St George Cardiology

02 8580 1649

Suite 7H, Level 5, 1 South St
Kogarah NSW 2217

Holroyd Heart Centre

02 8604 0933

Suite 7H, Level 5, 1 South St
Kogarah NSW 2217

Choosing your interventional cardiologist.

Posted By Dr George Touma  
09:00 AM

Hello everybody.


Not all tradesmen are equal in ability. Not all accountants are equal in ability. Not all lawyers are equal in ability. Similarly, not all interventional cardiologists are equal in ability with regard to management of coronary disease. 


An interventional cardiologist is a cardiologist that performs invasive procedures such as coronary stenting, valve implantation. A non invasive cardiologist is one that does not. 


While all doctors in Australia are qualified, skill level is vastly different between different specialists. That's really not a big surprise. 


So how does a patient know who to select for there coronary artery care? Does my GP know who is best ?


Well its complicated. Very complicated. Let's run through some of the issues and misconceptions.


Firstly, its important to note that competency and expertise in the catheter lab is difficult to define, quantify and measure. Among colleagues, we often think we know "who is best at implanting coronary stents". This is usually partly objective and partly subjective. People not trained in coronary stents (non invasive cardiologists) often refer to interventional cardiologists. Their selection criteria is variable and may or may not result in selection of the best interventional cardiologist. 


A GP and other specialists will refer to a particular specialist for a variety of reasons - reputation, friendship, accessibility, thoroughness. Often a referring doctor will be "in the loop" as to who is truly skilled and often they will not. 


A very useful first step is - what do patients think of their cardiologist via online reviews? This will inform bedside manner, approachability and people skills but usually doesn't determine skill level at the procedural or stenting level.  Example "A nice guy may be a terrible surgeon and a rude ignorant person may be fantastic". A good review by current patients may correlate with skill level, but there is no guarantee. 





1. My interventional cardiologist is a professor or has post doctoral PhD so he/she must be more competent to perform my procedure.


Maybe, maybe not. Academic qualifications correlate poorly with procedural skill level. More important is maintaining the latest evidence based techniques and a willingness to let go of old habits and techniques that don't work in favour of new ones that do. A high volume of cases regularly helps a great deal. This so called adaptability and flexibility is a key attribute of a successful interventional cardiologist.



2. My interventional cardiologist is employed in a public hospital and is therefore better than a private cardiologist of similar experience.


Not necessarily. Public hospital appointment of doctors are usually based on many considerations. Actual clinical ability may be on that list of priorities. It may not. The most qualified and competent doctor can and often does miss out on a public hospital job. Usually, there is zero correlation between skill level and a public hospital job. In fact, the reverse may be true. 



3. My doctor has very few complications with their procedures so he/she must be more skilled.


Probably, but there are some important considerations that must be mentioned. Firstly, cardiologists that are referred the most complex patients, or patients where colleagues have been unsuccessful may have higher complication rates due to the more difficult nature of the procedure. Also, cardiologists that take on older and more frail patients may well experience higher complications than those that only choose straightforward patients. 



4. My cardiologist completed overseas training after Australian training, so they must be more skilled. This is called an overseas fellowship. 


This is a common misconception. Overseas training is a tool many use to increase procedural numbers which can be limited in Australia due to the limitation of training programs in some Australian Hospitals. Whether this translates to a more skilled stenting operator in the end depends on many factors - intrinsic skill of the student, willingness to learn, teachability among other things. Generally, overseas fellowships, much like a public hospital job, correlate poorly with final skill level. Put another way, some people are simply "unteachable". It is also highly debatable whether large centres overseas are better places to learn the nuances of coronary stenting. Given that knowledge is outdated almost as soon as it is learned,  ongoing education is vital to maintain best practice. Commitment to continued learning is likely equally important. Be wary of doctors that say "I've always done it his way".



5. A doctor with a long waiting list is usually more skilled.


This common misconception is absolutely false. Many non competency related factors determine a waiting list for any given specialist. If a specialist shows adequate concern for an urgent patient, it’s almost always possible to “fit them in”



6. My procedure is more safely performed in the public hospital.


This is a common misconception. Safety depends on many variables. For example, almost all procedures are performed by the registrar or doctor in training in a public teaching hospital. This is fine, as we are all students at some point (and we are always learning). If the specialist is on hand to teach, assist and help should a complication occur, then safety is maximised. The problem is, there is no way to guarantee your specialist will be present. It is not uncommon for specialists to be absent when junior doctors are performing procedures on you. In a private hospital, the specialist always performs the procedure and an assisting doctor may or may not be present. It is quite possible that a specialist may not be present to supervise (and even be off site) during a procedure performed by a doctor in training in a public hospital. This is suboptimal and indeed may be unsafe. Doctor's that are absent are usually not reprimanded by the hospital and this practice places patients at risk. It's a very important consideration that should prompt you to consider private health insurance. 



7. My cardiologist does complex cases with another cardiologist - is this a good thing?


Absolutely. Two operators often have better outcomes than a single operator when performing complex coronary artery procedures. 



Here are some key questions to ask your interventional cardiologist before your procedure


1. Do they use imaging within the artery (IVUS, OCT) both before and after stenting to get the best result for you long term? If not, why not?


2. Will your angiogram be performed via your radial (wrist) artery rather than the groin? If not, why not?


3. Are they experienced in the use of covered stents and coils should a major complication occur during your procedure? If not, why not?


4. Are they confident in the use of rotational atherectomy and shockwave lithotripsy to treat heavily calcified coronary disease? If not, why not?


5. Is the doctor aware of their limitations and able to stay within their level of training to ensure patient safety? If not, why not?


6. Will your specialist or another specialist be present to supervise the training doctor for your procedure in the public hospital? If not, why not?


7. Does your cardiologist use FFR, to determine if moderate coronary blockages (50-70%) actually need a stent? If not, why not?