Worldwide, an estimated three million coronary angiograms and angioplasties are performed each year. These interventions are used to look for blockages in coronary arteries and to open them with balloons and stents. Global Industry Analysts (2011) predict that by the year 2017, the global market of coronary angioplasty products is likely to be close to US$ 1.84 billion (about 100 billion Indian rupees).
Big numbers, these. Two weeks ago, I contributed a tiny drop to the angioplasty ocean. Admittedly, the drop was small but it caught the eyes of those treading along the shore. For, they were unable to fathom what made me land up in a cardiac catheterization lab.
Cardiologists use several risk assessment tools to estimate the person’s 10- year risk of developing cardiovascular disease. Almost all scores placed me in a low risk category. For example, the Framingham Risk Score (2004) suggested that 6 of 100 people like me would develop a cardiac problem over a ten-year period. The Interheart Study (Yusuf et al., 2004) revealed that nine risk factors explain 90% of the global risk for heart attacks. I lacked all nine factors.
And yet strangely, I developed cardiac pain on that Monday noon which eventually led to an angioplasty. I was lucky on several counts, though. I was working in the hospital when my chest pain began; my pain was severe enough to make me rush to the outpatient department of the hospital; my physicians swiftly administered me aspirin, clopidogrel, heparin, and atorvastatin- drugs with proven benefits. My electrocardiogram showed no infarction; the echocardiogram showed no damage to the cardiac muscle. My colleagues in the ICU consulted each other and decided to accompany me to a cardiac hospital- 50 miles away.
Six hours following my chest pain, I was wheeled into the cardiac catheterization lab. The angiography began. The cardiologist chose my radial artery to insert a sheath, deftly threaded the catheter to my coronary arteries and injected the dye through the catheter.
As the dye began to fill my coronary arteries, the cardiologist smiled at me: “Good, you have no calcium lining the walls of your coronaries.” And, after a few seconds his smiling voice brought music to my ears again, “Your left main coronary artery is perfect.” The dye found its way into the left anterior descending artery where it hit a cholesterol-filled plaque that had grown large enough to bulge out of the artery wall and into the bloodstream. Like a rock sitting in a stream, it was causing the dye to move a bit sluggish into the distal coronary bed. The cause for my cardiac pain was found.
The cardiologist explained to a coterie of anxious family, friends and professional colleagues that he would like to use a balloon to prop open the clogged artery and then would place a stent to make sure that it stayed open. “Will it make sense to first try medical therapy, and turn to angioplasty if it doesn’t work?” – a shaky voice emerged from a tremulous lip. “The obstruction was preventing a part of the heart from getting as much blood as it needs, and therefore, I would rather recommend angioplasty,” he gently explained. He waited patiently seeking approval from my professional colleague and family.
Everybody gave a quick approving nod. So did I. For, I wasn’t a doctor anymore. I was a patient. My world had collapsed into a small sterile technology-filled universe and my perceptions were getting easily swayed by the ebb and flow of events. The light from the overhead lamps failed to brighten my thinking brain. Lying on the cath lab table, draped from neck to toes, I was simply watching the events around me, making no conscious effort to understand what was going inside and around me. The frenetic cadence of rapid triage, transport and urgency of treatment had created a pressurised milieu that precluded an in-depth informed consent process, a fact I was conscious of. I was as submissive and as irrational as most ignorant Indian patients are.
He mounted a collapsed stent over a deflated balloon at the end of a catheter. Next, he advanced it gingerly into my diseased coronary artery, positioned it at the blocked site and inflated the balloon under pressure. The stent expanded against the wall of the artery. The balloon was then deflated and the catheter removed, leaving the stent in place. The dye injected to test the success of the procedure filled the entire coronary bed. A collective sigh of relief was audible in the waiting room adjacent to the cath lab. Few minutes later, I was wheeled into the ICU, with an expensive platinum-chromium wire mesh in my coronary artery- a drug-eluting stent. Two days later, I was discharged home.
I received many calls, emails and messages during my hospitalization. One message stands out: “What kind of a patient are you? Obedient or full of questions? Compliant or sceptical?” This was a perfectly natural query for I had cared for patients with heart diseases for long and was a firm believer in the practice of evidence-based medicine. My colleague wanted to know if my behaviour, choices and perceptions differed from those of ordinary patients.
Choosing wisely is a challenging task- more so when doctors find themselves not at, but on the hospital bed. I thought- rather naively- that because I had a rich experience of treating similar disorders and knew the pluses and minuses of each intervention, I could easily decide what is best for me. My brief stay in the ICU has left me with feelings that are sobering and touching. I have learned about the distress and anguish that patients face, along with their desire to find hope-wherever it may lie. My coronaries have gifted me insight and perspectives that are profound- ones which I probably would not have gained, had I not entered the cath lab. I wanted an evidence-based intervention that was customized to my individual needs. And I suddenly realized that my choices were not my choices- they were also guided by so many factors: my doctor’s recommendation, pressure from family and loved ones, prevailing practice patterns, confusing numbers, and my own biases.
I acutely became aware of the limitations of modern medicine, a science that is imprecise, uncertain and is constantly evolving. I also realized that making choices is not easy, and we sorely need simple systems that will help doctors and patients make best individualised decisions. For example, the latest evidence- based recommendations on angiography and angioplasty come from the 2011 AHA practice guidelines (Levine et al., 2012). But how does one access these sources of knowledge during an emergency? And even if one does, how does one go through an 82- page long document to choose the best option? Although I carried my cell phone and iPad with me in the ICU and was connected with the World Wide Web all the time, I found it nearly impossible to keep my left and right brain evenly balanced. A doctor- patient, I found, is as vulnerable and as likely to be confused as an ordinary patient in the hospital.
In their recent book, Your Medical Mind (Groopman J & Hartzband P, 2011), the authors describe and analyze what goes on in the patients’ mind when patients try to weigh different options. The authors argue that patients’ mind-sets heavily influence the treatment options they choose. After reading the book, I asked myself what mindset I possessed. Was I a minimalist who prefers minimal or no tests or drugs, or a maximalist who wants his doctor to aggressively pursue diagnostics and interventions? Was I a naturalist who believed that nature is best or a technology aficionado, who trusted cutting-edge interventions and innovative procedures? Or was I a hybrid of minimalist-technologist whose preferences are shaped by the perceived gravity of medical disorders- from as little as possible to the best available. Was I a believer who hopes that for every problem there is a successful solution or a doubter who approaches all treatment options with profound scepticism? Although I couldn’t decide what group best described my mind-set, I found these categories interesting. “In our role as doctors,” Groopman and Hartzband emphasize, “our aim is to help our patients understand what makes sense for them, what treatments are right given their individual values and goals.” This is “judgement –based medicine”- doctors choose the best evidence-based therapy and then spend time to understand what their patients want and respect their values, priorities and perceptions. An approach that blends art with science.
Art and science are key components of evidence-based medicine. And yet, doctors often fail to integrate best scientific evidence with individual clinical expertise and tend to marginalize patient’s values, preferences, priorities, expectations and concerns. Medical professionals do not use data as often as they should, and instead, base their decisions on prevailing practice patterns, individual perceptions and experiences. This must change.
My illness has helped me understand medicine from a patient’s perspective. “When doctors enter the hospital as a patient,” my friend, a lawyer, wrote me after I was discharged home, “they have several advantages: an insider’s knowledge, access to master diagnosticians, quick second opinions from skilled colleagues, no appointments nor waiting, and no loss of identity when they are wheeled in the different sections of the hospital.” He used an amusing analogy: “It is almost like a policeman going to another police station. He has no idea of what a common citizen goes through in a police station.” True. I enjoyed the privilege of being a doctor-patient. My cardiologist and his staff treated me and my family with respect, often going out of way to ensure that my hospitalization was as comfortable as possible. Ordinary patients are often not as lucky- they are unable to find the right doctors; right hospitals; find it difficult to choose right options and do not get right answers to their questions.
“If traditional risk factors failed to predict your acute coronary syndrome, why not get tested for novel and sophisticated biomarkers that might help you gain rich insight into the coronary tree?” My colleagues advised me after I returned home. Much as I am touched by their love and affection for me, I have decided to say no to additional tests. For, I am only beginning to fathom the imprecision of medical diagnostics and risk prediction rules. As Blaise Pascal famously said, “The heart has its reasons which the reason knows nothing of.”
