Monday, December 29, 2014

Hey Doc, Please go Away

Aaron Carroll,  over at The Incidental Economist,summarizes a study suggesting that patients do better when cardiologists are away at academic meetings.

High risk patients admitted with heart failure during meetings had a 30-day mortality rate of 17.5%, compared to 24.8% when more cardiologists were there. Cardiac arrest 30-day mortality was 59% during meetings and 69.4% at other times. 
Why is this?
There are a number of ways to interpret this. Maybe the best cardiologists were the ones who stayed home. Maybe with fewer cardiologists available, fewer invasive procedures get done, and that leads to better outcomes. Maybe they tell more low-risk patients to wait when fewer cardiologists are available, which gets the higher risk patients more attention and better outcomes. Maybe it’s something else.
I favor the second explanation and am reminded of the excellent judgment of my PCP back in 2007 when I was asked by the touring company to take a stress test before a two-week long kayaking trip to Patagonia.
She says, “No. I refuse to order a stress test for you.”
“Huh?” I reply intelligently.
“Here’s the deal,” she says. “If I order the stress test, our especially attentive (knowing who you are) cardiologist will note some odd peculiarity about your heartbeat.

 He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience.”

Minor ST segment changes, may be non-specific.
” I will not authorize a stress test.”

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