{"id":28253,"date":"2012-04-16T08:00:37","date_gmt":"2012-04-16T12:00:37","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=28253"},"modified":"2012-04-13T07:58:33","modified_gmt":"2012-04-13T11:58:33","slug":"the-audible","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2012\/04\/16\/the-audible\/","title":{"rendered":"The Audible"},"content":{"rendered":"

CardioExchange welcomes this guest post from\u00a0Dr. Westby Fisher, an electrophysiologist practicing at\u00a0NorthShore University HealthSystem in Evanston, Illinois, and a Clinical Associate Professor of Medicine at\u00a0University of Chicago\u2019s Pritzker School of Medicine.\u00a0This piece originally appeared on his blog,\u00a0Dr. Wes<\/a>.<\/em><\/p>\n

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The EKG hung outside the door with a new name attached. On a cursory glace, it looked pretty normal. He entered the room. There before him was a relatively young patient, medium build, nothing unusual. The computer schedule suggested it was just another case of atrial fibrillation (AF). You\u2019ve got an hour, he thought. Plenty of time. But he knew there was never just another case of AF. There are just too many plays in the playbook for this disorder.<\/p>\n<\/div>\n

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But he was a seasoned veteran at the game. He had seen most things and had strategies for most of them. If X, then Y. If Y, then Z. Not that hard, really. Most of the time. But this was not to be \u201cmost of the time.\u201d<\/p>\n<\/div>\n

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He reviewed the story, examined the patient, and reviewed the tracings. Delightful patient: productive, married, young kids, otherwise healthy, no risk factors for stroke. Amongst the screens and screens of collected data on this nice person, there it was: classic paroxysmal AF with relatively fast ventricular response, starting and stopping, starting and stopping, again and again on the Holter recording.<\/p>\n<\/div>\n

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At first, it seemed like a chip shot: \u201cI can fix this<\/em>.\u201d<\/p>\n<\/div>\n

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Until he inquired further. \u201cSeriously, you don\u2019t feel this<\/em>?\u201d<\/p>\n<\/div>\n

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Didn\u2019t feel a thing. Felt fine, in fact. If it weren\u2019t for the spouse, the patient wouldn\u2019t be here.<\/p>\n<\/div>\n

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He paused.<\/p>\n<\/div>\n

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\u201cBut I can fix this!\u201d<\/em><\/p>\n<\/div>\n

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Then he thought: \u201cBut what if the cure is worse than the disease? What if there was a complication? What if he made things worse instead of better? Imagine a stroke in this person, this parent, this worker. How much better can you make someone who\u2019s asymptomatic<\/em>?\u201d<\/p>\n<\/div>\n

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\u201cBut I can fix this!\u201d<\/em><\/p>\n<\/div>\n

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There are a million things we can do to patients with AF: ablations, cardioversions, atrial occlusion devices, lariats, endocardial and epicardial mazes, all in the interest of curing the disorder. Our training, skills, equipment, reimbursement, marketing teams, egos, productivity clauses, and culture of care constantly drives this process. In turn, we splash the happy patient who was cured from their disorder across our billboards, ever eager to do more.<\/p>\n<\/div>\n

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But what most people will never see is the patient who is turned away; the one for whom doing nothing invasive was the safest and best treatment, even though the procedure, more likely than not, would have been successful.<\/p>\n<\/div>\n

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Such a play is not sexy. It\u2019s not innovative. It occasionally results in an adverse patient online rating. And for the system, it\u2019s not lucrative.<\/p>\n<\/div>\n

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But\u00a0good medicine often calls an audible to the playbook.<\/p>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Every electrophysiologist knows there are a million things that can be done for patients with atrial fibrillation. But sometimes not doing an invasive procedure is the best choice.<\/p>\n","protected":false},"author":1177,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[13],"tags":[238,341],"class_list":["post-28253","post","type-post","status-publish","format-standard","hentry","category-electrophysiology","tag-ablation","tag-atrial-fibrillation"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/28253","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/1177"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=28253"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/28253\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=28253"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=28253"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=28253"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}