I am ashamed to admit this, but I think I am becoming an “anti-semantic!” Surely it is scandalous that an editor is beginning to find some ordinary words and phrases obnoxious? But consider the following excerpt from an Oct. 30 Bloomberg News article by Peter Waldman: “The American College of Cardiology is changing its guidelines for when implanting coronary stents is appropriate – by banishing the term ‘Inappropriate’ (replacing it with ‘Rarely Appropriate’). Another category in cases in which there is medical doubt will switch from ‘Uncertain’ to ‘May Be Appropriate’”
So with the sweep of the pen or rather the delete key on the computer, thousands of coronary stents with no valid indication may suddenly be justified. I assume that these heart specialists also believe that peripheral stents placed in asymptomatic patients with normal arteries may be appropriate.
It’s not surprising that the specialty that pioneered endovascular procedures for anyone with a heart or leg would also adopt euphemisms to justify unsupported interventions. Remember, this is the same group that popularized the words “high-risk” in order to promote the widespread adoption of carotid stenting.
According to the Bloomberg News article (titled, Doctors Use Euphemism for $2.4 Billion in Needless Stents), Dr. Robert Hendel, a cardiologist at the University of Miami, stated that “A lot of regulators and payers were saying if it’s inappropriate why should we pay for it and why should it be done at all?” I must admit I agree with the regulators and payers. Why should an insurance company or Medicare pay for a procedure that was completely unjustified?
Like most vascular surgeons, I have seen countless patients with stents up and down their lower extremity arteries, all occluded and now with limb-threatening ischemia. Invariably the patients were asymptomatic before the first stent but told that if they did not have the stent they would require an amputation. Now because of their “Rarely Appropriate” treatment they will actually lose their leg.
Dr. Hendel stated that the word “inappropriate” caused a “visceral response” which I presume implied that cardiologists didn’t like being told that what they may be doing in some cases was “wrong” (they haven’t banned that word yet!). I recently had a similar visceral response when called at midnight to fix a pseudo-aneurysm after a heart specialist attempted to open an occluded popliteal in a 90-year-old wheelchair-bound Alzheimer’s patient.
In case I sound prejudiced, let me say that I can sympathize with some of the cardiologists’ misgivings. Sometimes society or specialty guidelines can be too restrictive and will prevent the patient from getting a treatment that is really needed. Our writing groups need to be adroit in developing these recommendations. Clearly every clinical situation cannot be anticipated, but surely certain scenarios can be identified where interventions should never be performed.
I also believe Dr. Hendel correctly implied that the terms “inappropriate” and “uncertain” were fodder for hungry malpractice lawyers. Vascular surgeons don’t want to feed these litigators’ avarice either. But is that reason enough to allow wordsmiths to manipulate language with the unintended result that we condone bad medicine?
As vascular specialists whose primary interest is the preservation of life and limb, shouldn’t we admit that it’s “appropriate” that some treatments are just “inappropriate”?
Dr. Samson is a clinical professor of surgery (vascular), Florida State University Medical School, a member of Sarasota Vascular Specialists, Sarasota, Fla., and the medical editor of Vascular Specialist.