Month: September 2020

As readers of this blog might surmise, I am an avid believer in science and keeping an open mind. Dogma is the antithesis to scientific method. The ability to accept that known science may be wrong, is the underpinning of modern scientific method. The advent of COVID19 has changed everything. The nearly 1 million deaths worldwide are a tragedy, but the impact of COVID19 may have much more far-reaching consequences. Imagine if the events of the 1918 pandemic or the Black Plague had resulted in halting of the quantum mechanics and the industrial revolution respectively. The ability of modern medicine to save lives would have been stunted, resulting in billions of deaths. A sort of “butterfly effect”.

Science is under threat today.

Evangelical and religious people are not that threat. It is possible to both be a believer and to have faith and yet, accept science. Science is under threat from within. The core of our community has significant rot, where dogma and petty cronyism as well as politics have reared their ugly head.

Let me give you an example. As the proud few, that make up the readership of this blog, will recall, I signed up to receive the Moderna vaccine against COVID 19. I did it because I went through the due diligence to assure myself that the trialists and the technology proposed made sense. I did so, not as an expert in vaccine design, but as someone that believes that there have to be scientific underpinnings to any approach. Satisfied with the propriety of methodology, I have since received both the primary and booster doses.

The greatest pushback that I have experienced about doing so, has not been from rural farmers or evangelical priests or even some of my mask-refusing compatriots, it has been from so-called people of science: doctors, nurses and self-professed scientists.

This is indeed a surprise.

When I signed up for this, I thought there would be a crush of those who believed in science, lining for this. In fact, my experience is to the otherwise. I do not know of any of my colleagues – in medicine or science – who have agreed to receive the trial vaccine. When asked why, the replies are variants of a single theme:

“I don’t know if it is safe and I’m not willing to take a chance.”

Really?

If people of science do not sign up to these studies, then why should your patients or the public, believe in your scientific edicts. A randomized quadruple blinded research Phase III trial is as scientific and safeguarded as it gets.

Can bad effects occur?

Absolutely.

But I would rather these occurred in a scientific study and not during a wider release of the vaccine.

Many of my colleagues are so-called clinical researchers. This involved convincing patients to try “experimental” treatments. This adds to their scientific glory and promotion prospects. Yet, none of them, are willing to consider this a scientific endeavor that is necessary to change the world.

COVID19 has changed everything. As we wait for the second surge, the IHME modeling suggests mortality this fall, that will make heart disease sink to a second place. We need ALL the tools we can get to deal with this. the first step is accepting and enjoining scientific method as the single most effective tool against this.

I am a scientist and a devout believer. I respect the faith of those who believe in the almighty’s deliverance. I believe that science is a gift to Humankind from the Divine. While the role for faith is something I cannot explain or understand, as a physician, I have seen miracles abound. It does not dim my devotion to science.

The threat to science is not from maskless Evangelicals. It is not from creationists. It is not from the rural farmer who worries about how he/she will make payroll in these times. It is from pseudo-scientists out there, who would be happy for patients to enroll in their well-paying pharma-company sponsored trial, but lack the moral turpitude to stand up for a vaccine to the greatest threat to humanity in modern times.

I’d like to publish my response to your kind comments on the prior blog post. As an SCAI member, I value my Society and your response. But I would like to point out my specific concerns and some suggestions. 

As a long time SCAI member, it pains me to say that the current activities of the society do NOT reflect my perception of what a professional society for interventional cardiologists needs to be.  In these difficult times, it is becoming increasingly hard to practice as an interventional cardiologist out in the community. With multipronged rivalry from interventional radiologists, cardiac and vascular surgery as well as their strongly supportive professional organizations, many of us face uphill battles as we deal with credentialing and new procedures as medicine evolves. The need of the hour is an advocate for our cause, not a witness for the prosecution.  

While elite operators (read: high volume, academic – not necessarily high quality) prefer that we refer our cases to them – in their cocooned environs – this comes at a cost.

Firstly, the patients often need to travel long distances, and deal with physicians and hospitals they are unfamiliar with. For instance, an 81-year old rural farmer with no family in the city, this is a major issue. On top of that, many of our patients are country folk for whom these large cities and mega hospitals are a forbidding prospect, even prior to their high-risk procedures surrounded by people they don’t know or can’t relate to.

Secondly, as you are well aware, the complexity of disease, driven by aging, obesity and diabetes has only increased. By reducing volume in the community and promoting the “high quality (i.e. high volume) referral center” model, it also means that operators in the community are less confident at dealing with these patients when they present in an emergency at 2AM on Christmas night, when the “referral center” team, tens or hundreds of miles away, is warmly tucked away.

How, then, does taking away procedures from us, the community cardiologists, help the specialty? How does it help our patients? What are the metrics that decide who gets to do what?

Here are my suggestions:

As a former member of the QI and advocacy committees, as well as working with Dawn on the PAC, I am only too keenly aware of how lacking we are in member engagement. These are the concerns that I have heard from my colleagues and in this missive, hope to transmit these to you.

1. SCAI, possibly partnering with industry, needs to take the lead in training operators in the community to enhance the procedures they perform, as well as, engage them in ensuring they have the resources to do these safely. 

2. SCAI needs to find ways to HELP interventionalists negotiate the credentialing processes in their local areas to ensure that they are able to deliver the appropriate and safe care to the patients – IN THEIR COMMUNITY.

3. Rather than focusing on volume metrics, SCAI should help operators in the community with creating QUALITY metrics to enhance the safety and appropriateness of the procedures, because we can do it BETTER than any other specialty. 

4. Mandate that at least 30% of the SCAI leadership, at any given time, consist of community cardiologists (not just academic “leaders”). This will need recruitment and engagement but it is work that needs to be done for the good of the Society and the specialty. 

I do not want this letter to come across as self-serving. I am secure in where I am and am writing to you, out of a sense of alarm, rather than a desire to look for any academic growth. While I am happy to help in ALL the society’s efforts, I do not want to seem like I am angling for a position in this. My only interest is preventing the decline in our specialty and our Society. I remain committed to the ideals of SCAI with the same enthusiasm as I did in 2006 and hope that we can reclaim this lost ground. 

Best regards,

Kartik Mani FSCAI

In the interests of keeping this an open discussion, I am highlighting the reply from the president of SCAI on the blog.

“As President of SCAI, I have made it my mission to represent the membership, not the elitists.
We share your concerns about the “competency” article. Let me assure you that SCAI DID NOT author this article or endorse it. Its publication was a surprise to all of us. The journal CCI publishes many independent articles, as it did in this case.
We are in the process of writing a rebuttal to this article and its harsh recommendations, and to let everyone know that SCAI HAD NOTHING TO DO WITH THIS ARTICLE
SCAI is trying to be inclusive and we’ve created an opportunity to submit cases through SCAI.org, apply for committee membership and is having several webinars where you can give commentary.
Please let me know how we can do a better job.
Cindy Grines”

The society for coronary angiographers and interventionalists is a medical professionals group that portrays itself as a representative for the interventional cardiology community – both in the US and abroad. Things could not be further from the truth. As a card-carrying member of the organization, I would like to bring to light exactly how bad things are. Even if you are not an interventional cardiologist, you may want to read this, just to see how a “professional society” devolves from high ideals to petty protectionism and selfish elitism.

I joined SCAI as a wide-eyed interventional cardiology trainee in 2006. I was dazzled by the camaraderie and focus on quality. A determined effort to maintain high procedural quality and an academic approach – alone – even in the face of strong commercial and industry influence taking over many others. Over the years, as a member, subsequently a Fellow and committee member, I have seen with dismay as the society has devolved into an elitist club, focused more on pet agendas of “leadership” as well as promoting their own, with no emphasis on trying to honestly represent the large body of interventional cardiologists in the community.

For years SCAI has pushed an agenda portraying themselves as representing the interests of patients’ as purveyors and guardians of procedural quality. While this may have held true in yesteryear, the present sings a different story. Most present “multi-society” documents, no longer include SCAI, partly because of their vanishing relevance. Whether in discussion of outpatient surgery centers, high risk coronary procedures, valve procedures, the society is lead by individuals who believe that they are the only people capable of doing these procedures. Akin to royalty, they do dole out permissions to the humble average board certified interventional cardiologist out there, but the paying procedures (that the SCAI fights for expanded reimbursement using society money at the national level) should be preferentially sent to “quality” operators (per their own self affirming guidelines).

Take for instance the most recent”competencies” document they have generated.

https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.29229?campaign=wolearlyview

In this wondrous piece of work, the authoritarian authors promulgate that training for high-risk PCI be driven by numbers that would result in less people available to do these procedures than are currently out there. Without delving into details, their guidelines are clearly likely to benefit the authors of the document. Rather than focusing on improving the standards of procedures performed in the patient’s neighborhood by focusing on education and engagement of the society’s membership, the statement is to put unrealistic numbers to prevent “low-volume” operators. Of course this is put out in the guise of a training document, i.e. applicable to training of new operators, but it is a short hop from these becoming standards that hospitals use to determine privileges and renewal thereof in existing operators. For example they recommend 150 CTO procedures at a minimum to be considered competent. The number of such centers that do 150 CTO procedures nationally is tiny. Then, they insist on technical aspects to further limit access. What broke the camel’s back was the fact that in order to qualify as a “high risk operator” a physician had to be reckless enough with at least 15 patients to have to demonstrate competence in rescuing a ruptured coronary artery with injecting fat or a plastic covered metal coil or a possibly dangerous heart support device (where significant safety questions have been raised by 2 independent non-industry funded studies).

In all of this, where is the patient, you ask? Nowhere, there are no mentions of outcome metrics with these procedures. There is no mention of metrics to ensure that appropriate medical therapy is ascertained. There are no metrics of procedural followup of these patients. It makes me wonder why the focus is only on things which can be billed for?

Is this what we have become? Is this who we are? As an interventional cardiologist and a Fellow of the Society, it pains to me to see this. I could quit the Society. But how would that help. No. The society won’t be rid of me that easy. I will stay and fight. I will be the thorn in their side, till every last one of them cries uncle. I will be there until the best outcome for the patient and the MAJORITY of interventional cardiologists, is back at the center of the discussion.

Why the majority?

Most interventional cardiologists, unlike the ivory tower elitists running the society, are regular folk. They are part of the continuum of the patient’s life. They have to live with their decisions WITH their patients, unlike the elite who deign to touch the patients and return to eliteland, never to see the patient again. The regular interventionalist knows his patient, their families and their social fabric. These elite don’t.

And yet, the elite are the one’s making decisions on how the regular interventionalist cares for his patients. In other words, they are trying to take away the patient’s own decision making by substituting their own.

This has to stop.

I may be one voice. I may be shunted aside. But it will not be for a lack of trying. Join me. Retweet this. Share this. Email this. Print this and post on your notice board.

We will not be silenced.

Readers of this blog will have noticed my repeated references to a very pretty Guards Red Carrera Targa. To say that I was enamored of it might be an understatement. However, living in a family with 3 others who lacked any real enthusiasm for it, can get a little exhausting. Still, the sunday morning blasts and the rare car event, made it worthwhile.

A few weeks ago, on a whim, I was visiting a classic showroom. I happened to see a really cool looking Dodge Viper. It had many of the things that would make owning a classic, fun. Air conditioning. A water cooled engine that mechanic joe in any small town garage, would be able to set right. A noise that was exhilarating and a menace in it’s appearance that would ensure you knew that messing with the owner was not cool.

Meeting with the crew at Fast Lane Cars, I wandered through their huge collection of American muscle and, was amazed at the ingenuity of my own country’s ponies. For years, the lackluster 80s, 90s and 00s, with the exception of an occasional flash of brilliance, US made cars represented the dreary and mediocre. As a formative car enthusiast in these years, I gravitated to fantasize about wildly stylish Italian, the staid and precise weapon-like German and, yes, even some mad high revving Japanese cars. Unsurprisingly, my car history is checkered by a series of German and British cars, buying American never an option.

As I walked through this temple of chrome, tuned to the sonorous drumbeat of thundering engines, I stood amazed, in wonder. The beauty, and artistry of manufacture of these wonderful wonderful machines. The ability to distill the American spirit into a tonne of chrome and steel is truly incredible. To embody our own brutish, boyish, rebellious, devil-may-care and ferocious yet lovable, simple and easy to please nature into 4 wheels and a transmission, is art. These cars are who we are. The ones’ that noone thought was really capable, but in a pinch would be the only ones to count on. America, indeed.

I just had to bring my wife, another firm believer, in the American ideals to see this (and that Viper).

That did not go as I expected. Having dragged her to innumerable car shows with her “Yes, Dear.” expression plastered to the face, I expected the same lack of enthusiasm, despite my own Ameri-car-na Epiphany. She did not disappoint.

The puckering of the lips and wide eyed shock, as well as the disdain for the “old look (read 1980s look)” flashed across her visage. Even sitting in the aforesaid large cushy seat in this north american serpent car did little to assuage her complete disinterest.

Until…

To watch the transformation of facial expressions from “the unsweetened lime juice” look to one of slack-jawed wonder is an interesting sight. After 3 decades of traveling through life together, it isn’t often that we surprise each other, but this is one that surprised me. This Porsche Blue replica car with stainless steel side exhausts had her smiling with a longing that I have never seen with ANY vehicle. Ever.

Comfortably sliding into it, she looks at me and says, “This is what we should get.”

Imagine that.

Even in my wildest dreams, the original Snake was always out of reach.

Of course, we could not afford this (no, not even the replica!) at this time without dipping into our savings. But to find something unexpectedly that we both liked and enjoyed, after nearly 30 years, 6 homes, 12 cars, 2 children and a dog, was a shock of unimaginable proportions.

So. Here we are. We have decided to put an end to my dalliance with the Europeans and stick with our own this time. The Red One, bids us adieu as we look to save up for Venomous Vixen, somewhere in the future.