ACC Day 1: Dr Ralph Brindis and the doctrine of cardiovascular ecumenism

Dr Ralph Brindis (University of California, San Francisco), president of the ACC, began this morning's plenary session with the sermon of the century for cardiovascular healthcare providers. "If you don't measure it, you can't manage it," he said. The opening speech was suffused with the essential elements of motivation, chastisement, and transformational power. Like any good sermon, the plan of salvation was laid bare. Redemption for our profession must come through cost containment, public reporting, and examination of the evidence basis for every single procedure and imaging study we perform.

I agree with Dr Brindis, but I have parallel allegiances. I fear I will have difficulty serving my new American healthcare system and my patient simultaneously. I admit that I've enjoyed my 20 years as an invasive cardiologist who arose daily and looked forward to whatever hand the emergency room or the office dealt me. I looked at each patient as an individual, not as part of a system. I fought for the best medical care I could provide and went home satisfied for the most part. I practiced based on "evidence" mixed with a moderate dose of common sense and a splash of anecdote. If we admit it, it's what most of us do, but maybe it's this line of thinking that is breaking the bank in America. Maybe there needs to be less of "me" in the formula of the care I provide. I'm just not certain how I can manage that at this stage of the game.

Like a good audience member, I hung on every word and indulged in self- reflection at every point. Have I ever performed unnecessary procedures on anyone? What about that 32-year-old female that would not stop coming to the ER a few years ago with chest pain, despite a normal stress exam, negative biomarkers, and a normal resting ECG? She called my office saying, "Everyone in my family dies with heart disease. I think I'm going to die, and no one is taking me seriously." What on earth is a cardiologist to do with that statement? I literally dragged my feet on the way to the cath lab with my shoulders down because I knew it would be normal. However, as soon as I produced images of her beautiful, "slick-clean" coronaries to display on her refrigerator, she stopped coming to the ER and to the office. She went on her merry way with a new lease on life. So was that really an "unnecessary procedure"? Will that type of thinking count against me in the future? My partner Dr Jim Whiteside says a "normal cath" is not necessarily a bad thing. "You've just done them a favor," he would say. Is this a "favor" that only today's private practitioner does without consequence? I got away with it because I reported nothing to anyone.

Dr Brindis then gave the example of an AMI patient who was defibrillated 21 times on arrival to the ER with an acute injury pattern anteriorly. She was transferred to a tertiary center, where the receiving interventionalist had to make a decision to take this 50-something-year-old patient to the cath lab with what appeared to be a wrecked ventricle, "fixed and dilated pupils," and little hope for a meaningful recovery. After several "what ifs," which included, "What if your hospital is being reviewed for procedural appropriateness? What if you are under the microscope for procedure selection?" And the greater question: "What if I save her ventricle but she spends the rest of her days on a ventilator, slowly decaying in a nursing home?" Long story short, her LAD was PCIed with total recovery and she is now living a full life with no neurological deficit. Was that procedure inappropriate? Should we have let her die because she was a long shot or because the majority of patients like her wind up as another driver of the unnecessary cost of healthcare?

Dr Brindis quoted Dr Mehmet Oz, who made the statement that 50% of all angioplasty procedures are unnecessary. Dr Brindis stated that a review of the NCDR data revealed this number is really only around 8%. No matter, the review confirmed a substantial variability in hospital and operator practice. Dr Oz should have better qualified his statement, as nearly 100% of all PCI procedures in STEMI patients are absolutely necessary to save lives and myocardium. Elective cases, however, are more life-changing than life-saving; still, is it an "unnecessary procedure" if all we did was make someone's life less miserable? Decrease the number of medications required? Help someone walk to the mailbox without taking a nitro?

Finally, Dr Brindis, with ardent fervor, said, "We cannot continue to stubbornly stonewall the measuring of outcomes and cost-effectiveness. We cannot afford to abdicate our responsibilities. If we are not on the menu, we will be on the table," he advised. I actually enjoyed participating in NRMI and CRUSADE and knowing our cath lab data is reported to the ACC, but all of that was voluntary. I have enjoyed the practice of cardiology enormously, but I don't want to have to worry about the number of caths or stresses I perform. I don't want someone knocking on my door and telling me my "normal" cath rate is too low or too high or that my nuclear stress exam doesn't or does correlate with my cath data. I just want to keep on doing what seems to work for my patients and for me, but it appears Dr Brindis is correct. My head knows it is time for a change, my heart stubbornly clings to the status quo, but I fear we can't afford doctors like the "old" me anymore. I either have to change or get out. I need to drink the Kool-Aid of the ecumenical movement of healthcare reform. I just hope the patient will benefit from my conformation. Anything less is truly blasphemy against the honorable profession of cardiology.

Your comments

	ACC Day 1: Dr Ralph Brindis and the doctrine of cardiovascular ecumenism
	# 1 of 4	April 4, 2011 10:43 (EDT)
	Edward M. Fleegler, MD, FACP	I am taken with the sincerity of Dr. Walton-Shirley's personal statement(s). I was not at Dr. Brindis' "sermon" or "labelled speech," but I could hear his message clearly.  I am not a specialist.  I am engaged in facilitating more efficient health care delivery for the vulnerable elderly.  I have carefully been following the discussion regarding ACA (officially Patient Protection and Affordable Care Act).  It is a true statement that the healthcare paradigm is in the process of change.  I favor the words communication, cooperation and coordination of care as a personal perspective regarding the important role of physicians in advocating for the continued importance of professional service/care in the patient-physician relationship. The concept of patient-centric care stated by NQF (National Quality Forum) are echoed in the goals of IHI Triple AIM--quality, cost and patient experience.  These concepts are central to all healthcare  blogs and physician dialogue. I am sure that Dr. Watson-Shirley is an excellent physician, clinician and human being.  I read Dr. Brindis' comments and interpreted them in the light of the words of a former colleague of mine, Risa Lavizzo-Mourey, who is CEO of the RWJF.  Risa quoted an old Nigerian proverb in her annual statement several years ago: "In a time of crisis, wise men build bridges and fools build dams."  No one said that change is going to be easy.  Physicians will be able to provide thoughtful care in the interest of individual patients as the payment system reforms as long as they remain engaged in the transformation.  The important decision for Dr. Watson-Shirley will be to engage with her health care system in advocating for her patients as the paradigm shift occurs.  Her comments are those of a professional with that professional lens.
	# 2 of 4	April 5, 2011 06:54 (EDT)
	G. Proença MD	Despite of all the science and evidence based arguments , intervention cardiologists still continue to act and decide not infrequently based on personal beliefs. Making them think in terms of cost-effectiveness is and will be a challenge in many cases. The same applies to non interventional cardiologists regarding echo and stress/functional tests and to doctors in general. When a 32 year-old patient with  very low probability of CAD trusts an angiogram but not the attending doctors something is very wrong with the patient-doctor relationship. And that relation is basilar in medicine and, by any means, can or should be replaced by expensive exams.
	# 3 of 4	April 8, 2011 07:15 (EDT)
	Eric Tiblier	Dear Melissa,   The problem with today's healthcare system is not from quality cardiologists like yourself who have the uncommon capacity for introspection and reflection.  I would bet that the vast majority of your procedures fall under the AUC, Appropriate Use Criteria, for all the tests that you order and perform. (leaving plenty of room for anecdotes and common sense).  The real cancer in our profession is in self-absorbed physicians who place blatant monetary gains over the needs of the patient; those doctors have never even heard of AUC, much less applied them in practice.  The ACC needs to do a better job of rooting them out.   If Dr. Fleegler thinks that ALL doctors should quit thinking and just join up with all the other doctors who are being hired by hospitals (because everyone else is doing it), I caution him to look before jumping on with a herd of physicians heading toward a cliff.   Dr. Fleegler's utopian vision needs to be interrupted with current reality.  Costs have actually INCREASED in our community as the "wise men", cardiologists who built bridges to the hospital, have became hospital employees.  I saw a patient today, because her hospital hired & owned cardiologist ordered an echocardiogram which would have cost her $1,500 at the local religious not-for-profit hospital "Heart Institute".  However, she found out through her insurance that her echo in my office would be $75 copayment (my contracted reimbursement for the echo is a tiny fraction of the $1,500).  The people at IHI really need to do their homework before making blanket claims, because it is a fact, according to the ACC,  that cardiology spending INCREASED in 2010 from cost shifting to the hospitals derived from physician employment.  If cost containment is really a goal of the IHI, then they need to stop advocating for vertical healthcare for the masses, because the super-rich can buy ANYTHING they want and costs are going up for everyone else.   Furthermore, the healthcare debate is lacking because so  many people in society have lost the art of critical analysis.  Too many people make assumptions, like giant health care must be good because someone at RWJF or at Harvard said so.  God gave us free will. We need to use our cerebral cortex and question everything.   EST, FACC, MD.
	# 4 of 4	April 11, 2011 09:28 (EDT)
	Melissa	Eric, Your note was extremely enlightening. I agree with "looking before you leap". I learned this weekend that an acquaintaince of mine who was "bought" by his hospital some time ago had just started getting into a comfortable rhythm it seemed only to be told that he will now be handed off to another "for profit" entity. With any change in your salary provider will come a change in the rules of the game.  Furthermore, the entourage he's been handed to help him with his day's work will impact his salary so he's now forced to consider letting some of them go.  Despite an entire army's worth of physicians and extenders, disorganization continues to foil even the easiest of schedules for them, so it's not what it was cracked up to be it seems and the in-fighting has begun. He would have been far better off to have stayed where he was to begin with but the grass always looks greener.  Thanks for your comments. Have a great practice week! Melissa

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