Heart Team seems to be a-la-mode for not only decision-making in Cardiology and Cardiac
Surgery, but now even for performance of the procedure. The concept, though originated
in 1940s with the 'tumour boards', came to fruition in cardiac services only after the
pivotal SYNTAX trial and was in fact given a firm footing with the development of the
transcatheter technology for aortic valve replacement and hybrid cardiac interventions.
With a strong evidence base in its favor, when applied with right intent, pragmatically
the concept seems to be a 'Platonic' illusion in most parts of the developing world,
outside the European and North American continents[.Though it enjoys a class I (C) level of recommendation, there are a large number of
practical issues in implementing the Heart Team concept. The logistics of the
availability of all the constituents of the Heart Team in form of the interventional
cardiologist, cardiac surgeon, clinical cardiologist, family physician and the patient -
all at an anointed time, and obvious funding requirements for implementing this concept
- are important bottlenecks. The fact that Medicine is at best an imprecise science, and
that it is also a rapidly evolving and moving target, so that the data is not always
black and white and there are multiple shades of gray applicable to any given clinical
scenario, does not helps matters. Ignorance of the patient, as also his/her lack of the
ability to comprehend critical issues involved in decision-making, too hampers the
concept of the Heart Team. In such situations, the patient is virtually incapable to
make critical decisions, and both the patient and the relatives leave the
decision-making to the treating doctor, even when an honest attempt is made to involve
them. In the developing parts of the world, societal personality is still subservient to
the 'Master-Subject' relationship, and even under circumstances where an opportunity is
offered, they refuse to emerge from it. In fact, on the very contrary, they find comfort
in this provider-receiver equation, which is the very antithesis to the concept of the
Heart Team. In addition, most of the institutions in the developing world are run on
hierarchical basis, so 'Evidence-Based Medicine' yields and loses out to the
'Eminence-Based Medicine'. Though it may not be acknowledged in public, the verdict of
the senior most person, specially the one sitting at the helm of the administrative
affairs, goes unchallenged and prevails. To bring up the rear, it is a no brainer that,
with the ulterior fiscal interests of corporatization of Medicine, the poor 'medical'
therapy would hardly have a chance to stand up to its powerful and almighty cousin - the
'Interventional' therapies.Certainly, I am not decrying the concept of teamwork-based approach to any facet of
Medicine, or, in fact, life in generic terms, but all I am trying to bring forward is
that this concept, at least at this moment in time, is more in vogue on paper than in
reality. However, I have no qualms ceding ground that it needs to change and the
silo-based vertical streams that we run in most fields of Medicine, should now integrate
laterally, and only when that happens, will the team-based ideology evolve and progress
universally. In fact, it is a vicious circle, and even the vice-versa is true. Heart
Team may facilitate dispensation of holistic and more organic medical care and thus
needs to be encouraged. At the peril of repetition, I re-emphasise that its not the
concept, but the logistics of its implementation which are at the core of this comment.
It is therefore the need of the hour that the bull is taken by the horn, and the
proverbial straw that breaks the camel's back could be a dictate from the regulatory
bodies, or a premandated requirement of reimbursing agencies, for every disease process
to have a combined decision-making before implementation. In the developing world,
self-regulation may not produce the desired results and the salutary developments may
have to be mandated by regulatory and reimbursing authorities, to deliver their
purported goodness to the suffering humanity.Another mundane question that needs to be addressed is: who should head the Heart Team?
The captain should be one who can take a wider holistic view of the entire patient and
not one with a narrow tubular vision. Therefore, intuitively that would be an internist.
However, as Mircea Cinteza quips, "Does this guy live anymore? - I am afraid not". So,
pragmatically speaking, the profile of the captain should be "... that guy of middle
age, who puts together the intempestive solutions of the young and the too wise
solutions of the old. And he or she elaborates and applies the winning midway
solution"[.
And if I can add my two pence, the head of the team should have the where-withal to
tamper and moderate the personal egos and ulterior motives of the silo-based
specialists. The fast-getting extinct species of Internal Medicine specialists have the
best credentials and, hopefully, should fit the bill efficiently and effectively.Epilogue - Can we have cross pollination of ideologies and thoughts of different
ethnicities and continents through regular columns in each other's journals, a kind of
"Editors' Heart Team"!Food for thought!