The power of the specialist physician — and stewardship

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My latest column over at discusses the disordered balance of power in the doctor-patient relationship.

As most of you know, I harbor strong biases about the quality of medical decisions, especially in the elderly. Attached. Yes, I am attached to the issue of decision quality. Nearly all of electrophysiology, and much of cardiology, involves preference-sensitive decisions. This means doctors are called to align treatments with the goals of the patient. We hold great power; we must use it justly and wisely.

My latest essay arose from an unusual source. The prominent medical journal Circulation Outcomes publishes a section they call Caregiver Viewpoint. The editors aim to understand patients’ experience of cardiovascular disease. Patients, families or caregivers write articles that explore the effects of treatment–on them. (Remember Dr. Montori’s discussion on the burden of care.)

You can imagine that this exercise–of looking at how patients experience communication, decision making, care coordination, access, cost, timeliness and safety–could get thorny for doctors.

In the latest Caregiver Viewpoint, two physician daughters wrote about their Dad’s experience with an ICD at the end of his life. Their father, a retired psychiatrist, survived a cardiac arrest at age 79. He had an ICD and stent placed at that time. He then did pretty well. The ICD never had to act. He aged. So did his ICD, which developed a lead problem that forced a medical decision at age 86. He faced two choices: deactivate the device (because a malfunctioning lead can cause inappropriate shocks) or undergo a risky lead revision surgery.

The bulk of the story centers on the daughters’ view of their Dad’s experience with his specialists. They felt he experienced less than ideal decision quality.

Here is the title and link of my essay: The Specialist: With Great Power Comes Great Responsibility

If you read it, take time to look at the comments. My good friend Dr. Jay Schloss took issue with both mine and the daughters’ one-sided viewpoint. His words made me think.


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