Steps in the Right Direction

When I was launching the cardiology portion of my career, almost everyone’s counsel was to remember how fast medicine moves. How clinicians must be lifelong learners because much of what they learn eventually will be revised, perhaps even reversed. Researchers who studied a year of New England Journal of Medicine publications found that 13 percent of articles announcing a claim about a medical practice were reversals of a current clinical protocol (Arch Intern Med 2011;171[18]:1675-6).

Then again, going too fast, via shortcuts, doesn’t work. In February, Fast Company noted, “The ‘move fast, break things’ mentality ... doesn’t fly in health care,” as demonstrated by the problems at Theranos. One message from that story could be that healthcare startups may need to slow down because medicine, with its big clinical trials, complicated compliance requirements and slow approval processes, often needs to move slowly to get it right for patients.

In this issue, we focus on questions the cardiovascular community is tackling at varying paces, heading step by step in the direction of answers. Our cover story, for example, examines efforts underway to fill the PAD knowledge gap so clinicians can right-size the number of interventions and amputations being performed and recommend the right option for each individual patient. Our story on heart failure readmissions considers the small steps—forward and backward—that are refining how remote monitoring might be used to keep patients from returning to the hospital and reduce the penalties levied under the Hospital Readmissions Reduction Program.

Fast or slow, it has to be frustrating for clinicians. On the one hand, they may have found themselves forced by new evidence to reverse course on treatment recommendations, such as for managing stable angina or prescribing hormone replacement therapy. On the other hand, clinicians are expected to deliver optimal care for each patient even when the data are murky or missing. Perhaps the antidote to the frustration is a mix of patience, enthusiasm and adaptability, as shown in our feature on the Tc-99m shortage, where we observe how nuclear cardiologists are transforming a possible crisis into opportunities to provide better care and patient satisfaction.