It is not surprising that patients do not understand the issues. Goff et al.(1) found that cardiologists tend to overstate the benefits and understate the risks of angiography. They “found evidence that cardiologists may contribute to patients’ misperceptions of benefit through explicit or implicit overstatement of benefits, understatement of risks, and communication styles that may hinder patient understanding and/or participation in decision making.”
While attending the annual Veith Symposium in New York, a conference for vascular surgeons and interventional cardiologists and radiologists, I have often heard the term “ticking time bomb” used in reference to asymptomatic carotid stenosis, a condition that in 90% of cases is better treated with medical therapy than with endarterectomy or stenting (2). That phrase turned up in research by Helen Reifler and Pamela Wescott of the Foundation for Informed Medical Decision among patients considering intervention for asymptomatic carotid stenosis, during focus groups they conducted in San Diego (3).
“Cardiologists and cardiac surgeons frequently resort to frightening verbiage in summarizing angiographic findings. This no doubt compels unquestioning acceptance of the recommended procedure. Over the years I have heard several hundred expressions, such as: “You have a time bomb in your chest” and its variant “You are a walking time bomb.” Or, “This narrowed coronary is a widow maker.” And if patients wish to delay an intervention, a series of fear-mongering expressions hasten their resolve to proceed: “We must not lose any time by playing Hamlet.” Or, “You are living on borrowed time.” Or, “You are in luck — a slot is available on the operating schedule.” Maiming words can infantilize patients so they regard doctors as parental figures to guide them to some safe harbor.”
This pattern of communication is all too common, and probably not only perpetrated by cardiologists. Patients deserve better.
References
(1) Goff SL, Mazor KM, Ting HH, Kleppel R, Rothberg MB. How Cardiologists Present the Benefits of Percutaneous Coronary Interventions to Patients With Stable Angina: A Qualitative Analysis. JAMA Intern Med 2014;174:1614-21.
(2) Spence JD, Pelz D, Veith FJ. Asymptomatic Carotid Stenosis: Identifying Patients at High Enough Risk to Warrant Endarterectomy or Stenting. Stroke 2014;45:655-7.
(3) Reifler EJ, Wescott P. Carotid Endarterectomy A Shared Decision Making Lost Opportunity. 16-6-2009. http://www.powershow.com/view/122b6b-MzBkY/Carotid_Endarterectomy_A_Shar... Presented at the International Shared Decision Making Conference, Boston, MA, Foundation for informed medical decision making. Accessed October 7, 2014.
Competing interests:
No competing interests
15 October 2014
J. David Spence
Physician
Robarts Research Institute, Western University
Stroke Prevention & Atherosclerosis Research Centre, 1400 Western Road, London, ON, Canada N6G 2V2
Rapid Response:
It is not surprising that patients do not understand the issues. Goff et al.(1) found that cardiologists tend to overstate the benefits and understate the risks of angiography. They “found evidence that cardiologists may contribute to patients’ misperceptions of benefit through explicit or implicit overstatement of benefits, understatement of risks, and communication styles that may hinder patient understanding and/or participation in decision making.”
While attending the annual Veith Symposium in New York, a conference for vascular surgeons and interventional cardiologists and radiologists, I have often heard the term “ticking time bomb” used in reference to asymptomatic carotid stenosis, a condition that in 90% of cases is better treated with medical therapy than with endarterectomy or stenting (2). That phrase turned up in research by Helen Reifler and Pamela Wescott of the Foundation for Informed Medical Decision among patients considering intervention for asymptomatic carotid stenosis, during focus groups they conducted in San Diego (3).
A blog post by Dr. Bernard Lown at http://bernardlown.wordpress.com/2012/03/10/mavericks-lonely-path-in-car... includes the following:
“Cardiologists and cardiac surgeons frequently resort to frightening verbiage in summarizing angiographic findings. This no doubt compels unquestioning acceptance of the recommended procedure. Over the years I have heard several hundred expressions, such as: “You have a time bomb in your chest” and its variant “You are a walking time bomb.” Or, “This narrowed coronary is a widow maker.” And if patients wish to delay an intervention, a series of fear-mongering expressions hasten their resolve to proceed: “We must not lose any time by playing Hamlet.” Or, “You are living on borrowed time.” Or, “You are in luck — a slot is available on the operating schedule.” Maiming words can infantilize patients so they regard doctors as parental figures to guide them to some safe harbor.”
This pattern of communication is all too common, and probably not only perpetrated by cardiologists. Patients deserve better.
References
(1) Goff SL, Mazor KM, Ting HH, Kleppel R, Rothberg MB. How Cardiologists Present the Benefits of Percutaneous Coronary Interventions to Patients With Stable Angina: A Qualitative Analysis. JAMA Intern Med 2014;174:1614-21.
(2) Spence JD, Pelz D, Veith FJ. Asymptomatic Carotid Stenosis: Identifying Patients at High Enough Risk to Warrant Endarterectomy or Stenting. Stroke 2014;45:655-7.
(3) Reifler EJ, Wescott P. Carotid Endarterectomy A Shared Decision Making Lost Opportunity. 16-6-2009. http://www.powershow.com/view/122b6b-MzBkY/Carotid_Endarterectomy_A_Shar... Presented at the International Shared Decision Making Conference, Boston, MA, Foundation for informed medical decision making. Accessed October 7, 2014.
Competing interests: No competing interests