Oooh a sizzler here, from the lab of John Spertus!
Could it really be true that we PCI docs are telling porkie-pies about whether our patients have angina?
Could it really be true that we PCI docs are telling porkie-pies about whether our patients have angina?
Why do you think this happens?
First vote is for "like stenting", which I think is true, and accords with my skeptical view that we are craven, moneygrabbing schemers.
However, unsurprisingly @rallamee has a kinder view of us as a profession.
However, unsurprisingly @rallamee has a kinder view of us as a profession.
When the patient is deciding whether they have angina or not, what are they relying on?
Yup, the patients have one source of information.
We, in contrast, have a wagon load of printouts, scans and whatnot to look at.
To obtain this info we have:
We, in contrast, have a wagon load of printouts, scans and whatnot to look at.
To obtain this info we have:
And of course, having done all the above, we are honour bound to "look at the full clinical picture".
Incidentally whenever anyone says this, when talking about interpreting a diagnostic, I burst out laughing.
Incidentally whenever anyone says this, when talking about interpreting a diagnostic, I burst out laughing.
When they stare at me indignantly for interrupting their lecture, I say, "We have a term for that in research. It's called fraud."
People look baffled and I have to leave by the side door.
Because in clinical practice, we cheat, and are proud of it! We teach others to do it too
People look baffled and I have to leave by the side door.
Because in clinical practice, we cheat, and are proud of it! We teach others to do it too
When a cardiologist is advising whether a patient should have a stent, she *thinks* she is listening to his symptoms.
But she doesn't realise she is getting a lot of other information.
Anatomy: Ooh its tight!
Physiology: FFR/iFR/blah blah
Ischemia: pile of scan results
But she doesn't realise she is getting a lot of other information.
Anatomy: Ooh its tight!
Physiology: FFR/iFR/blah blah
Ischemia: pile of scan results
And in that context of convincing test data, it is blindingly obvious that the dubious symptom is indeed "typical angina", and she dutifully writes that down.
On with the life-saving stent.
We don't TELL him it's life-saving, that would be lying. But we ACT as though it is. We've rushed him to have tests, and book his PCI displacing his work and leisure plans.
"Of course I need it! Otherwise why would they be doing all this stuff?"
We don't TELL him it's life-saving, that would be lying. But we ACT as though it is. We've rushed him to have tests, and book his PCI displacing his work and leisure plans.
"Of course I need it! Otherwise why would they be doing all this stuff?"
Even if we TELL them it is NOT life-saving, they won't believe it.
"They are just saying that to scare me into stopping smoking, or take those wretched statins that people on the internet say are bad for you. I will just have the stent, thanks. I can read between the lines."
"They are just saying that to scare me into stopping smoking, or take those wretched statins that people on the internet say are bad for you. I will just have the stent, thanks. I can read between the lines."
When the patient returns for followup after the PCI, and the dubious symptom is there, what do you do?
(For interventional fellows out there - option A is WRONG, OK?)
The first answerer was "Do tests"
The only better answer than that, is an option I did not offer, which is "Take a history", i.e. ask about the nature of the pain.
The first answerer was "Do tests"
The only better answer than that, is an option I did not offer, which is "Take a history", i.e. ask about the nature of the pain.
The tests will (if you have put the stent in roughly the right vessel, etc) now be negative.
*Now* is the time that the serious history-taking is done.
One eye on the patient, and one eye on the resoundingly normal test results.
*Now* is the time that the serious history-taking is done.
One eye on the patient, and one eye on the resoundingly normal test results.
... and in your mind, the jury returns a resounding unanimous "INNOCENT"!
So even if the symptoms are the same before and after, if they are of a dubious nature where you have been TRAINED in medical school to "Take into account the full clinical context" (i.e. cheat), the PCI will be documented in the records as being
And everyone will be happy.
The patient is reassured, "Not only did they save my life, but they have got rid of my angina, and I only have rubbish symptoms now. Isn't that great?"
Doctor is happy
Researchers reporting effect of PCI truthfully report a dramatic fall in symptoms
The patient is reassured, "Not only did they save my life, but they have got rid of my angina, and I only have rubbish symptoms now. Isn't that great?"
Doctor is happy
Researchers reporting effect of PCI truthfully report a dramatic fall in symptoms
So in the @rallamee theory, we docs get it wrong because we have Too Much Information.
That's a somewhat nicey-nicey way to put it, avoiding any mention of lying, cheating, stealing etc.
That's a somewhat nicey-nicey way to put it, avoiding any mention of lying, cheating, stealing etc.
Everything goes smoothly until some people who've drunk our own Kool-Aid do a blinded study of it, expecting it to be really good.
Oops.
(Complaints to @rallamee please. ORBITA was nothing to do with me)
Oops.
(Complaints to @rallamee please. ORBITA was nothing to do with me)
