How do you tell someone to up their game or quit playing? This may be one of the hardest facts of life to face. As we get older, all of us eventually will have to quit something — skiing, golf, ping pong, interventional cardiology, cath lab on-call nights, you name it. Does one always have to change to a lesser intensity activity or quit the game altogether? Mostly, the answer is yes. In the world of sports or business, you must perform or you are out. If you are in medicine, you must (or you should, to be a safe practitioner) keep up with advances to practice in a modern way. In other words, one must “retool or retire.”
A stent story
For cath lab work, I have heard stories about change from a number of places and from a number of cath lab nurses, fellows, and technologists. The stories are about how changing or even introducing a new practice in their lab is nearly impossible. It’s human nature to resist change. Most recently, at a cardiology fellows’ course, I heard this story: “…I (the fellow) was in the cath lab. The angiogram showed an intermediate 50% diameter narrowing in an LAD. The patient’s stress test was equivocal and he had no chest pain or other symptoms. I said to my attending, ‘We should do FFR on this lesion.’ He said he didn’t need to [read this as want to, know how to, or trust the result]. He knew a lesion that needed a stent when he saw it. So we just stented it. Why? ‘I’m old school,’ the attending said. What’s a young cath lab guy supposed to say to that?”
I told the fellow, “Say to him [the older cardiologist], ‘retool or retire’. Why? We have no excuse to not use widely available techniques which provide better outcomes, safer procedures, and lower costs.” Try explaining to anyone why you practice medicine the way they did 10, 15, or 20 years ago. This scenario is unacceptable given what we know today. The only question is, why do some labs (physicians mostly) practice that way in spite of all evidence to the contrary?
Unfreeze, then change
My partner, Dr. Pranav Patel, and I wrote an editorial about overcoming the resistance to change in becoming a radial-first laboratory.1 According to social psychologist Kurt Lewin, there are 3 behavioral stages of change: moving from one static state to a state of activity, and then to another static state, i.e. unfreezing, changing, and re-freezing. Change is difficult, because people like the safety, comfort and feeling of control over their environment. Change naturally causes discomfort. Significant effort is required to ‘unfreeze’ and to overcome the negative momentum to stay still in the status quo. This theory applies strongly to medical practices. The distilled dictum of change, ‘retool or retire,’ can be said to apply to every procedure, technique, therapy, or policy in medicine. One need only review the history of medicine over the last 30 years to see how radically things have changed and evolved. We dropped the old, inefficient, ineffective, outdated, unsafe, and untested methods for the newer ones that proved to be safer and better, while at times doing so at lesser expense. I use fractional flow reserve (FFR) as the prime example, but the same ‘retool or retire’ mantra should be cited for use of intravascular ultrasound (IVUS), new, better anticoagulants, antiarrthymics, antiplatelet agents, radial access, the Impella left ventricular assist device (Abiomed), filter wires for saphenous vein graft percutaneous coronary intervention (SVG PCI), and so on (see Table 1).
Of course, each of these retooled methods has to be used in its appropriate way and at the appropriate time. Some methods should completely replace older ones, while others should share the stage. Some of the new procedures should only be used in specific and uncommon circumstances. No matter which of these scenarios apply, we should all be familiar with the advantages and disadvantages of the newer procedures compared to the conventional methods. We should always use the newer methods when the advantages to the patient are clearly superior to those of its predecessor. It would be even a more powerful incentive to use the new method if it did the better job at a reasonable or lower price. The advantages to the patient must also be sufficiently strong to outweigh the perceived disadvantages to the cardiologist using the method. However, the cardiologist must put best practices in front of his/her own discomfort. The operator must have a clear reason why they would not employ the better practice.
In modern medicine, clinical studies support, justify and drive physician (and cath lab) behavior for the use of new methods. The outcomes of these studies are the basis for accepting or rejecting the method. Studies on the use of new drugs, new stents, and new devices support the use or disuse of the drug or method. In many cases, multiple studies are needed over time and by different centers to provide the strongest and most irrefutable proof needed by many practitioners to change. This is particularly relevant to those individuals reluctant to relinquish their “tried and true” ways of doing things. However, all practices must change eventually, as better outcomes and more supporting studies are revealed and repeatedly validated.
This same ‘retool or retire’ concept applies as much or more so to the cath lab nurses and technologists. Many new techniques have been shown to provide better care. The lab should embrace better practices. They should know how and when to use the tools [e.g., IVUS, optical coherence tomography (OCT), FFR, Impella, etc.] and what to expect of their doctors. The confluence of uninterested, older (often, but not always, older in age, but certainly older in mindset) attending physicians, not comfortable with or knowledgeable about new and better techniques, in a hurry to finish their work, coupled with complacent and unmotivated cath lab nurses leads to a pitiful and mediocre experience for the patients. Eventually, such a lab will demonstrate worse outcomes, inappropriate procedures, and be shown to be a lab that is truly behind the times.
An obligation to change
The subject of retooling or upgrading work habits has been addressed in these pages over the last few years in numerous disguises. We heard about the “ODNT” syndrome, (old dog, new tricks), motivations to change, leadership, learning, going to meetings, and other short topics on how to improve your life and your patients’ lives as you both move through the cath lab experience. I think this is such an important aspect of being a medical care provider that it is not only a duty, but an obligation, to the patient to provide him or her the best — the best attitude, the best knowledge, the best equipment and the best care. Give the patient what you would want for yourself and your family members. Insist others do the same and accept nothing less than the best.
Let 2013 be the year of excellence. Shun the inferior. I say to each lab and to each member of the lab, think about, and then do what is best for the patients. Then say to each other and all those who drag their feet to make things better, “retool or retire.”
(I think I must have eaten a chili pepper the day I wrote this editor’s page.)
1. Patel PM, Kern MJ. Transradial cardiac catheterization: the “unfreeze-change” theory. Cathet Cardiovasc Intervent. 2012; 80: 258-259. doi: 10.1002/ccd.24530
2. Applegate RJ, Grabarczyk MA, Little WC. Vascular closure devices in patients treated with anticoagulation and iib/iiia receptor inhibitors during percutaneous revascularization. J Am Coll Cardiol. 2002; 40(1): 78-83.
3. Kimura T, Morimoto T, Natsuaki M, Shiomi H, Igarashi K, Kadota K, et al. Comparison of everolimus-eluting and sirolimus-eluting coronary stents: 1-year outcomes from the Randomized Evaluation of Sirolimus-Eluting Versus Everolimus-Eluting Stent Trial (RESET). Circulation. 2012 Sep 4; 126(10): 1225-1236.
4. Bittl JA, Strony J, Brinker JA, Ahmed WH, Meckel CR, Chaitman BR, Maraganore J, Deutsch E, Adelman B. Treatment with bivalirudin (Hirulog) as compared with heparin during coronary angioplasty for unstable or post infarction angina. Hirulog Angioplasty Study Investigators. N Engl J Med. 1995; 333: 764-769.