One of my fellows gave a discharge summary for a 62 year old patient with stable diabetic CAD who had Triple vessel disease with a final advice reading as CABG / PCI/or OMT .
There was a near fury over his angiogram report in the cath meet. How can be eligible for all the three Intervention at the same time ?.(PCI -Percutaneous coroanry Inervention ,CABG-Coroanry artery by-pass graft, OMT-Optimal medical therapy )
The lesion in question was , Triple vessel disease(Non critical LAD) and significant LCX and again a non critical RCA .Syntax was less than 22 for sure , however the patient had class 2 angina (now reducing ) .When asked to explain , the fellow argued since the patient is symptomatic , has DM with TVD he is eligible for CABG , since LCX lesion was discrete and PCI was distinctly possible , of course as all three lesions would be eligible for OMT on any given day ! he inferred .
How can a cardiologist be so casual and non-commital in an important medical decision where a life of a heart is at stake.There was a unanimous condemnation about the report. As a consultant he has to be specific , one can’t leave the decision to your patient’s whims . . . rather it’s our scientific whims that should prevail !
The curiosity continued and looked amusing for many. I was the only one supporting his argument ! After all , he is being frank and understood the futility of applying evolving knowledge base in critical decision making. But, I asked him to grade the choices .In my opinion OMT should be the first choice if it can be administered , but reality tells me true OMT is rare as a modality at-least in this part of world . However every one should insist for it.
Apart from poor compliance for OMT , pressure mounts for a procedure from peers and non peers . I am sure many patients will end up with an invasive modality sooner or later backed by a second or third opinion driven by that elusive googled intellect !
Final message
When clinical decision making is debatable with available knowledge (Especially with futile and evolving knowledge base !) , please include your patient into the debate and you may even consider giving him the veto power.If Hippocrates is alive today , I am sure he will argue for medical knowledge and ignorance should be equally shared with their patients.
Counter thoughts
Don’t give the choice to your patient . . . that would mean you lack clarity, wisdom and confidence !
No, I don’t agree , I know there are some patients who are well informed , rational , more focused than even a professional !
Dr.S.Venkatesan MD 