malhotra was the first cardiologist to call for patient consent forms to have a mandatory disclosure stating that stents offer “no prognostic benefit in the treatment of stable angina”. At the time, Sir Prof Terence Stephenson, now Chairman of the UK’s General Medical Council, backed the calls.

“We need to empower patients with the principles of Choosing Wisely. That is, asking their doctor, ‘Do I really need this procedure? What are the risks? What happens if I do nothing? And are there alternatives? If every patient asked this question to their doctors before they had a procedure or medication, a significant proportion of our health care crisis would be solved,” says Dr Malhotra.

“We need bravery for frank conversations with patients about the uncertainty in medicine,” wrote a group of cardiologists in a recent paper. “We should not forget the old surgical adage; a good surgeon knows how to operate, a better one knows when to operate, and the best know when not to operate”.

——————-

The author, Dr Maryanne Demasi, is a PhD Rheumatology and has reported extensively on statins and diabetes and the sugar lobby.

Maryanne can be contacted on Twitter at @MaryanneDemasi

This story is not medical advice; it is a journalistic investigation.