COMMENTARY

Three Concerning Trends in the Electrophysiology Clinic

John Mandrola

Disclosures

October 31, 2014

The essence of electrophysiology is pattern recognition. I like to say heart-rhythm doctors are trained observers. What follows are three changing patterns I've noticed in my office practice. I write of these patterns because fixing things in medicine first requires seeing the problem.

Trend 1: Creating Unnecessary Fear

More and more, I feel like I am in the fear-removal business. Heart-rhythm issues have always scared patients and doctors. Lately, though, it seems worse. "You must see this patient as soon as possible." "What for?" I ask. "Premature ventricular contractions [PVCs]. They are causing all kinds of problems; she and her family are very concerned."

Then, when I saw the patient, I learned she didn't have symptoms. She felt well. Her heart tested normally on numerous expensive tests.

This patient was fine until she saw doctors. The premature beat was discovered on an unnecessary ECG[1] during an unnecessary yearly check-up[2] at her primary-care doctor's office. The healthcare machine almost succeeded in making a well person unwell.

Although I chose a PVC case, I could have used asymptomatic bradycardia, atrial ectopy, erroneous computer ECG readings, or a host of others. The pattern here is a collective disconnect with the cardinal rule of doctoring: if a person tells you she feels well, your first responsibility is not messing that up.

Why are data distracting us from seeing the human being before us?

Trend 2: Too Much Testing; Too Little Communication

Another pattern I am noticing is the withholding of vital information, especially when it involves lifestyle choices. I recently saw a patient with a pesky but benign arrhythmia. The patient sought me out because he was unhappy with his first cardiologist. Why? Did the previous doctor do anything wrong? No. Well, maybe. You decide.

This patient's cardiologist, one of our state's highest Medicare billers, ordered an echocardiogram, nuclear stress test, and multiple cardiac monitors. After thousands of dollars of testing, the patient told me the specialist came in the room and said there was nothing wrong with the heart. And that was it. The (productive) doctor then left the room.

Technically, the first cardiologist was correct. And, on a spreadsheet, he delivered quality care. But now the patient was seeing me for treatment of his chief complaint—the abnormal heart rhythm.

The solution in this case, which is another obvious pattern here in Kentucky, one of America's least healthy states, was lifestyle adjustments. His arrhythmia promptly improved with diet changes, sleep measures, and regular exercise.

Why did it take a board-certified electrophysiologist to offer basic health information?

Trend 3: Managing the Disease and Not the Person

Another trend in my office practice is an increase in second (and third) opinions for the treatment of atrial fibrillation. What is going wrong with the first opinions? In most cases, it is not mismanagement of the disease atrial fibrillation, but rather, a failure to manage the person with atrial fibrillation.

When patients seek me out because their first ablation for AF did not control the disease, the issue is most often a communication problem rather than an ablation problem. If I ablate a person with AF and he is surprised the index procedure did not control the symptoms, I consider this a failure of communication. Honest EP doctors report single-procedure AF-ablation success rates of . . . well . . . let's just say they report their results honestly. Well-informed patients, thus, aren't surprised to learn they may require a second procedure. They know that overzealous ablation in the first procedure exposes them to danger.

People management is a vital part of AF care. If I could say one thing to the cardiology community about AF, it would be to stop seeing AF as an electrical disease that can be "fixed" like paroxysmal supraventricular tachycardia (PSVT). Instead, I suggest seeing AF as a window onto the health of people.

Management of people with AF requires candor about obesity, sleep apnea, alcohol intake, hypertension, aging, and perhaps less appreciated, the inflammation inherent in always being on the gas—physically, mentally, and emotionally. AF patients must also hear the truth about the limits of our treatments.

I am surprised health-policy people have not seen arrhythmia, particularly AF, as a disease of emphasis, like pneumonia, heart failure, or venous thromboembolism. I look forward to that day. Maybe then, with the bundled payments and monies for extra educational resources, such as advanced nurses,[3] electrophysiologists will have more time to use their hard-won talents in the EP lab, rather than in the office undoing fear and promoting that which should be obvious—the healing powers of good sleep, good food, good movement, and good attitudes.

JMM

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