See it, stent it: the Oculostenotic Reflex

A small, but important study was summarized in JAMA Internal Medicine last week, “How Cardiologists Present the Benefits of Percutaneous Coronary Interventions to Patients With Stable Angina.”

It was an analysis of 40 discussions between patients and cardiologists about whether to pursue angiograms (catheters inject dye into the heart arteries so imaging can show blockages) and stents (cathethers insert tiny wire mesh scaffolding to try to open blocked arteries) – or percutaneous coronary intervention or PCI.

Dr. Richard Lehman wrote about the study in his weekly BMJ blog journal review:

People with chronic stable coronary disease do just as well on maximal medical treatment as after revascularization procedures. Putting stents in the pipes does not prevent more infarcts than taking pills. This is what the COURAGE trial taught us in 2007. But seven years later, one third of PCIs in America are still being done for stable CAD. In 40 observed consultations, “Few cardiologists discussed the evidence based benefits of angiogram and PCI for stable CAD, and some implicitly or explicitly overstated the benefits.” So that’s what cardiologists do when qualitative researchers are watching.”

So what happens when qualitative researchers aren’t watching?

A commentary in the same issue of JAMA Internal Medicine was entitled, “Fighting the ‘Oculostenotic Reflex’. ”  That’s a term to describe doctors who act on the belief, “Any blockage you see is a blockage you treat, even if evidence suggests no benefit.” The commentary concludes:

Interventions such as PCI have enhanced the lives of patients. However, use of treatments in inappropriately selected patients is wasteful and has the potential to do great harm, particularly if patients are undergoing procedures that, if informed, they would not have chosen for themselves. Physicians are integral to the decision-making process, and thus they hold the key to changing it. Providing patients with accurate and complete information appears to be an effective way to combat the reliance on the oculostenotic reflex. The standard of care should be a high-quality, shared decision-making process, and physicians should be held accountable for ensuring that treatment decisions are evidence-based and patient-centered. Achieving such a standard is critical to interrupting the diagnostic-therapeutic cascade and preventing patients from receiving unneeded and unwanted care.

Maybe my search was too limited or too brief, but I couldn’t find any mainstream media news coverage of these papers.


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