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ACC Day 1: Dr Ralph Brindis and the doctrine of cardiovascular ecumenismApr 4, 2011 01:03 EDT
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.