by Carolyn Thomas ♥ @HeartSisters
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.”
See also:
- 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.
.
.
Heart Sisters 
Carolyn,
I think there are two different issues here. One is doctor/hospital competency – which unfortunately will never be known or resolved by the majority of us who need ACUTE critical care. Finding anyone who is expert/competent in their field – NO matter the field – takes dedication, research capabilities, connections and TIME (with a bit of luck thrown in).
The other is communication – verbal, face to face communication at its best is difficult. What the “senders” INTENTION is and the “receivers” interpretation/experience is are rarely the same (even if we think it is). Social media has massive limitations as do humans!
It’s too bad we all don’t have classes in how to talk, listen and clarify along with reading, writing and rithmetic.
Having put in my 3 cents, Social media is still a great way to stir up discussion, provide information and the medical field, by and large, is to be celebrated.
LikeLike
Hello and thanks for your input here. You are exactly right. And these two issues are indeed different – but very intertwined in medicine.
LikeLike
Carolyn, I appreciate the willingness of doctors to weigh in on your post. It still troubles me, though, that, at a most vulnerable time, we are told “trust me I know what I’m doing” when we have absolutely no way to verify the information from the back of an ambulance.
Here’s the deal – if you need insider information on MY previous career, I can tell you all about which flights get cancelled and why, best connection airports, best seats on specific aircraft and specific airlines, etc etc. but when I was in uniform I had to bite my tongue on many occasion as things went wrong- even as I knew they would. So my family and friends call me for info when planning a flight.
So, yes, if I had a cardiologist in the family, he or she would have things to say about my care BUT I don’t, so I have to rely on my gut and recommendations from doctors who have known me a long time.
But I still was referred to a lunatic doc who told me to go on Wellbutrin cause I didn’t have a cardiac problem. And I am SURE he is a great interventionalist – just not for non-standard cases like mine.
The difference between cardiology and a flight across country is that the likelihood of dying in the airplane is far less than being misdiagnosed as a non-cardiac patient even as I am deteriorating in the ER.
Obviously you’ve hit an exposed nerve . .
JG
LikeLike
Welcome back, JG! Although the likelihood of dying in an airplane is far less than being misdiagnosed/undertreated/mistreated in hospital, most of us likely spend more time and energy booking a flight, choosing our seats, ordering drinks, and arranging ground transportation than we think we need to when trusting our lives to a health care professional whose competence we know very little about.
LikeLike
Hmmm, back in the beginning of all this I had the insurance that paid for everything with no pre-approvals required. I had the opportunity to go whereever I wanted to go and so I ended up at Mayo.
Now Mayo finally got the dx right (where others were previously so completely wrong) but the working treatment was not right FOR ME. And when I questioned the efficacy, got dead silence in return. So I had to go elsewhere to finally get a daily treatment that worked.
Without a proper dx, how would I know whose credentials to check?
And when it comes to the ER – what a can of worms!! You have zero idea of who you will see!
Of course you didn’t check my credentials when you might have been on a flight with me – you trust that the FAA and my airline training department have weeded out the incompetent.
LikeLike
Insurance that paid for everything with no pre-approvals required?! Luxury . . .
Re the FAA-training department weeding out the incompetent – despite a number of doctors implying that somehow “practice variation” is just one of those things we have to accept in medicine, how much “practice variation” is tolerated in flying a plane? More on this at: “Why Do Doctors Call It ‘Practice Variation’ Instead of Poor Care?”
LikeLike
Well, Carolyn, there is SOME difference in minor things between pilots, but a big difference between us and docs is that OUR butts are on the line with yours in the aluminum tube. Not so with doctors. Don’t get me wrong – I’ve had fab docs in my lifetime but they aren’t as common as I’d like.
So when dealing with significant emergencies on the aircraft, people may ask “did you think about all the people on board?” and the truth is usually “no”. Not beyond the notification and the plan of action with the flight attendants unless it is a very specific emergency or two.
I am much more concerned about us flight crew types getting ourselves to the ground safely and a happy coincidence is that you’ll get there too. If I got bogged down in the 150 souls on board I’d probably freeze up.
JG
LikeLike
Carolyn, I agree with Dr. Stohrer that physicians do not generally police their ranks. They seem to have this complicated social relationship with each other and seem to be quite uncomfortable confronting others or questioning their practice.
On your comment about nurses not being able to judge the competence of a physician, you are way off base. In the operating room, the cath lab, endoscopy lab, or other site where nurses assist physicians doing procedures day in and day out, an experienced nurse is quite capable of judging how well a particular physician practices. An experienced, qualified cath lab nurse knows what the current standards are and has seen possibly thousands of procedures performed by dozens of physicians. They generally work with the same doctors day after day. They see what the outcomes of the procedures are or when patients come back for a redo a few hours later or have to go emergently to the OR for open heart surgery. All physicians have a certain percentage of these types of outcomes, but one expects those percentages to be in line with regional and national averages.
The nurses also know which doctors are cooperative in following hospital policies such as performing a “time out” before each procedure (reviewing with all personnel involved in a procedure that we have the right patient, the right procedure, the right site, etc.), infection control measures, or informed consent. Nurses observe how the doctor interacts with the patient and how the doctor acts when the patient is sedated. They also know which doctor acts like a jackass and which behaves professionally when paged to deal with a patient issue. I could go on but I’m sure you get the idea.
You are absolutely right that most patients do not have nurse friends or acquaintances to ask about who’s good and who isn’t. As Dr. Dillon said, in an emergency you get whoever is on call and you just have to hope or pray that you get someone good.
Fortunately, most docs are at least competent. The “knuckleheads” are generally outliers. I will say, if you have the choice, go to a center that does lots of whatever you are having done. Also, patients having a diagnostic cath should not have one done at a cath lab that doesn’t do interventions. The stepdown unit I worked in some years ago got dozens of patients a year flown in from a hospital in a neighboring city to have interventions done after having a diagnostic cath. Often they kept the sheath in the femoral artery until the patient got into the cath lab at my hospital to have their stent done. Uncomfortable and inconvenient and needlessly costly in my point of view.
Sorry about the novel, but I have one more point to address. In my area not that many docs are doing radial caths yet. The radial approach takes more finesse due to the small size of the artery. I’ve had 4 femoral caths without problem and I’d much rather have a femoral cath than a radial if the physician in question is not skilled in the radial approach.
Thanks for giving everyone food for thought and engaging all these physicians in the discussion.
LikeLike
Hello C.C. – I am two steps ahead of you, honey! I’ve worked with nurses for many years (am not one myself) and you are 100% correct in reminding us of how nurses are in the very best position to give laser-like analyses of the good, the bad and the ugly among the physicians they work alongside. (And Docs, if you think that you’re not the subject of impromptu daily performance reviews from the nurses you work with, please think again!)
As I did say in my post, nurses “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)” At no point did I even hint that nurses are “not able to judge the competence of physicians” (and if I ever did, my nurse friends would hunt me down and hurt me!)
What I did say, in fact, was that Dr. Dillon’s advice that heart patients should somehow track down cath lab nurses for their personal feedback on their colleagues is completely unrealistic advice, given that most of us don’t know any cath lab nurses – and our likely first-ever encounter with one is when they wheel us into the cath lab. And as JetGirl comments here elsewhere, if she had doctors in her family, she WOULD be seeking their expert opinions on other doctors, but she doesn’t. Most of us don’t.
You make an interesting point in your last paragraph about radial vs femoral caths. I’d be more likely to buy this commonly held view if it weren’t for all those countries in which radial is indeed the default access – how have they all managed to deal with the smaller vessels/more finesse issues while U.S. docs seem unable/unwilling to?
LikeLike
I apologize Carolyn, I misread the statement about nurses assessing competence of physicians.
On radial vs. femoral, I’m not saying it’s not possible or desirable to use radial access. I’m saying the physicians do not have the training and/or practice doing radials. With the extreme emphasis on productivity these days, I imagine it can be hard for a doc to take the time to learn and practice some new techniques.
For example, a pulmonologist/intensivist I worked with in the ICU was interested in placing PICC (periperally inserted central catheter) lines in his patients instead of percutaneously placed subclavian central lines. When the intensivist puts a line in someone, it is generally a critically ill patient that needs a central line immediately in order to receive high volume of fluids or drugs that are dangerous to use in a regular IV. PICCs have some advantages over central lines, namely lower infection rate and able to keep it in much longer. The con is they take more time to place correctly. The doc gave up on doing the PICCs himself because they took easily 5 times as long to do and he had a somewhat lower success rate. It all came down to time and the doc needing to be in 5 places at once. He couldn’t afford the time to use a technique that took longer and required much practice to master. We will see an increase in radial caths hereabouts as newer doctors who received more training in that technique during residency come into practice. It takes time to institute change.
LikeLike
Great analogy with the PICC line case, and yet another example of how optimal care options can be sacrificed for the sake of time (and money).
LikeLike
Excellent post! I’ve been dis-improved by two surgeons who were much loved and respected by the OR nurses, and down right mangled by a third with a stellar reputation. I’ve been misdiagnosed by the best, as well.
Now my pesky, and as yet unidentified, arrhythmia is getting bad enough that I’m considering another ablation. Your comment about inability to accurately interpret an EKG is very disturbing. How on earth is a patient with no ties to the medical field supposed to know who’s safe and who is not? It is an EXTREMELY aggravating and frustrating process to choose someone to do the work.
LikeLike
“Dis-improved” sounds ever so much less horrid than its alternatives, doesn’t it?
For some reason, your description of your trio of docs with their “stellar reputations” reminds me of interviews I did with heart attack survivors in which one told us of a highly-regarded cardiologist who discussed her heart condition while “filing his nails, leaning against a desk”. Filing his nails, leaning against a desk. Yet other docs and nurses probably gave this guy an A+ rating. So let me say that one more time: “FILING HIS NAILS, LEANING AGAINST A DESK!” This is what we’re up against, folks.
LikeLike
Or walking in the exam room jingling keys as if my appt with you was interfering with your kids carpool.
AWESOME!
LikeLike
Okay, we’ve got to stop with the examples here – or this will turn into a whole new post. Oh yeah, I already wrote that one . . .
LikeLike
I think it is overly optimistic to assume that all doctors are great at what they do. After all, 50% of doctors graduated at the bottom of their class.
As patients, that puts us in a precarious position, but why be upset at the doctor on Twitter who was just being honest about variability of care? If anything I would welcome the admission from this professional that not all doctor colleagues are brilliant ‘god-like’ medical performers.
The reality of the professions is that doctors go out of their way to protect each other and close ranks, so as patients we have to do what we can to protect ourselves from harm from doctors. That means, reading up, educating ourselves and asking around for recommendations from other patients or from medical insiders of our acquaintance.
LikeLike
“…as patients we have to do what we can to protect ourselves from harm from doctors…” That’s a very sad commentary, isn’t it?
LikeLike
Yes it is, but it’s pretty much the truth. That was the good part of the original tweet. Only a few docs will acknowledge and help us avoid harm from the others, and I have docs in the family. It’s the Thin White Line.
On hearing that a PCP completely disagreed with treatment an out-of-town doc gave a vacationing parent and that he said, “It was perfectly obvious from the xray,” my sister-in-law promptly said, “He shouldn’t be saying things like that!”
When a well-reputed orthopedic surgeon messed up my knees, and a brilliant knee specialist clearly explained how the particular technique itself caused damage: the reason he no longer used it, my brother was angry with the second surgeon for “sideline criticism.”
No comment about my knees, btw.
LikeLike
Hi Kathleen – these kinds of stories make me insane.
Not the part about other docs disputing the decisions of others, but that two fully-qualified, highly-educated brainiacs could come up with diametrically opposed courses of treatment, each one convinced that theirs is clearly superior. What’s a poor dull-witted patient to do amid all this?
Yet more examples of what docs blithely refer to as “practice variation” – claiming that it’s just a fact of life in medicine and must be somehow tolerated by patients.
LikeLike
In my own case, my knees say the second one was clearly right, but that’s hindsight. In the course of all this, l learned that the first surgeon is a company rep for the surgical procedure (and equipment) in question, and that it’s still in standard use. At the time, I had the option of going to the second surgeon, but, due to legal changes, that would not be an option today. Scary, as it’s made a huge difference in my quality of life.
Especially here in the US, I have also come to see “practice variation” as a term to protect docs and insurance companies or HMOs.
A surgeon at our HMO operated on my shoulder after a dislocation, and I was in worse pain a year after surgery. Back to Brilliant Surgeon (this time out of pocket) he told me that it looks like the first doc did a “Standard Fix” for my tear without considering that there is absolutely nothing standard about my shoulders. (I am an anatomy sample of one. We all are, of course, but I am, for various reasons, more than most.) He recommended another procedure to reduce pain and improve function, but a series of docs at my HMO just rubber stamped what the first one had done.
I filed a grievance for additional surgery, appealed the denial, and even appealed to the state regulator. There I was told “What the HMO did wasn’t right, but it’s Accepted Practice. And that’s what you are entitled to.” In the meantime, I found yet another HMO surgeon who did not agree with any of her colleagues and she did the surgery. Again – huge difference in function, pain relief and quality of life.
But what if I hadn’t found her? I’d rather still be working, but if I were I’d never have anything close to the time it takes to do all the necessary research and political machinations to get appropriate (to me) medical care.
It’s like a stressful part-time job. Which, of course, is the point of your original post.
LikeLike
Aaarrrrrrgggghh!! 😦
LikeLike
CT…You know that I am a huge fan of your work. There is little doubt that patient empowerment through knowledge improves healthcare. You do amazing work in this way.
With the greatest respect, I would like to add a few words in support of my friend and colleague Bill Dillon. See, I led with my conflict. I know you appreciate full disclosure. Grin.
Bill and I trained together at Indiana. We have been partners in private practice for nearly 15 years; he the plumber, I the electrician. Just like in Geometry proofs, we should add in a few givens.
Number 1: Bill is one of the finest Interventional cardiologists that I have ever seen. He has skills, daring and judgement. He would be my interventionalist, if I ever need one. Any of your readers with difficult coronary lesions would be lucky to have Bill as their doc, not just because of his hand-eye skills, but far more importantly: he might decide NOT to do the procedure. He would actually talk to the patient about options and lifestyle changes. That’s huge.
Number 2: The reason why Dr Dillon got on Twitter was to promote his most recent endeavor–improving the dismal Acute MI care in Kentucky (We rank 49/50 states.) He runs around the state meeting with local hospitals and EMS folks in an effort to duplicate what North Carolina is doing. His motivation for giving of his personal time fighting through political red tape to improve MI treatment–It’s the same as yours…He cares. It matters. He wants to make an impact.
Number 3: Caring about REAL quality healthcare these days presents a conundrum for us real-world doctors. Though smart docs, say writer-surgeons, like to make Medical practice out to be easy as making Cheesecake, if only we had more checklists and protocols, the truth is much harder to handle. The truth is that good medical practice will always be difficult, perhaps impossible, to judge and score. Good doctors know who the good doctors are. Good doctors had good training and continue to stay engaged. Good doctors still make mistakes. It’s also a good bet that the experienced cath lab nurse knows the best interventionalist. Another toughie: the doctor with the best bedside manner isn’t always the best technically–and vice versa. See..it’s all so hard to measure.
Number 4: As far as hospitals go, they aren’t incented to pick the doc with the best skills. Right now, sadly, they are incented to pick the most productive. Hospital ownership of docs further skews referral patterns. When a group of local PCPs with whom I had had a great relationship with for years were bought by a competing hospital, the only patients they referred to me were family members. Their patients went to their hospital’s docs. Quality and skills is one thing; business is another. That’s frustrating. But really hard to tweet about.
Number 5: I am certain that you and Bill want the same thing. You want better healthcare. You want patient empowerment. You guys would like each other if given the chance.
Best,
John
LikeLike
Dr. Mandrola brings up a great point regarding productivity. I have met doctors who would crank out ridiculous numbers of procedures a day. I don’t know what motivated them to do that whether money or pride. I just know I wouldn’t want to be an ortho doc’s seventh knee surgery of the day. Doctors are left to their own devices to determine what safe practice is for them. Who protects patients from the surgeon or other type of physician that is only interested in doing a record number of procedures?
LikeLike
Good question indeed, C.C. A New York study, for example, recently suggested that two-thirds of the justifications for implanting coronary stents in non-emergency patients were either “uncertain” or “inappropriate“. TWO-THIRDS. For more on stent-happy docs, read this.
LikeLike
Thanks so much for such a comprehensive response, Dr. John. You know that I am a huge fan of your work, too (and indeed you might consider me a groupie based simply on how many times I quote yet another Mandrola-ism during my talks on women’s heart health!)
Please see my response below to Deborah’s comment (essentially defending Dr. D as a person!) My concerns about his tweets are not personal, of course. I completely agree with your own good guess that both of us are on the same page when it comes to wanting the same outcomes for patients. In fact, had his original post stopped after his first two lines, I would have cheered him on. Yay! Radial caths!
Dr. D. is absolutely correct that, like golf, practice makes perfect when it comes to radial caths (or ablations, or any medical procedure, right?) But it was the last line of the tweet, and then confusing subsequent tweets, where he utterly lost me.
But this issue isn’t so much about patient “empowerment” – a term I don’t even like much, to tell you the truth. It’s about patients having the right to expect that the expert we are trusting with our very lives is “good” at what he/she is doing to us. Not the right to investigate the competence of the experts! And as much as I love the nurses I’ve worked with, expecting patients to call nurses for doc references is a non-starter.
Just today, I had my little Smart Car into the shop for a new fuel pump. I’m entirely confident that the skilled mechanic who worked on my car today is licensed, well-trained, has been certified in doing this type of work, and knows precisely how to replace an ailing fuel pump. How do I know this? I know that if he weren’t, the shop’s Service Manager would not allow him to practice his trade there. Period. I don’t have to call around other shops and find other mechanics to vouch for his skill – I’m already very well aware of the service and ongoing training at this shop (we happen to have the country’s busiest Smart dealership here in Victoria).
And that’s all I’m expecting from my physicians. Before they pick up a scalpel to cut me, I’d like to be able to trust that the hospital we’re at would simply not allow cardiologists who, as Dr. Dillon contends, “will never be good” at radial caths to practice on me – until they had attained minimal (certified) standards of competence to do so. Do you think that this is too much for patients to expect?
Regards,
CT
LikeLike
Have been tempted into commenting on this as I have just had a twitter discussion in which I said I didn’t think the original tweet was that bad.
From a patients perspective comparing sporting skill to medical prowess is not ideal – I accept that. I also accept it is unacceptable that the possibility of significant variation in the delivery of care exists. However the latter has always been the case (there are loads of references). Anything which highlights this fact and empowers the public & patients to continue to pressure organisations to improve patient safety and ensure excellence and not adequacy in the delivery of care is a good thing.
The very nature of the tweet and resulting blog is just one small step in that direction.
If only one patient who reads this goes to their hospital and asks for comparisons of outcomes then the original tweet was worth it.
COI: Medical Professional
LikeLike
Thanks a lot for taking the time to comment here, Dr. Roland (and thank you also for retweeting this link).
Please read Dr. Stohrer’s observations here about how inappropriate it is to expect patients to carry the burden of assessing the professional competence – particularly technical competence – of our health care professionals. This expectation also ignores the psychosocial needs of people who are about to undergo a frickety-frackin’ HEART PROCEDURE, for Pete’s sake. My guess is that going to the hospital ahead of time to explore “comparisons of outcomes” is regrettably unlikely for those facing this frightening scenario.
I’m writing another post on a loosely-related topic about an interesting California study of patients’ tendency to “defer to authority” – even among a sample group described by researchers as “wealthy, highly-educated people from an affluent suburb in California, generally thought to be in a position of considerable social privilege and therefore more likely than others to be able to assert themselves.” Trouble is: they don’t. We don’t – for fear of being labelled “difficult”. It’s a very complicated issue – I suspect we need help from a top-down solution.
LikeLike
Thanks Carolyn,
Think my posting was a little brief – I entirely agree that just before the procedure itself is no time to worry about this (!) and also that I think it is inappropriate for patients to carry the assessment burden.
My point, and I hope partially proved by the discussion this has generated, is that twitter prompts discussion; hopefully ultimately for the good.
Significant (appreciating the challenge there is in defining this causes) variation in care, education and health remains unacceptable
LikeLike
Very good point about Twitter prompting discussion – I was stunned by the flurry of tweets and retweets and the quality of conversation provoked by my article, from both patients and physicians, in the U.K, North America and beyond! Thank you for being part of it.
LikeLike
Hello Carolyn,
When I first read your blog post I interpreted the story as one of a slightly arrogant doctor much as you did. But when I shared it on Twitter I was surprised that several people, mainly doctors, commented that what this cardiologist had said was the truth and that the real risk was misinterpretation on Twitter. This surprised me more than your post.
This may have come about because in England there is a lot of talk about choice in healthcare at the moment, and a belief that patients will choose providers based on clinical outcomes if the data is available. Does that mean that the burden of assuring competency is now with the patient? When that cardiologist said that some doctors would ‘never be good’ is that the same as saying they will never be competent? If so it would mean that the notion of regulation (including self-regulation) in medicine had gone entirely because surely such a doctor should be stopped from performing surgery by colleagues if there was any form of regulation at all.
So I hope that this is not what the cardiologist was saying.
Anne Marie
LikeLike
Hello Anne Marie,
In response to your question: “When that cardiologist said that some doctors would ‘never be good’ is that the same as saying they will never be competent?” – my translation of his original tweet was pretty much that a doctor who “will never be good” at performing radial caths is a doctor who is not “competent” to perform radial caths. U.K. doctors may attach a different “interpretation” to that term “will never be good”, but honestly, I cannot think what it might be, can you? “Will never be good” seems pretty self-explanatory!
From a patient’s perspective, my next question would be: then why is this (incompetent) person allowed within close range of any patient about to undergo a radial cath?
LikeLike
Offhand, dismissive, arrogant, and a loose cannon in social media. Just the kind of guy I’d like as my doc.
Thank you for challenging him, Carolyn. I won’t write any more because most of what I’d like to say is unprintable.
LikeLike
Hello Deborah and thanks very much for your comment here. The thing is, this particular doc may very well be a lovely man in person (kind, caring, competent – everything we want in a physician) who perhaps just let his Twitticisms run away with himself. Too bad it’s too early in the day for us to have a nice glass of wine over this topic . . .
LikeLike
I do not think physicians police their own as they should. It is not the patient’s burden to assess competency in a technological field in which they have no expertise. If a physician’s performance is substandard, it is incumbent on his/her peers, department head, etc to arrange remediation or a removal of privileges, whatever is appropriate.
Unfortunately, this is a longstanding issue in medicine.
LikeLike
Thanks so much for wading in here, Anne. I appreciate your professional perspective, and particularly how you nailed my point that “it is NOT the patient’s burden to assess competency” (a point which I fear is being missed by those docs on Twitter this morning who are discussing how “over sensitive” I am being!)
LikeLike
I’m struggling with the decision to obtain a second opinion on my cardiology care plan. The decree from my current cardiologist that this may be as good as it gets and that I need to get used to my new normal life doesn’t sit well with me. This article reinforces my decision to get a second opinion and maybe a third.
Thanks for your articles, they are very informative.
LikeLike
Getting a second opinion is your right. Good luck to you!
LikeLike
Hi Carolyn,
Oh My! You found a good one today! 3 caths all femoral – 2 at Mayo 1 local. No incompetence no drama. (I know, I know, I’m usually good for SOME horror story)
Loved the 12 word quote from Mayo: “Don’t Lie. Don’t Pry. Don’t Cheat. Can’t Delete. Don’t Steal. Don’t Reveal.” It’s not just for healthcare 🙂
Had 8 radiologists from 3 different med centers (all top notch hospitals) read the SAME CT scan. 7/8 came to the same conclusion – surgery was needed immediately.
What if I’d only had the one dissenter on my case? Would I even be alive? Troubling, huh?
JG
LikeLike
Hi JG – you are so right! Dr. Timimi’s 12-Word Rule should be required reading for anybody on social media.
Your radiology story is telling. Dr. Jerome Groopman’s book “How Doctors Think” reports on a study on physician accuracy in interpreting EKG results. To test their diagnostic skills, cardiologists in this study were given a number of EKG readings to assess, half showing myocardial infarction, 1/4 normal, 1/4 with some abnormality.
The study’s results were disturbing. Even among specialists examining a routine test like an EKG, there were “widely divergent conclusions”.
Again, as you say: ….. what if? ….
LikeLike
For my MI in 2003, a skilled cardiologist administered emergency care and inserted one stent to unblock the 100% blockage. I was then scheduled for a second cath to stent in one month to unblock an 80%.
My primary cardiologist (now retired) performed that one, and my heart stopped for 30 seconds in the process, having to be defibrillated to be restarted. It seems the physician crossed a main artery with the stent thus causing my heart to stop.
For my most recent emergency stents (10-29-12) I had a third emergency physician who performed the exercise without a hitch. Two out of three must be the odds.
Now I might have to trust a fourth cardiologist (my new primary) to install an ICD if I do not resume full heart function in three months. Am I afraid? Yep.
It seems at this point I trust the emergency cardiologists the most. As far as asking a nurse, forget it. I believe they will favor the doctor in almost every instance.
LikeLike
Thanks for sharing your considerable experience here, Annie. The trouble is, we just don’t know whether ‘hitches’ occur because of a simple accident of fate, or because of incompetence.
LikeLike
Very interesting discussion. I think it´s everywhere in the world the same.
Dr. Dillon hit the nail:
When we moved to this area 17 years ago, I began to have more problems with my heart than before. My triple bypass was 16 years old and I needed a family doctor. I had found one in the telephone book, but I did not get along with him. So I asked the participants of my french course and they all recommended me an internist. This doctor said to me at my first visit, he would like to do something good for me and send me to the best heart hospital he knew.
There I had luck, too: One of the nurses introduced me to a person responsible for patient medical papers, because she was a landsman of me. She has been my friend since then. She told me which doctors are the best in the cath.lab. and many other useful things about the crew.
The first thing I ask, when my husband brings me there is, if my cardiologist for cath is in the house. If he is not there, I have even refused to go to the cath and have waited for him. In this case, I had no pain anymore and my troponin was not high.
Once I was brought by the helicopter and straight away to the cath lab. — My troponin was elevated. I was lying on the table. The lab nurse came in and said: “Oh, it´s you Mrs. Meier. I must go and see who will do the cath.”
Having been there about 12 times in the last 17 years I know a lot of lab nurses there and more important, they know me by sight. It is like going home, when I go there. It is so important for me that I do not like to go on holidays.
LikeLike
Hello Mirjami – the only positive aspect of being such an experienced heart patient is that you know (and trust) the nurses – and your doctor – and they know you! Must be like a reunion when you come back. Good luck – hope you don’t have too many more reunions!
LikeLike