A succinct and humorous definition of time was written by the otherwise forgotten pulp SF writer Ray Cummings in his 1922 story The Girl in the Golden Atom — “Time is what keeps everything from happening at once.” For a busy EP doctor though, time isn’t doing a very good job of preventing everything from happening at once. On top of the constant interruptions provided by text messages, phone calls, and the “urgent” need to sign disability forms and what-not, I am expected to see 12 patients, up to half of them new patients, in a 4 hour period in the office. This pace is driven by a lot of factors which I don’t have much control over, but it does create a constant struggle to provide a fair exposition to patients of what they are getting into when they sign on to have complicated procedures like catheter ablation or device implantation. The nuances of the decision making for these patients are wonderfully laid out by my friend and colleague Dr. John Mandrola in his recent theHeart.org blog. To do justice to my patients I have to spend more time than I have allotted with them, meaning patients often have to wait longer than they should in the waiting room. I am sorry about that. It is the lesser of evils. It would be worse to resort to the “here’s what you need, Next patient” approach. But with the constant time pressure involved in medicine today, it would be easy to fall into that trap. This temptation to just tell the patient what to do is also aided and abetted by the existence of published medical guidelines. Guidelines are good in the sense that they can summarize a lot of scientific data and expert opinions in a brief format. Guidelines are bad when they become more than just guidelines. They are bad when they become a substitute for judgment, when they become a strict algorithm that must be followed in every case.
There was a lot of furor generated by the announcement that some ICDs were implanted in patients who did not meet the CMS guidelines for ICD implantation. I am more worried about the opposite problem: patients who get implants because they meet the guidelines, even when they are really not good candidates for device implantation due to factors such as co-morbid conditions or end-of-life preferences. The mere existence of these guidelines (and the fact that they are considered more than just guidelines, more like federal statues, the violation of which could result in monetary damages and even jail time) results in pressure to implant ICDs on everyone who technically meets the guidelines — which I think is a bad thing. This eagerness to implant in everybody who meets the guidelines may stem in part from the litigious nature of society, i.e. the fear that if I don’t implant an ICD in a patient who meets the guidelines and that patient dies (as he or she invariably will!), I will be subject to a negligence lawsuit. Other factors may be intellectual laziness, profit motives, and lack of time to have a full discussion with the patient about the pros and cons of device implantation. It is so much easier (and quicker and profitable!) to implant in everyone who meets the guidelines, and this approach has the added advantage that no one will sue you or arrest you — your actions are covered by the published guidelines. But it is a betrayal of what should be a private contract between the patient and the physician. It is a step away from a humanistic approach to medicine and towards a form of medicine that can be delivered by a computer programmed to follow the guidelines. It is algorithmic medicine. Certainly patients need to be told whether or not an ICD is recommended based on simple data such as their ejection fraction, heart failure class, and so forth. But they also need to know the downsides of implant and the effect or lack thereof on quality of life — all the things so eloquently discussed in Dr. Mandrola’s post. This decision is between the doctor and patient alone. Leave the lawyers, the guideline writers, the coders, the insurance companies and the federal government out of it. In my former life as a Professor of Medicine at the University of Colorado I used to tell trainees that the field of Medicine was both a Science and a Humanity. In our eagerness to please the arbiters of “Best Medical Practices” we are in danger of losing the human side of Medicine.