By Lloyd W. Klein, MD

A patient brings a unique context and perspective to medical decisions that the physician cannot emulate: the choices made will impact the patient forever.

We learned in medical school that the physician must listen to the patient almost to the point of cliché, yet interventional cardiology guidelines and appropriate use criteria (AUC) for coronary revascularization as written expressly exclude such considerations. Rather, physicians select the proper treatment strategy based on the evidence, and when the data clearly show that a particular option is superior, that approach should always be presented to the patient as the preferred one.

However, when there are advantages and disadvantages to contemplate, the various alternatives should be discussed in detail. The current AUC presume the absence of extenuating circumstances, and generally disregard the essential role of patient preference as to what treatment strategy should be employed. Since every patient is unique, and nearly all have preconceived opinions concerning treatment choices, these premises oversimplify decision making.

For example, a 59-year-old referring physician confided to me one day at lunch that he had been having shortness of breath during intercourse for 6 months. He had no chest pain, and had no symptoms with any other type of exertion or stress. Long story short, his symptoms completely disappeared and have remained in abeyance for 3 years following a stent to treat a mid-LAD stenosis. I did not attempt medical therapy and he would not have accepted it; moreover, I have no idea how his symptom should be classified on the angina scale. These reflections would appear to be senseless in this context, except that the procedure would be considered "inappropriate" according to the AUC.

Incorporating Patient Perspective in the Guidelines

As a member of the AUC technical panel, I am familiar with the reasoning that underlies the matrix constructed for stable ischemic heart disease (SIHD): according to the COURAGE trial, there should be no incremental survival benefit to a stent versus optimal medical therapy in my patient's circumstances despite greater cost. But are body and greenback counts the only endpoints we should recognize?

Reducing or eliminating symptoms and enhancing quality of life (irrespective of whether the symptoms are disabling or if medical therapy has been attempted first) are important from our patients' perspective and ought to be part of the decision-making process. Why shouldn't patients participate in defining the goals of their treatment? And, why should physicians have to choose between serving the patient's expectations or violating the AUC criteria? Shouldn't these be on a parallel path? From my patient's viewpoint, the treatment strategy I advised was truly a patient-centered approach, and one he thinks was totally appropriate.

The complexities of clinical decision-making cannot be approximated with a matrix composed of five or six variables. Usually, physicians take a heuristic approach, in which every new detail or piece of information can alter considerably the context and implication of what came before. We often obtain information in an order that does not correspond with its relative importance, yet we must process it in relation to its value in making the judgment. In that sense, doctors make decisions algorithmically, and if we could diagram its development, our thinking might resemble a winding road. There may be bits of data that are unexpected and unlikely, but when discovered, could reasonably alter the apparent trajectory: e.g., a patient who refuses surgery because his brother died during that operation, or someone who consistently has adverse effects with medications and is thus apprehensive of that treatment method.

Future Directions

ACC is currently in the process of revising the 2012 Coronary Revascularization Appropriate Use Criteria. ACC's Interventional Council and SCAI worked together to develop and submit a set of recommendations for consideration, which are currently being reviewed by the Appropriate Use Criteria Task Force and Coronary Revascularization Appropriate Use Criteria Writing Group.

The next generation of AUC should evaluate cardiologists in the context of how decisions are actually made. An outside agency cannot rationally determine whether a decision is appropriate without considering all of the factors that influenced that choice. And, with the possibility of reimbursement tied to such assessments in the near future, the stakes have never been higher to get this right, every time. A practical concern as to whether this might create a loophole is easily allayed by measuring how often an operator cites this reason for otherwise nonindicated decisions.

Perspective and context convey meaning. No capable physician makes treatment decisions discounting the patient's viewpoint. Shouldn't the way in which our skills are appraised reflect that experience? By restructuring the AUC to pragmatically address the realities facing clinicians on a daily basis, they will be strengthened and become a more valid assessment tool.

Lloyd W. Klein, MD, is Professor of Medicine, Rush Medical College, and Advocate Illinois Masonic Medical Center in Chicago.

Keywords: Physicians, Choice Behavior, Decision Making, Quality of Life, Constriction, Pathologic, Dyspnea, Patient Preference, Stents

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