Thursday, April 12, 2012

The Audible

The EKG hung outside the door with a new name attached.   On a cursory glance, it looked pretty normal.  He entered the room.  There before him was a relatively young patient, medium build, nothing unusual.  The computer schedule suggested it was just another case of atrial fibrillation.  You’ve got an hour, he thought.  Plenty of time.  But he knew there was never just another case of atrial fibrillation.  There are just too many plays in the playbook for this disorder. 

But he was a seasoned veteran at the game.  He had seen most things and had strategies for most of them.  If X, then Y.  If Y then Z.  Not that hard, really.  Most of the time.  But this was not to be “most of the time.” 

He reviewed the story, examined the patient, and reviewed the tracings.  Delightful patient: productive, married, young kids, otherwise healthy, no risk factors for stroke.  Amongst the screens and screens of collected data on this nice person, there it was: classic paroxysmal atrial fibrillation with relatively fast ventricular response, starting and stopping, starting and stopping, again and again on the Holter recording.

At first, it seemed like a chip shot: “I can fix this.”

Until he inquired further. “Seriously, you don’t feel this?”

Didn’t feel a thing.  Felt fine, in fact.  If it weren’t for the spouse, the patient wouldn’t be here.

He paused.

“But I can fix this!”

Then he thought: “But what if the cure is worse than the disease?  What if there was a complication?  What if he made things worse instead of better?  Imagine a stroke in this person, this parent, this worker.  How much better can you make someone who’s asymptomatic?”

But I can fix this!”

There are a million things we can do to patients with atrial fibrillation: ablations, cardioversions, atrial occlusion devises, lariats, endocardial and epicardial mazes, all in the interest of curing the disorder.  Our training, skills, equipment, reimbursement, marketing teams, egos, productivity clauses and culture of care constantly drives this process.  In turn, we splash the happy patient who was cured from their disorder across our billboards, ever eager to do more.

But what most people will never see is the patient who is turned away; the one whom doing nothing invasive was the safest and best treatment for that individual even though the procedure, more likely than not, would have been successful. 

Such a play  is not sexy.  It’s not innovative.  It occassionally results in an adverse patient online rating. And for the system, it’s not lucrative.

But good medicine often calls an audible to the playbook.  



Dennis said...

As in any game, its tough making the right call.

Anonymous said...

...and a good QB knows when he has to call an audible, whether it proves to be a popular move or not. Sometimes just keeping the ball and staying put prevents a big loss or even takeover ("We're weak against the safety blitz," etc.), but maybe no one will ever know.

Physicians who, after careful deliberation, stand by that kind of call in their practice are worthy of a lot of respect.

Tim Sanborn MD said...


As you propose, doing what is best for the patient with good evidenced based medical care rather than preforming unnecessary procedures will be a necessary and worthy "game plan" if we are going to control escalating healthcare costs,

Tim Sanborn MD

madam_sassy_pants said...

Well said! It's a difficult lesson to learn...