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A medical conundrum

Are heart stents being used unnecessarily in Pakistan?

A medical conundrum

Heart stents have been in the news recently. Evidently, after many years these stents will now be manufactured in Pakistan. Also a recent article in The New York Times asked whether stents were being used unnecessarily. Both of these stories have an undercurrent of possible corruption or at least misuse of this treatment for personal gain by unscrupulous physicians.

Let me first explain a bit about the importance of stents. The commonest cause of death in adults is blockages of heart arteries leading to heart attacks. This is true in the western countries and is probably also true in Pakistan. Stents are small metal mesh tubes that are inserted through catheters by medical heart doctors (cardiologists) into blocked up heart arteries to open these arteries. This is obviously done if these blockages are producing problems.

Clearly stents have decreased the incidence of heart attacks and also interrupted many ongoing heart attacks. The problem arises when blockages of the heart arteries can be treated without stents and yet stents are inserted by cardiologists. This is a medical conundrum that is being addressed in the United States by medical insurance organisations including the federal government. In time, stent insertions will be scrutinised and strict guidelines will be established.

The safest treatment of heart artery blockages in such a patient probably is to put in a couple of stents, add some blood thinning and cholesterol lowering medicines and hope for the best.

Stents are a valuable method available to treat heart artery blockages. That said, stent procedures are a very lucrative source of income for hospitals where these procedures are performed and for cardiologists that perform these procedures. As such at the periphery of what is often a lifesaving procedure inevitably lurks the stench of corruption.

Here I would like to state that many if not most cardiologists performing the stent procedures are doing an honest job. That statement obviously presumes that some cardiologists are not doing an honest job. And that is a sad fact.

Yes, by now my readers are probably getting ready to bandy around words like messiahs, selfless service to humanity, Hippocratic Oath, ethics, and what not. The basic point is simple. There are personal and social ethics and then there are medical ethics. We must remember that doctors are people too and they imbibe the same set of social and personal ethics that abound around them. However, there are a set of professional ethics that all professionals must adhere to if they wish to be successful in their professions.

Most importantly, financial success only comes to those professionals that provide the best service possible. And that is also true of doctors. The underhanded, the devious and the dishonest might make some extra money on the side but they will never be successful and will always stay at the fringes of their professions.

There are the moral and social ethics we learn as we grow up. We learn these at home and during our early education. These ethics cannot be legislated or taught in medical schools. But what can be taught in medical school is medicine. Conceptually medical education is quite straightforward. There is disease and then there are established ways of diagnosing and treating it. But the most important thing that also needs to be taught is that these ‘established’ methods evolve and change as medicine advances and new information becomes available.

In my personal opinion then, the most important and most basic part of medical ethics is the ability to provide the best treatment possible based on the latest information that is available. And I strongly believe that physicians should be able to make a decent and an honourable living based upon their professional activities. But making a good living must go hand in hand with providing good medical care.

Coming back to stents, yes money was made through dishonest practices by some cardiologists and they were exposed for what they did. There are others that are possibly doing some underhand stuff but these are not the busy and successful cardiologists. Busy cardiologists in private practice that are putting in an eighteen hour day six days a week and are performing a large volume of procedures and seeing a lot of patients are only able to do all that because they are providing the best possible care available, in Pakistan at least. And yes, they don’t need any underhand activity to augment their incomes.

The exception to the above rule are doctors working in government hospitals where they have a captured patient population and are often provide substandard care without being held responsible. The reason why people in such ‘lucrative’ positions can get away with providing inadequate medicinal care along with some dishonest activity on the side is because they are often the ‘darlings’ of the ‘appointing authority’.

Staying on the subject of stents, there is an additional problem with stenting that creates much of the aura of dishonesty around them. Good quality stents are relatively expensive. And also these stents have to be imported since they are not manufactured or even ‘assembled’ in Pakistan. The less expensive and the less effective stents will probably be manufactured in Pakistan over the next few years but unfortunately their long term effectiveness is not very good in patients with the worst type of blockages.

Here I think a quick word or two about the good and the not so good stents is worth putting down. As I mentioned above stents are basically metal meshes that are pushed inside a blockage in a heart artery and then pushed up to keep the artery open. The original stents were just plain metal and are called Bare Metal Stents (BMS). These are relatively inexpensive and are the ones that might be manufactured in Pakistan. Then there are the Drug Eluting Stents (DES) that have the metal mesh coated with special medicines to keep the opened artery from closing down.

If given a choice most cardiologists will prefer using DES and most patients when told about the difference would also prefer these stents over the BMS. The problem is that the DES are of many different types and made by many different companies with variable quality and pricing. It is in the interchange of the less expensive DES for the more expensive ones that money can be made by dishonest doctors, stent salesmen, and stent importers. And it is in this area that government oversight is necessary.

The other problem I alluded to above was whether stents were being used in patients that could be treated equally well with medicines and significant life style changes. And therein lies a serious problem for even the best doctors. It is difficult to imagine that most fifty five year old men that are ten kilos overweight, haven’t exercised ever, and enjoy their ‘nihari’ and ‘siri-paye’ are going to give all that up and start running five miles a day and live on kale. The safest treatment of heart artery blockages in such a patient probably is to put in a couple of stents, add some blood thinning and cholesterol lowering medicines and hope for the best.

So far I have only talks about heart artery stents but stents are also being used to open arteries in the neck and in the legs. That is a story for another day.

Syed Mansoor Hussain

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The author has served as Professor and Chairman, Department of Cardiac Surgery, King Edward Medical University.

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