It is 4:50 p.m. on a Thursday. Your last patient is a 67-year-old with heart failure with reduced ejection fraction. He has been hospitalized twice this year. His medications look familiar. A beta-blocker. An ACE inhibitor. A loop diuretic. But something is missing. You scroll through the chart. No mineralocorticoid receptor antagonist. No SGLT2 inhibitor. No ARNI. You pause. You know the guidelines. You have heard the talks. You have seen the data. And yet, this is not unusual.

The uncomfortable truth about heart failure care

We now have four foundational drug classes that reduce mortality in heart failure:

• Beta-blockers
• Renin-angiotensin system inhibition or ARNI
• Mineralocorticoid receptor antagonists
• SGLT2 inhibitors

When used together, these therapies substantially reduce death and hospitalization. Most patients are eligible. Studies suggest that nearly three quarters of patients hospitalized with heart failure could receive all four classes. But in real-world practice, far fewer actually do. A contemporary registry found that only about 44 percent of patients were on all four classes, and roughly 1 percent reached target doses. Other cohorts show that many patients remain on only one or two agents despite clear evidence supporting combination therapy. We are not talking about rare edge cases. We are talking about routine care.

This is not a knowledge problem

It is tempting to assume this gap reflects a lack of awareness. But most clinicians managing heart failure know the guidelines. They recognize the drug classes. They understand the benefits. The issue is more practical than that. It is the difference between recognizing information and being able to consistently apply it in a busy clinic, at the end of a long day, across dozens of competing demands.

The illusion of learning

Much of continuing medical education is built on exposure. We attend conferences. We listen to lectures. We review slides. And then we move on. But cognitive science has shown for over a century that we forget most newly learned information within days to weeks if it is not revisited. One of the most studied ways to counter this is spaced repetition. At its core, spaced repetition is simple. Instead of reviewing information once, you revisit it multiple times over increasing intervals. For example, a key concept might be reviewed a few days after initial exposure, then again a couple of weeks later, then one month later. Each time you recall the information, the memory trace strengthens. Equally important is the act of retrieval. Actively trying to recall a concept, rather than passively rereading it, makes it more likely to stick and more likely to be usable later. Over time, what was once effortful becomes automatic. That is the difference between knowing something in theory and being able to use it in practice.

Why heart failure exposes this gap

Heart failure management is not a single decision. It requires:

• Recognizing eligibility for each medication class
• Initiating therapy in the right sequence
• Titrating doses over time
• Revisiting decisions at follow-up visits

This is cognitively demanding. In a compressed visit, clinicians rely on what comes to mind quickly. If the full framework is not readily accessible, care often defaults to partial therapy. Not because we do not know better, but because the knowledge is not reinforced enough to be easily retrieved.

The cost of partial treatment

The difference between partial and complete therapy is not subtle. Patients receiving more complete guideline-directed therapy have significantly lower rates of death and hospitalization compared to those on fewer medications. Every missed medication is a missed opportunity to improve outcomes. Across a population, those missed opportunities add up.

Rethinking how we educate physicians

If we want to close the gap in heart failure care, we need to rethink how education is delivered. Not just what we teach, but how we reinforce it. Imagine a model where key treatment frameworks are revisited over months, not just introduced once. Where medication sequencing is reinforced repeatedly. Where simple algorithms are encountered often enough that they become second nature. In that kind of system, recalling the four pillars of therapy would not require effort. It would be automatic. And when recall becomes automatic, implementation follows.

Back to the patient in front of you

It is now 5:00 p.m. Your last patient is still waiting. You open the medication list again. This time, you add an SGLT2 inhibitor. You plan a transition to ARNI. You arrange follow-up to titrate therapy further. Small decisions. But they matter. Because in heart failure, we already have treatments that change outcomes. The challenge is not discovering what works. It is making sure our patients actually receive it.

Vimal George is a family physician.