A recent Bloomberg headline screamed “doctors use euphemism for 2.4 billion in needless stents,” a reference to the appropriate use criteria language change from “inappropriate” to “rarely appropriate.”  If only it were that simple.

The author, like most non-medical novitiate, wishes to perceive medicine as crisp, clean and unambiguous, governed by a set of inviolate rules to which adherence should be absolute and deviation considered detrimental.

The painful truth is that the medical decision making process is messy, its subtlety difficult to articulate, and in the vast majority of cases a decision’s direction is tinted by the life experiences of the patient and their family, the medical version of “beauty is in the eye of the beholder.”  And so it is with “inappropriate” and “rarely appropriate,” categories simply reflecting that sometimes a patient’s decisions just go against the rules, and sometimes the circumstances are simply extraordinary.

But there are other issues afoot in the appropriate use criteria, unspoken and somehow considered perfunctory.

One is that they are decidedly one-sided, sins of commission whose criteria is not just medical necessity but “financial gain.”  Let’s face it, we would not have appropriate use criteria for stenting if it cost $10 a patient. The sins of “omission,” perhaps viewed as “inappropriately” not doing something are held to a different standard, the purveyors of this “inappropriate” care alternately called “compassionate” caregiver or “defendant,” again depending upon your perspective.

Another issue is the assumption that the decision maker is medically literate and fully informed.  Who decides and monitors what information is “appropriate” and correctly shared with the patient, what is “uncertain,” and most significantly what is “inappropriate?”

Several things are, however, starkly clear and outside the realm of appropriate use criteria.  Implanting a stent where there is no stenosis is a criminal assault and should be persecuted to the fullest extent of the law.  Lying to a patient regarding the benefits of a procedure in clear contradistinction to currently accepted medical doctrine, then benefiting financially from such a procedure while perhaps not criminal is certainly fraudulent and should be dealt with severely.  Neither situation should be handled by some twisted attempt to apply the appropriate use criteria.

But what are we to do?

First, we need to have “intervention boards” just as we have “tumor boards” to review elective cases, be sure that the patient is informed fully and help with a discussion of the benefits and risks implied in the appropriate use ratings which capture current best practices.  These are, after all, elective cases in which such a time constant would be acceptable. These decisions should be complemented by early engagement of the patient’s primary care physician, their general cardiologist, and others significant to the patient’s decision making.  This must include a conversation about the nature of coronary disease, the role of imaging, medications, procedures and lifestyle to ensure the care is responsive to individual preferences.

This seems to me to be the only reliable mechanism to assure the patient that they have been fully appraised of their choices and would serve to educate our physicians as what is “appropriate” while preserving the doctor patient relationship by having the patient’s physician do the procedure.

Secondly, we as a professional body need to refuse to allow those among our ranks who seek to use patients as an annuity for their own profit.  To allow such behavior is to condone it and that is simply a euphemism for “guilty as charged.”

I would like to hear your thoughts.

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