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- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions⁎ ()
- ↵⁎Address correspondence to:
Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions, Saint Joseph's Heart and Vascular Institute, 5665 Peachtree Dunwoody Road, NE, Atlanta, Georgia 30342
In this issue of JACC: Cardiovascular Interventions, is an exploration of a question I have been asked many times since I cast my lot with interventional techniques 32 years ago. Is live case demonstration teaching safe? Is it effective? We know it is popular since seats were hard to come by in the first 2 years of live demonstration courses given by Andreas Gruentzig put on in Zurich, or the subsequent ones we did with him at Emory and many others elsewhere. I can remember many times when I was not so sure it was a good idea. The last procedure of the first course at Emory was a case in point. The patient was chosen because he had a short, discreet left anterior descending (LAD) lesion easily accessible with the “DG” balloon (nonsteerable) device we had to work with. I was moderating the session in front of the massive 10×10 foot high-definition screens we had convinced the university to buy in order to ensure that the audience of 450 cardiologists would have the best educational experience. As Andreas began the case, he said that this is the kind of case that new operators should choose as they begin because of the straightforward, simple challenge it presented. The first balloon inflation was followed by an injection of contrast media that did not flow into the LAD beyond the lesion. This image was soon accompanied by ventricular fibrillation and resuscitation efforts in the catheterization laboratory. I immediately terminated the transmission so as not to distract those efforts. Soon the patient was in the operating room and fortunately survived. That night at a reception I had severe doubts about live transmission, but Andreas said that the case was of great educational value and perhaps saved many lives by convincing a portion of the audience to abandon any intention of performing angioplasty.
Fortunately, the tools available today are of great benefit in preventing and coping with emergencies, but live case demonstrations are now performed in much more complex situations. In this issue of the Journal, the subject of the safety of live case demonstrations is evaluated (1) and comments from an early pioneer and industry sponsor, John Simpson, and the regulatory agency (Food and Drug Administration) contributor, Andrew Farb, bring perspective. Since live case demonstrations have become common around the world, we should reflect not only on the safety but also the educational value. Some say that a well-structured recorded case has the advantage of demonstrating the maneuvers needed to successfully perform a procedure or the tricks used to get out of a complication that may arise. Others would contend that the unexpected is commonplace and is “real world.” Certainly the suspense keeps the audience awake and sometimes riveted. I used to tell Andreas that the real reason the huge crowds came to the demonstration courses was the same reason they went to stock car races—to see the crash!
But we must ask ourselves whether the live case demonstration is education, entertainment, or theater. There is obviously benefit to the recipient of the show in learning from the performers. There is also benefit to the performers whose prowess is demonstrated to the students. Is this any different than the professor lecturing to the class and impressing them with his vast knowledge? Well, there is a difference. There is a primary event going on that must not be forgotten. The patient is central and the patient's welfare must trump any education, entertainment, or theater. Andreas used to invite the family of the patient into the audience of the live demonstration courses, something I was never willing to do. I still think it is a bad idea but performing interventions, to include the decision about whether to perform them, with the idea that the family is watching what we do does focus the mind on the important person in the “theater” (Fig. 1).
Some things must be demonstrated and whether it is one-on-one with fellows-in-training or televised demonstration to the masses, the patient's benefit is not the most important consideration, but the consideration that must trump all others. Is there benefit in the “wisdom of crowds” as it relates to live demonstration with expert panels giving input to decision making? I have seen it go both ways. Some sage advice from the panel has resulted in decisions that have benefited the patient. On other occasions, the discussion can disrupt the operator and cause some action that is not what would be done absent the eyes of the camera.
Interventional cardiology has replaced surgery in many ways and the “operating theater” has now been replaced by the “interventional studio.” As long as the patients' benefit trumps all other considerations, then the educational experience can many times be rich and even a little theater can be tolerated.
- American College of Cardiology Foundation