It all started when cardiologist Dr. William Dillon of Louisville, Kentucky made this observation on his Twitter page about doing cardiac catheterization procedures:
As a two-time veteran of transradial (wrist) caths*, I felt just a wee bit alarmed by the last line of his tweet. We heart patients tend to get a wee bit alarmed by implications that those we trust may “never be good” at what they’ve just done to us, as described by the very people who work alongside them – those known as interventional cardiologists.
I felt similarly alarmed, by the way, during the recent FDA recall of defective Riata cardiac defibrillator leads when Dr. Laurence Epstein of Harvard’s Brigham and Women’s Hospital told Heartwire interviewers that ICD leads are sometimes “implanted poorly”, bluntly adding:
“You can’t account for knuckleheads putting them in. Some lead failures are going to be expected . . . Others fail because people put them in in horrible ways.”
I don’t know about you, heart sisters, but personally, I hate to hear any cardiologists described by their peers as “knuckleheads” who perform our delicate surgical procedures in “horrible ways”.
It makes basic sense to assume that the more skilled your cardiologist is, the better the procedure outcome for patients, and vice versa.
Dr. Sanjit Jolly, the lead author of the RIVAL study comparing two types of cardiac catheterization access (wrist or groin)**, had this observation about doctors doing radial caths:
“Experience and expertise do matter, and the more procedures you do, the better you get.”
This caution is especially useful to keep in mind in light of Dr. Dillon’s recent contrary opinion of his fellow radial-challenged interventionalists who “will never be good at it, no matter how hard they try.”
How could I – or any other patient – possibly know the difference between a “good” and a “will never be good” interventional cardiologist?
So I pose this question to Dr. Dillon:
And very promptly, Dr. Dillon tweets back to me:
I have to actually sit on this tweet overnight because I frankly have no clue how to respond.
First, I don’t personally know the nurses working in my heart hospital’s cath lab. (Do any of you?) And secondly, I wonder why a doctor would be suggesting that patients ask nurses for help in weeding out the “will never be good” cardiologists in a hospital’s cath lab. Isn’t that the job of the head of cardiology? And I also wonder why hospitals would keep these “will never be good” cardiologists on staff – doing procedures on unsuspecting patients who think they’re being treated by good doctors.
So next day, I respond:
Dr. Dillon answers in this way:
So now this conversation is getting more confusing by the minute.
I can understand, of course, that patients have to “take what you get” when you’re in the middle of a heart attack, which is precisely what happened to me. (Luckily, when I was in the E.R., I was immediately sent upstairs to an interventionalist who happens to be a respected pioneer in transradial catheterizations).
But according to Dr. D, it is now apparently the patient’s responsibility to interview paramedics and first-responders while en route to the E.R. when you think you’re having a heart attack – asking about which docs at which hospitals are better at doing radial caths.
And while I can fully accept that nurses are likely able to accurately assess the competence of cardiologists they are assisting in the cath lab (and, for that matter, the competence of virtually any doc in any hospital, based on the calibre of nurses I have worked with), how realistic is it to expect busy nurses to share their personal opinions with perfect strangers seeking references on the phone, given professional liability and privacy considerations? I wonder if Dr. Dillon actually believes that nurses are going to openly blackball those docs who “will never be good”?
More to the point, what kind of hospital turns a blind eye to cardiologists on staff who are performing procedures that even their colleagues opine “will never be good”?
So my next questions to Dr. Dillon are:
But so far, I have heard nothing back from Dr. Dillon in reaction to these last two questions. Perhaps our conversation on Twitter is over.
I can’t say I’m surprised. It’s very challenging in Twitter’s 140-character limitations to fully explain that original bombshell tweet of his. And perhaps he may feel reluctant to continue down what looks like an increasingly loaded road. Perhaps he assumed that this pesky patient at Heart Sisters would just accept his Twitter explanations and go away. Perhaps he felt surprised that I haven’t yet.
That’s the funny thing about heart patients, though.
We tend to pay very close attention when doctors speak, particularly when they’re speaking about procedures that we ourselves have gone through.
We want – and need – to believe that our doctors are good and skilled and trustworthy people, that they are not treating us as if we’re witless guinea pigs, and (unlike Dr. Dillon’s offhand prediction) that their procedural skills will indeed improve with lots of practice.
You see, it’s hard enough to be a patient living with a heart disease diagnosis. It’s even harder when we read cardiologists trashing their own peers with terms like “knuckleheads” or “horrible” – or Dr. D’s own “will never be good”.
It’s hard because these may well be the physicians who are caring for us – and that’s a disturbing prospect for all patients.
It’s also hard because such dismissiveness indicates how little some doctors truly get what it’s like to be that vulnerable, overwhelmed and frightened heart patient lying there on the hospital gurney. Like many health care professionals do, it’s too easy to mistakenly forget that even though a procedure is absolutely routine to you, it can still feel absolutely traumatic to your patient.
It turns out that doctors are not known to be particularly forthcoming in publicly reporting the unacceptably poor performance of their professional colleagues. For example, the alarming results of a study published in the Journal of the American Medical Association two years ago revealed that, although most physicians claim that their medical colleagues who are “significantly impaired or incompetent to practice medicine” should be reported, the reality is that a disturbing number actually chose instead to sit by and do nothing - even when the physicians admitted they had “direct personal knowledge” of such impairment or incompetence.
And by “reporting”, we don’t mean making cryptic comments on Twitter. We mean directly telling somebody who has the ability to protect patients from poor quality care.
For all doctors writing on blogs, Facebook, Twitter or any other type of social media, please keep in mind that if you write something, anything, that might be construed as being remotely controversial (like criticizing the competence of your colleagues, for example), be prepared to hear from your readers about it.
And even if you don’t hear from us, know that we will be talking about you and your own reputation.
It is, of course, entirely possible that I could be misinterpreting Dr. Dillon’s original tweet. Maybe he was talking about golf, and golf alone? Maybe he was just describing his own lack of ability to perform high-quality radial caths, one of those poor unfortunates he describes who – like so many golfers – “will never be good at it no matter how much they try”? But because a number of his earlier enthusiastic tweets told of very positive outcomes in the cath lab, I don’t think so.
(In case this actually was a thinly veiled criticism of your lesser colleagues, Dr. Dillon, please try not to do this on social media any more. It just comes across as unprofessional and arrogant).
And speaking of unprofessional, with all due respect, it’s prudent to be very careful when playing fast and loose with Twitter posts in which specific patients are mentioned. For example, on October 23rd, Dr. D. posted a tweet in which he describes one of his patients by height, weight, number of daily pills prescribed, prior cardiac and aortic stents, noted that the patient’s weight was up by 10 lbs and, finally, his prognosis:
“This is not going to end well.”
It’s important to ask yourself before posting something like this how the patient being described here – or their family members – might react to having this grimly insensitive post publicly aired for all the Twitterverse to read. Even without a name, this patient is readily identifiable to others including friends, family members, colleagues, neighbours or hospital staff based simply on personal descriptors and the posting date.
Warning: any inappropriate post like this could and should send up serious protection-of-privacy caution flags. If you have an entry like this lurking on any of your social media accounts, go back and delete it now.
Need convincing? Just ask 48-year old E.R. physician Dr. Alexandra Thran, who learned the hard way that she really shouldn’t be chatting about patients on her Facebook page. She was fired from her Rhode Island hospital last year, and subsequently reprimanded by her state medical board because she had posted personal information online about a trauma patient. Although her Facebook post did not include the patient’s name, the board found that she had violated the patient’s privacy rights by writing enough that others in the community could easily identify the person.
And here’s yet another reminder to all docs playing online, in the wise words of Dr. Farris Timimi of Mayo Clinic’s Center for Social Media, whose brilliant 12-word social media guide for health care professionals is simply:
“Don’t Lie. Don’t Pry. Don’t Cheat. Can’t Delete. Don’t Steal. Don’t Reveal.”
- What doctors should do – but don’t – when their colleagues are “significantly impaired or incompetent to practice medicine”
- Doctors behaving badly online
- Why some people should avoid social media completely
* If you undergo angiography, the interventional cardiologist performing the procedure will have to choose which part of your body will be cut into in order to insert the catheter that will be threaded up through an artery en route to your heart. One body part option is the groin (through the femoral artery in the leg) and the other is the wrist (through the radial artery in the arm).
Femoral access has been around far longer and (especially in the U.S.) is far more commonly used – despite a number of good studies showing radial access is associated with fewer complications, less bleeding, shorter hospital stays and far greater patient satisfaction. I’ve made two separate trips to the cardiac catheterization lab since my heart attack, and both were for radial caths – which is the default access here in my local heart hospital (as it is in many parts of Canada, France, Italy, Spain, Japan, India and several other countries. In Norway, for example, almost 90% of all cases are transradial).
This of course begs the question about why, as an editorial in Lancet recently asked, so many American interventionalists are “stubbornly refusing to embrace this technique?”
One reason may simply be that docs (just like the rest of us) prefer to do what they’re used to and what they’re already good at doing. So the more often you do a transradial access procedure in the cath lab, the more skilled you’ll become. And of course the less often you do it, the less skill you’ll have.
But in the contrary conclusions of Dr. Dillon, some cardiologists now performing radial caths on their hapless patients will “never be good” at doing them, no matter how much practice they get.
If he is indeed right, isn’t it a pity that patients may continue to be at the mercy of doctors in this category? And what are the “good” cardiologists doing to address this poor cardiac care?
♥ Read Dr. Dillon’s response (December 7, 2012)
** Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography in patients with acute coronary syndromes (RIVAL): A randomized, parallel group, multicenter trial. Lancet 2011; DOI:10.1016/S0140-6736(11)60404-2.