[I wrote this in the spring of 2006, when articles came out about possible of conflict of interest in surgeons who treat atrial fibrillation. This appearance was created by their having financial stake in the device they use for their procedure.]

A patient’s perspective on success rates, competition amongst surgeons,

and commercial conflict-of-interest:

As a patient, I am interested in getting the best possible treatment for my particular condition, and in finding the best doctor to do this treatment. 

As I go about making this very important choice: 

1)     I need to have good data on success rates and on possible complications that I can use in making comparisons among procedures and doctors; and, 

2)     I must believe that doctor is not  engaged in other activities that might get in the way of doing the best that he can for me.

I am not sure that either of these criteria is being met.

Let’s look at success rates. Ideally, success rates should be presented in  table, whose dimensions would be:

• Type of atrial fibrillation: continuous vs. intermittent

• Definition of success: NSR + off all medication;  or NSR with some medication

• Chronicity (length of time in either continuous or intermittent AF

The name of the doctor doing the procedure and the length of follow-up time on which the rates were based would also be included, along with the number of cases on which the success rates were based. These cases should be ones in which the doctor was the primary surgeon or EP, because his personal rates may be different from the averages reported in the literature for the procedure as done by others.

These dimensions are simplified in the table below. There will be more gradations as categories are refined on the basis of their relevance for treatment, and when there are enough cases to provide an adequate number for each category.

% of Success at [how many] Months/Years for [how many] Treatments for Atrial Fibrillation

                                                                                                    done by Dr _______

      * ... or whatever period of time is considered relevant to choice of treatment or likelihood of success

You will also want to know the reasons for failures, so you can determine whether these reasons might apply to you.

You will also want to know the percentage of complications that occurred with what type of patient so that you can try to determine the risk the procedure poses in your particular case.

And you will want to know the success rates of different post-operative responses; for example, for those who convert during the operation and remain continuously free of AF vs. those who have some AF during some number of months after the operation. These could all be reported in separate tables.

As has been pointed out elsewhere, there are a number of obstacles to the reporting and comparison of meaningful success rates:

•  The sample sizes of new or constantly changing treatments are not big enough to provide reliable estimates of success. A finding based on a few cases will be less likely to be replicated. And a big spread around the means (averages)  for two or more groups can make comparisons meaningless. 

•  Success rates for treating different types of AF are not presented. People still are using different sets of dimensions to categorize AF.

•  The definition of success varies. A single rate will sometimes be given which includes patients that are off- or on medication or who are on a reduced dose.  

• Success rates are given for varying time periods: 3 months, 6 months, 1 year – periods that are terribly short when compared to the track-record length of treatments for other illnesses.

•  The presence or absence of AF after a period of months is sometimes determined by a monitor reading, and sometimes by a much less reliable verbal report over the phone.

What a mess! As a medical consumer, I would hope to get the same kind of data that I would get, say, on the safety and performance of an automobile that I was thinking about buying.

So, what is going on?  Certainly, problems are inevitable in evaluating treatments that are new and evolving and therefore present “moving targets” for evaluation. And research is only one of the activities of doctors who are busy treating patients, teaching and traveling. But I would hope that they are keeping a running total of how they are doing using the dimensions in the table above.

I wonder about the effects of competition and money on the reporting of success rates.

I have wondered whether doctors are looking over their shoulder at the rates of others and feeling pressure to report equal or better ones. Because of the internet, these rates can be widely publicized. Probably “advertised” is a better word. Since more and more prospective patients are googling and comparing these rates, and there can be a rush to sign on with the doctor with the highest rate.

I have wondered if this situation leads to reports that gloss over distinctions both between rates for different types of AF and between different definitions of success.  

Success rates will be highest both for those with intermittent, non-chronic AF and when “successful” cases include those who are still on medication. Success rates will also be highest when it is defined as freedom from NSR after a short period of time and when presence of NSR is determined from verbal reports. So over-all success rates are impossible for a patient to apply to his situation or to compare with the rates of other doctors without further explanation.

Personal competition with other doctors is not the only factor that can potentially distort success rates. Well-known surgeons who treat AF apparently have financial interests in the devices they are using or have helped develop because they have been signed as paid consultants. Sometimes payment includes stock options, which increases the perception of conflict of interest, especially when the fees are substantial (see articles cited below).

I have wondered whether this situation might lead to lack of reporting of problems with a device, or the honest comparison of a device with another with regard to advantages and disadvantages.  I have wondered whether a doctor could or would use a device instead of or in addition to the one made by the company whose  payroll he is on.

Hospitals may be another factor in increasing pressure to report success, as treatment of an increasing number of cases of AF is a big money-maker.  Wait until the baby-boomers hit the market!

The situation is similar to that of politicians, where to the outsider, it seems clear that idealism and self-interest are fighting a running battle.

I cannot see into the minds of doctors as a group or measure the motives of any individual doctor and determine how he resolves this conflict.

I do know that patients tend to put their doctors on a pedestal of idealism and expect them to put the interest of the patient first.

I can also see that often when the power and money that come from winning a competition are at stake, idealism can take a back seat, so that safeguards must be put in place to protect the public interest.

Medical journals have already done this by requiring that doctors divulge any business involvements that might be perceived as influencing their research.

(See how this rule has been broken in a Dec 12, 2005  Wall Street Journal article: “How a famed hospital invests in device it uses”    http://www.post-gazette.com/pg/05346/621193.stm  )

(Also see http://www.bizjournals.com/industries/health_care/physician_practices/2005/12/26/cincinnati_daily12.html )

For now, one can only hope that doctors will be completely forthcoming about their commercial involvement. They should learn from politicians that perceived defensiveness and attempts to cover-up can be extremely costly, and that once trust is lost, it is difficult to regain.  It would be in their and our best interests for them to do everything that they can to reassure their patients -- not that that we are  their only concern, but that we come first.

After that, we must rely on the trust that comes from our interactions with our doctor, plus, unfortunately, a leap of faith.