February 12, 2016 | James W. Hansen, DO
Education

Reflexes are an unconscious motor response to an outward stimulus, hard-wired into our neurologic system. The oculostenotic reflex is the stent deployment upon visualization of coronary disease. As cardiologists, the urge to fix things is to be understood and expected. We have gone through many years of training, seen many patients, seen many of them die, and now find ourselves in a unique position of making a difference. Or are we? Our nature implores us to fix what we know to be broken, to help one of our fellow humans. How can we not be saving someone’s life? And yet, the data tells us that we may not be.

Percutaneous revascularization, as tempting as it might be, is not always, or even often, the right answer. What about patients undergoing surgery? No. What about the guy with stable angina? No. What about the delayed presentation ST-elevated myocardial infarction? No. Three vessel disease? No. Two vessel or proximal LAD disease in diabetics? No. All of these things are, of course, subject to the clinical scenario as well as to change as technology advances, but at this point we risk doing more harm than good.

This is not new information, but it bears particular importance to FITs. As a first year fellow, one has a difficult enough time navigating this new world. Yesterday, you were an internist (or internal medicine resident) consulting cardiology. Today, you are the expert. In the cath lab, you spend your first week wondering where to stand, hesitating to breathe. Holding a needle, getting access, advancing a wire, clearing a manifold – all of these things are done with serious concentration, fearing the disdain of the attending, or worse having the tools taken from you. There is a serious high when you get to engage your first coronary artery. The contrast snakes its way down the vessels – and there it is: coronary artery disease.

The question of percutaneous coronary intervention is now on the table. What approach should we take? Drug eluting or bare metal stent? Heparin or bivalrudin?

In this excitement is when the most valuable lesson needs to be learned.  Just because it is within your power, it does not mean it is the right thing to do.  More colloquially, you have been handed the hammer, not everything is a nail. This is the opportunity to demonstrate why you chose to become a physician; why someone saw a physician in you. It was not because of an impulsive, trigger-finger attitude. At some point, you demonstrated the temperance of a physician, Dr. Osler’s famous Aequanimitas. By your career choice, you have been given a certain degree of power, accompanied by a higher level of responsibility than most. This is where your conscious brain must override the reflex. Knowing when not to exercise our skillset is the real power.

If our own sense of responsibility does not implore this moment of pause, then our sense of self-preservation will have to take its place. Cardiology, particularly intervention, is a common place for scrutiny among payers including the federal government. If we do not exercise discretion, we will have to answer before our own conscience and possibly a federal judge.

Intervention may be appropriate, but it is our obligation to know the data, to know the appropriate use criteria, and to make the best decision for the patient, not the best one for our egos or our wallets. Remember, hammers also break things.

This article was authored by James W. Hansen, DO, a fellow in training (FIT) at the Penn State Hershey Medical Center.