Cardiac catheterization by nonphysicians

magnet, the reed switch in this 9-year-old pacemaker opened partially, but did not “click in” to the magnet mode, and remained between the 2 settings. After removal of the magnet, the switch was postulated to return to the VVI mode and normal function was resumed. The patient was brought to the Cardiac Clinic of Grady Memorial Hospital. Electrocardiogram revealed a totally ventricular paced cardiac rhythm at a rate of 71 beats/min. Long rhythm strips, repeatedly using the Intermedics magnet to ascertain magnet mode function, revealed no evidence of pacemaker malfunction. A telephone call placed to the nursing home identified that they had used a Medtronics rather than an Intermedics magnet during the transtelephonic pacemaker check. This probably caused the pacemaker “malfunction” in switching from VVI to magnet mode when the magnet was aDDbed. .. Reuben Sheares, Nanette K. Wenger,

MD MD

Atlanta, Georgia 27 October 1987

Cardiac Catheterization Nonphysicians

by

As a cardiologist who has focused his career in the areas of cardiac catheterization and interventional cardiology, I read the article “Coronary Arteriography Performed by a Physician Assistant” by DeMots et al (1987;60:784-787) with interest. I was perplexed and disappointed by the conclusions. The complications reported in the 300 patients, whether studied by the “fellows” or the physician assistant, are too high. To state that 8 important complications (1 myocardial infarction , 1 transient ischemic attack, 1 retinal embolus, 1 episode of sepsis and 4 incomplete studies) is an acceptable level of complications is wrong. I respectfully suggest that the complication rates reported from the CASS study’ and the Registry Committee of the Society for Cardiac Angiography2 be reviewed again. Total frequency of all major complications reported by the Society for Cardiac Catheterization was 1.8% (Table VI: Major Complications-myocardial infarction 0.07%. stroke 0.07%. death 0.14%). arrhythmia 0.56%, vascular 0.57%, other 0.41%.* The complication rate reported by DeMots of 2.7% (3% fellows, 2% physician assistant) is 47% higher than that reported by the Society for Cardiac Angiography. Is this amount of complications really acceptable? I must also wonder whether the critically ill patients who have an expected higher frequency of complications were included by DeMots as they were in the other cited studies of complication rates.t.2 I concluded from the article by DeMots et al that their complication rates were too

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high (fellows or physician assistant). I wondered whether the “staff cardioloeist” was actually in the laboratory super&ing either junior group. How else could 4 of 300 studies have been judged later as incomplete? I suggest that either a physician assistant or a cardiology fellow should assist a cardiologist who has special interest and expertise in the performance of cardiac catheterizations. I do not believe our patients deserve less. The physician assistant can certaintly be utilized to make health care more efficient, but not by replacing the cardiologist. I believe we should be very careful in proposing an expanded role for less trained persons. We may be turning our profession over to physician-extenders. Is the question really whether or not we should have 1 cardiologist supervising specialized extenders who are performing consultation, echocardiography, exercise stress testing, nuclear cardiology and cardiac catheterization within a large hospital? Does anything make slightly more technically complex procedures such as permanent pacemaker implantation, coronary angioplasty or even cardiac and other surgeries sacrosanct and exempt from this scheme? I do not believe this is the type of medical care most of us or our patients desire. It is on-the-site clinical judgment in addition to technical skills that makes it important for these procedures to remain under the direct control of a well-trained physician. I hope it remains that way. Robert

L. Fetdman,

Gainesville,

MD

Florida

9 November 1987 1. Davis K, Kennedy JW, Kemp HC, Judkins MP, Gosselin AJ, Killip T. Complications of coronary arteriography -from the collaborative study of coronary artery surgery (CASS). Circulation 1979:59:1105-1112.

2. Kennedy JW, and the Registry Committee of the Society for Cardiac Angiography. Com-

in the study were obviously done by 1 physician assistant. There are several issues about which I am not very clear. The type and length of invasive training possessed by this person is not mentioned. The degree of assistance provided by the cardiologist during the procedure is also not mentioned. If “over the shoulder” supervision time is the same for fellows and physician assistants, I do not perceive any time savings for the cardiologist. Obviously, the physician assistant followed in this study is technically capable. My concern is that when a study like this is published, it will act as a precedent, saying that every physician assistant can do it. This is a dangerous extrapolation. Training a physician assistant cannot be a substitute for fellowship training, since a fellow can manage so many other things in the practice of cardiology that the physician assistant is unable to do. If there are too many fellows, the answer is to reduce recruitment to the level of need, rather than train a nonphysician to do invasive procedures. Let me emphasize that I have no prejudice against physician assistants, but I am concerned about potential dangers engendered by this development. The argument that those cardiologists in a teaching hospital cannot manage a large clinical practice as well as research is not tenable. Even if it were, the answer is not as simple as training a nonphysician to do complex clinical procedures. Over the years, many cardiologists who perform procedures have contributed a great deal to cardiology to promote progress in treatment and detection of disease. I am hopeful that this study does not give readers the impression anyone with simple technical training can perform coronary angiography. It requires the skill level of a cardiologist in attendance. V. Krishnaswami,

MD

Pittsburgh,

Pennsylvania 29 October 1987

plications associated with cardiac catheterization and angiography. Cachet Cardiovasc Diagn 1982;8:5-I I.

The article by DeMots et al that reports the safety and adequacy of coronary angiography done by physician assistants is provocative. Those physicians who have been involved in the training of cardiology fellows for many years know that successful cardiac catheterization, including coronary angiography, is a combination of mechanical skill backed by knowledge, experience and judgment. Mechanical skill can be acquired by anyone with inherent technical skills. The other aspects, however, are much more important. When a procedure goes well, things look easy. When complications develop, how one reacts is the quality that separates disaster from success. All the procedures

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REPLY: Ongoing vigorous quality assurance programs are the appropriate vehicle to assure the quality of care that Dr. Krishnaswami desires. Our article suggests that quality of care may be less closely related to the academic degree of the operator than previously thought. We defined the setting in which the results occurred and maki no claims that the same outcome would have occurred in a different setting. We can see no purpose in testing it in private practice unless some advantage in quality or cost to the patient is anticipated. We have not made the extrapolation that any physician assistant (or physician) could perform coronary ar*teriography successfully. All operators should develop the ability to participate in the management of complications but the availability of a person experienced in dealing with serious complications during training is crucial. In