Tuesday, March 08, 2011


The March 3 edition of the Pittsburh Tribune carried a report that two interventionist in Pennsylvania has resigned their position as they were found to have implanted "unnecessary" stents in 141 patients in 2010. These comes after reports of unnecessary stenting by two interventionist in Maryland last year and another such case in Texas. Looks like interventionist are being held to account for the stents that they put down.
This raises the very important issue of medical audit. Can doctors ( in this case interventionist ) in practice do whatever they wish to " help" the patient or must he answer to another body, the community at large? How then do the community at large determine what is necessary treatment and what is unnecessary treatment?
This issues become more and more important as medicine is being viewed ( sadly ) as a business and doctors as businessmen. We are all in this for the money. Make as much money as you can!! This has gone against the very ethos of our long established profession, of always doing good and never doing harm ( it can be said in so many ways ), or as some will say, always putting the patient first.
How do we determine that these few interventionist being haul up ( I think there are more waiting to be hauled up ), have implanted unnecessary stents. Yes, I know that there are guidelines, written by societies. But, each patient is different, and a standard guideline cannot apply strictly to one and all. Whats even worse in Malaysia ( looking at our own community ), is that we do not do any original research, so we apt the west. Our guidelines are literally copy and paste from the west. Can you imagine, we just take it that Malaysian CADs are the same as American / European CADs, and Asian hypertensives and the same as American / European hypertensives, and we copy and paste their guidelines, sometimes even their value levels. How can that be, their size is different, their height is different, their diets are, how they live is different, but we follow their value. That is why so many of us, have NO faith in the Malaysian guidelines. I remember, one of the first guideline meetings ( this was in the 80s when guidelines were a fad ), I was invited to help write the Malaysian guidelines on dyslipidemia. I asked them the same. Of course, I was the dissenting voice ( as always ). I was never invited again, despite my seniority and significant contribution.
In the issue of stenting, the guidelines are even more controversial. Symptoms or no symptoms, FFR or IVUS or non? These increase use of devices to document, increases cost, and many interventional centers in Malaysia do not even have them. Triple vessel disease, left main stem stenting ( those less then syntax score 33, and those above syntax score 33 ), the Euroscore, the competency of the interventionist? These are all very complex issues. How then to decide "necessary" from "unnecessary" stents.
The other point that I observe from this story reported in the Pittsburg Tribune, is that the lay public in US is following what the medical community is doing. Interventional cardiology is a high profile discipline. Not to mention that there are many cardiac surgeons eying ( can I say, with a bit of disdain ) what we are doing. The public is watching and asking us to account.
If this trend continues, hospitals and medical centers will be asked to form committees to vet what we are doing. This is good, if it can be done fairly and justly. There is no perfect committee. Everyone have their axe to grind, with someone else, and so a good thing can become a witch-hunt for personal gain. I understand that the first two cases ( the ones in Maryland and the complaint in Texas ), may be personality motivated. There is an axe to grind, with the interventionists involved.
Anyway, interventionists ( doctors ) beware. The public is looking and may be asking you to account for what you do. Be a good doctor, and not a successful businessman. I think that principle should stand us in good state.
Interventionist, be warned.

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