State warns heart doctors

By Michael Lasalandra

July 17, 2000 Web posted at: 3:07 PM EDT (1907 GMT)

BOSTON, Massachusetts (The Boston Herald) -- Some area cardiologists are apparently allowing physicians assistants to perform invasive heart procedures, including angioplasties, on their own - sometimes violating regulations - and the state's medical board says the practice is dangerous and must stop.

``A million things can go wrong,'' said Dr. Arnold Relman, former editor of the New England Journal of Medicine and a member of the Board of Registration in Medicine. ``You could kill the patient.''

In an operating-room setting, PAs may perform almost any task, as long as it is under the direct supervision of a licensed physician.

But Relman said a number of cardiologists have been allowing their assistants to perform complex heart procedures, including angioplasties and catheterizations, on their own, sometimes without the doctor even being in the operating room.

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``We understand there have been instances,'' he said. ``There are apparently some cardiologists around who feel so comfortable with their assistants that they are willing to have them do things in their absence. But we feel this is totally unsafe.''

The board intends to issue a strongly worded letter urging physicians not to allow their assistants to perform such procedures on their own, he said.

What licensed physicians assistants may and may not do generally is left up to the doctor who is supervising them.

Performing a catheterization or angioplasty - where a tube is snaked along an artery leading to the heart to diagnose or clear a blockage - may require nothing more than a good pair of hands, Relman said.

``It may be that some assistants who have had a lot of experience can do the procedure safely,'' he said. ``But most physicians assistants can't, and even those who have had a lot of experience don't have the medical judgment to know what to do in an emergency. What if something goes wrong? That's why you need a doctor.''

To become a licensed PA, one must have a bachelor's degree and complete a two-year training program at a college or hospital, then pass a national exam.

If a blockage is discovered during a catheterization, most cardiologists want to act quickly to perform an angioplasty, where a balloon is inflated on the end of the catheter to clear the blockage and then insert a metal tube or ``stent'' to keep the artery open, Relman said.

``No assistant should be doing that,'' he said.

The matter was brought to the attention of the medical board by the Department of Public Health, which licenses hospitals, not doctors, but is concerned about possible abuses by PAs, sources said.

Relman said the board cannot force physicians to keep their assistants from performing such procedures by themselves, but said that if it occurs and a problem ensues, the board will hold the doctors responsible.

Jim Anliot, counsel for the Division of Registration, which oversees the board regulating PAs, said his office received a request from Dr. Ferdinand Venditti, a Lahey Clinic cardiologist, asking for a clarification on just what PAs can and cannot do when it comes to catheterizations.

Anliot issued an advisory ruling saying that PAs may insert a catheter into the femoral artery near the groin, through the coronary artery and into the left ventricle of the heart, as long as the supervising physician makes all the decisions and is physically present at the time of the procedure. The ruling also said the PAs may be involved in procedures involving the injection of radioactive dyes.

DPH regulations say PAs may take part in such procedures as long as the doctor is present at the time, said spokeswoman Roseann Pawelak.

But Anliot said some DPH officials have expressed concerns that the regulations may be courting trouble, as they may result in a reduction in the actual number of catheterizations that are done by doctors at a time when a number of community hospitals are seeking approval to open cardiac cath labs.

Most experts believe that the more procedures a doctor performs, the better he or she will be at doing that procedure.

``The DPH's concern is that if the PAs are doing the hands-on work, the supervising physicians' manual skills may decline,'' Anliot said.

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