Cardiologists as communicators: One more opportunity for QI?

Recently, a study published in JAMA Internal Medicine re-introduced an issue that has come up before: How accurate and thorough are we in discussing both the benefits and risks for PCI with patients who have stable angina? Do we imply, or do patients infer, that PCI will prevent a heart attack? Never mind that this study examined only 40 patient encounters over a 4-year period or that only 20 physicians participated in the study, and only two of them were interventional cardiologists.

Small sample size and other limitations aside, some (but not all) media focused on the finding that only 5% of the encounters in this study involved a cardiologist explicitly stating that PCI in stable angina can improve symptoms but not reduce the risk for death or MI.

Chandan Devireddy

For many of us, the first reaction to this study was that a survey of only 40 cardiologist/patient encounters can hardly represent the thousands of such encounters that take place on a daily basis. Although I agree and personally believe that most of us do take the time to obtain truly informed consent, there is an important natural lesson to draw from this study and others like it: We must ensure — and perhaps also document — that our communications with patients are open, informative and honest about the benefits and drawbacks of invasive cardiac procedures.

I am proud to be part of a field that prioritizes evidence-based medicine and quality improvement in our daily practice. There are few specialties that track clinical outcome measures as closely as interventional cardiology does for both established and investigational therapies. We have tended to focus on what we can most easily measure — hard endpoints like death, heart attack, stroke and complications such as bleeding and contrast-induced nephropathy. Our studies, registries and rapidly expanding portfolio of quality improvement (QI) tools tackle these very important metrics to evaluate safety, effectiveness and quality of care. But, perhaps, given studies like this latest one, we need to take a harder look at how we are doing as communicators, especially in the current practice environment, where we are under increasing pressure to see more patients in less time.

For me, there is no doubt that interventional cardiologists want what’s right for our patients. This is exemplified by the recent “Choosing Wisely” campaign that SCAI participated in, which highlighted five things cardiologists and patients should question when considering invasive procedures. It is also demonstrated on SCAI’s public education website, SecondsCount.org, which is replete with information about conditions, tests and procedures, including lists of questions that patients are encouraged to print and take to their appointments to help them be engaged, active participants in their care.

The SCAI tools are examples of ways we can engage our patients in conversations about their care:

• But are there tools we can develop to help us as interventional cardiologists and other members of the cath lab teams?

• Should there be tools to make us better communicators?

• As we place increasing emphasis on leadership training for the future generations of interventional cardiologists, should we focus on communication training?

• How do you ensure that your patients hear and understand your counsel about the benefits and risks for the therapies you are recommending?

Reference:

Goff S. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2014.3328.

Chandan Devireddy, MD, FACC, FSCAI, is an interventional cardiologist, associate professor of medicine and assistant director of the interventional cardiology fellowship program at Emory University, Atlanta. He specializes in coronary, peripheral and structural heart interventions.

Disclosure: Devireddy serves on an advisory board for Medtronic.