Judicious use of complex medical procedures

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by Shanti Bansal, MD

In the cardiac catheterization lab one Tuesday morning, I encountered a situation that made me reflect on a bit of 18th-century British history.

At that time, the British government was overburdened with prisoners. A plan was hatched for sea captains to transport many of them to Australia. Due to poor conditions, up to one third died on the voyage. Politicians and clergy members desperately urged the sea captains to improve the conditions, but survival rates changed little. But then an economist suggested paying the captains for every prisoner who made it to Australia rather than for each one who boarded a boat. Survival quickly improved to 99%.

Back in the catheterization lab, there were no British prisoners — just a slim, gray-haired man with bristling facial hair lying on a stretcher in front of me. With his chart in hand, I greeted this Mr. Johnson and asked him how he had come to the attention of Dr. Attending, an interventional cardiologist.

“I was seeing him for my cholesterol,” Mr. Johnson replied, “and then I started to get a little short of breath after going up a few flights of stairs. He ran some tests, and next thing I know I’m here. I’m sure that any blockages they fix will prevent the next big heart attack, so I’m not worried.”

I perused a note written by Dr. Attending: “Mr. Johnson, a 75-year-old gentleman, remains highly symptomatic from shortness of breath. Since this may be his anginal equivalent, I will recommend a cardiac catheterization for further evaluation and treatment.”

Struck by the disparity between the clinical situation and the note, I nevertheless passed the consent form to Mr. Johnson, who signed it. He was whisked away to the catheterization lab, and with Dr. Attending by my side, we began the procedure. The catheter engaged the left-main and then the right coronary artery easily and accurately. The contrast illuminated the arteries like glow sticks on a sobering night. The right coronary was totally occluded.

“Well, this is clearly the cause of his shortness of breath!” Dr. Attending exclaimed. “We need to fix it!”

In the ensuing hours, we deployed a balloon pump to push blood over the diamond drill of the roto-rooter. It cut through the cemented plaque with hydraulic precision along the tracks of countless coronary wires. After the procedure, Mr. Johnson was admitted for a brief stay in the ICU and, later, to the hospital floor. When I saw him walking about in his standard-issue navy blue slippers, I asked him how he was doing.

“Good,” he said. “Still a bit short of breath though. I’m happy to be going home today.” The case left me feeling uneasy.

Did our complex medical procedure decrease Mr. Johnson’s risk for morbidity or mortality? If not, did we improve his quality of life? Has caring for patients become more about the journey than the destination? Can we instead give physicians and health care providers incentives to focus on outcomes, as the 18th-century British sea captains eventually received? In the 21st century, my experience with Mr. Johnson’s care read like the script of a MasterCard commercial:

Complex medical procedure plus hospitalization: $63,535.00

Outpatient follow-up: $56.50

Navy blue hospital slippers: $5.50

Judicious medical care: Priceless

Shanti Bansal is an internal medicine physician who blogs at CardioExchange , a NEJM Practice Community.

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