How We Learn and the Medical Decisions We Make: Lessons From Learning Networks in Interventional Pediatric Cardiology
How many times per day do you make a medical decision about one of your patients? How many times is that decision based on data versus experience? And more importantly, how confident are you that your decision gave your patient the highest chance of the best outcome? For most clinicians, the amount of medical information, the volume of scholarly articles, and the complexity of the patients for whom we care has overwhelmed our ability to read (must less critically evaluate), know, and make evidence-based decisions on a day-to-day basis. But this is only one of the many barriers we face when navigating medical decision-making. How do we make decisions when we have never seen something before? And what about institutional biases? How we practice is often determined by where we trained and the current practice patterns in the institution in which we work.
As an Interventional Pediatric Cardiologist, I am confronted with seemingly small but potentially critical decisions every day. I just placed a ductal stent for a patient with tetralogy of Fallot with pulmonary atresia. The procedure went great—high fives all around. But what should we do for stent thromboprophylaxis? Aspirin alone? Aspirin and clopidogrel? Aspirin and low-molecular weight heparin?? I know what I usually do because that is our institutional approach (notably with limited or no supporting data). But this decision might impact stent patency, pulmonary artery growth, and contribute to medication side effects. Or in a different scenario, I am doing a procedure for the first time. I read a case report about the procedure, and I believe I have the appropriate knowledge and technical skill to be successful. But I have never done this procedure, so how do I assess the likelihood of success and truly evaluate risk and benefit for my patient?
But I am also a Pediatric Cardiac Intensivist, and I know these dilemmas are not unique to the interventional world. A patient comes back after a complex biventricular repair and remains significantly vasoplegic with a raising lactatemia. I haven’t taken care of a patient like this before, so is this the expected degree of post-operative low cardiac output after this type of operation or is this outside what we should expect?
Fortunately, interventional pediatric cardiology is a pretty small community so “phone a friend” is alive and well. I actually have several group texts specifically to get rapid second opinions if needed and many of us have built small networks of trusted colleagues to help fill gaps in knowledge (and sometimes just to be there for emotional support).
But are there alternative ways to seek a wider variety of experience to help us make difficult decisions? One of the approaches now being used in interventional pediatric cardiology is the creation of large learning networks, like the DocMatter Community. This secure/password protected site was created through the partnership of the Pediatric and Congenital Interventional Cardiac Society (PICS) and the Congenital Cardiovascular Interventional Study Consortium (CCISC), and as a global network of clinicians (mostly interventional pediatric cardiologists), provides an open forum to ask questions and elicit responses from colleagues around the world. Questions can be very specific (“I have a patient with mid-aortic syndrome. This is what the angiogram looks like. I was thinking of placing a covered stent, but I have also heard cutting balloons are effective. Any suggestions?”) or much broader (“For PDA stent procedures, in what circumstances do you discontinue the prostaglandin infusion prior to the procedure?”). And regardless of the question, I have been impressed by both the rapid speed of responses and the wide variety of people who respond, allowing for quick and varied opinions to help with decision-making.
Besides this one example of a learning network in the interventional pediatric cardiology world, presentation of live cases remains a unique opportunity to see new procedures, contemplate the “what would I do in this situation,” learn from various leaders in the field, and ultimately, learn together as a community. For those attending the World Congress of Pediatric Cardiology and Cardiac Surgery this August, I encourage you to attend the concurrent PICS symposium, which includes a number of interesting live cases.
So how does what is happening in interventional cardiology apply to the intensive care world? I would argue that a platform like the DocMatter Community would be very easily adapted to and well suited for use in cardiac intensive care. Formal second opinions take time, and often decisions require faster help from colleagues. Many decisions lend themselves to less comprehensive reviews of medical records, and some situations are rare and necessitate casting a broad net to find experts. And I believe the infrastructure in the ICU may already exist. There is no better example of the power of learning networks in pediatric cardiology and pediatric cardiac intensive care than PC4. This well-established collaboration could provide a platform to connect us for real-time discussions of patient care in the cardiac ICU.
As a last thought, my career straddles the cath lab and cardiac ICU, but I am often reminded that individual subspecialties have become significantly siloed. But through networks like Cardiac Networks United, the ability to link various registries and data across pediatric cardiology has become a reality. So maybe our learning networks should attempt to do the same. I can only imagine how powerful our decision-making ability might be if we had multi-specialty learning network(s) to view our patients through the various lenses of our field simultaneously.
Jeffrey Zampi MD, FSCAI, FPICS
Director, Interventional Pediatric Cardiology
Associate Professor, Pediatric Cardiology
University of Michigan Congenital Heart Center
C.S. Mott Children’s Hospital
Ann Arbor, MI