Surgeons & EPs who treat atrial fibrillation  and their Prospective Patients

At present, the information patients need in order to chose a procedure to treat their AF and to select a doctor to do it is pretty scarce.

I think that one obstacle is competition amongst doctors, where the winners are those who have performed the most procedures,  who have advertised the highest success rates,  and who quote the lowest incidence of complications. This tempts those with less favorable numbers to be less forthcoming.   

There is more on the problems of competition and related issues in Success rates, competition, and commercial conflict-of-interest  so I won’t go on any more about them here, except to say that there are dilemmas for doctors as well as problems for patients.

There may be some things that can reduce the negative impact of competition on both patients and doctors. Here are a few ideas:

For prospective patients (PPs):

PPs should relax a bit about expecting their doctor to quote the best success rate in the business.

PPs should realize that differences among mean success rates without statistics that take into account the spread of ratings and their overlap among groups may not be statistically- or clinically significant (see Finding out what works for you... ) Furthermore, criteria for success vary in ways that can skew results (see the above article).                

PPs should accept the fact that a doctor may not have collected enough cases to break down success rates for different types of AF (i.e. intermittent vs. continuous), especially if the procedure is a new one.

So, meaningful statistics for your type of AF may not be available.

So what can the PP do?

Well, to find out about a procedure, you can politely insist that you be given what data there is. And, you may be able to get a better idea about a success rates for a procedure by reading the literature and by getting this data from several doctors who do the procedure.

Finding out about doctors is more difficult. Some will have the appropriate statistics, and their number will increase as time permits the gathering of data on more cases. If not, it doesn’t hurt to ask a doctor “Who would you go to have this done – besides yourself -- if you were me?” (Bad grammar!!)  My guess is that doctors find out a lot about each other through personal contact at conventions and conferences and so will be able to answer this question. Some will recommend the doctor who trained them, which is a step up the ladder of expertise.

What I would not do is to depend too much on testimonials or small series of case studies, whether these come from bulletin boards or from doctors’ themselves (see Finding out what works for you …).

On the other hand, BBs are a great source of information about what doctors have said about their procedures to other PPs who have gone to see them. And a BB can be a source of the most up-to-date information available if it presents reports of convention proceedings, as was done by Jackie Burgess of Hans Larsen's LAF Forum, who attended the  Cleveland Clinic Foundation Atrial Fibrillation Summit in October, 2005.   

Great news!! A few doctors have joined a BB (Jack Drum’s A-fibcures ).  In addition to respecting their skill,  I have great admiration for these professionals for taking the time -- or that of their staff -- to answer questions, some of which could be quite challenging. I hope this is the beginning of a trend.

What can a doctor do?

Here are some things I think a PP would want to hear from a doctor they are considering:

Those who have done a large number of procedures and who have good success rates for would report those, of course. The data should be broken down into the number of procedures done as the hands-on surgeon or EP, as opposed to those on which they assisted.

The PP will want to know the success rates for his type of AF. An honest answer may mean acknowledging the limits of a procedure. For example, it may that PVI-centered procedures are fine for intermittent AF, but that the the PP should pay cost of a bit more invasiveness if he has continuous AF.

Here are some other things that a PP might like to know about:;

• where you got your training and with whom (if the person is one of the more recognizable names);

• any recent techniques you have learned;

• how to access research publications or descriptions of your work; 

• descriptions of any special technology you are using and how it effects the procedure;

• what you will do or suggest doing if your first procedure doesn't work;

• anything that assures the patient that you will stick with him or her until the problem is resolved.

I think being able to adapt to new development is important. especially in a field that is developing as rapidly as treatment for AF.  Learning new techniques, or combining parts of another procedure with your own is impressive (I happen to know of one doctor that has done both of these things).

[As a PP, I have wondered about a couple of other possibilities. What about using a combination of energy sources to make use of the  advantages of each (RF/microwave+HIFU?).  Hopefully, a business connection with the maker of a device wouldn't prevent this kind of combination (see Success rates ,,, commercial conflict of interest ).  Or present your treatment as a series of steps, reframing the possible failure of a first procedure (which would be either catheter ablation or surgery) as “step one” that would often be followed by “step two”, which would be a “touch-up” procedure. It appears that some EPs are already doing this. ]

Here are a few things that can be reassuring coming from practitioners who have done relatively few procedures:

Experience with procedures that would transfer to the one you are offering. For example, a surgeon may have done lots of the more invasive full Cox mazes, but few of the latest version of the Cox mini-maze.

Mentoring. This would mean that the doctor who has done relatively few procedures can tell the PP,  "When I do your surgery, Dr S____ who has done a great many of them will be there helping."

Technology can also level the playing field: Robotics and 3-D imaging are examples of developments that can make the procedure a more effective, replicable, and safe undertaking, depending less on the artistry of a gifted few with extensive experience. In other words, technology can make for a lot more winners in the competition for success and for patients.

In conclusion...

Some PPs are suffering a great deal and extremely anxious about what to do. They will want assurances that a your procedure will completely solve their problem. So I would think deciding on the mixture of reassurance and reality that you communicate could be a tough call ...

Thanks for listening!      

 

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