through the whole extent of the last several years.

through the whole extent of the last several years, an increasing interest in medical practice patterns has been evident in this geographical division One practice that has been actively discussed is the performance of cardiac catheterization and angioplasty following thrombolytic therapy for acute myocardial infarction.[1,2] Several estimable studies have examined the part of angiography and revascularization, and they are consistent in their findings: patients without evidence of periodical ischemia or heart failure after myocardial infarction do as well with medical therapy as those managed with early catheterization and revascularization of diseased vessels[3-7] In spite of these observations, many patients are enthralled to cardiac catherization after thrombolysis, and coronary angioplasty is rarely preced by means of exercise testing in this population.[8,9] In about hospitals, virtually all patients who received thrombolytic therapy for acute myocardial infarction have cardiac catherization and revascularization prior to discharge (B Jahnke, RN personal communication, April, 1993)

This example of the discrepancy between published recommendations and clinical practices has caused us to consider on the reasons that clinicians like as ourselves practice medicine differently than is praiseed These arguments for our actions can be divided into four distinct classifications.

Intellectual

1 The studies are flawed.

2 The studies didn't include my patient.

3 All patients are different; I individualize my therapy.

Inherent in this category is that the practitioner understands the available data still is not sure of its applicability to his/her individual patients. chiefly studies have flaws, and clinicians must critically review newly published material before integrating changes in their practices. The argument for individualization of therapy may be used as an excuse, however, to justify a practice pattern that is inflexible. Indeed, if individualization of therapy is the argument for catheterization after thrombolysis, then managing the majority of postthrombolysis patients with cardiac catheterization provides exceedingly little individualization.

Emotional

4 What if this was your mother/father/self?[10]

5 We have to do SOMETHING![11]

6 Tradition! It is the standard of care and we have to provide it.

7 I know there are no data to support this, nevertheless I would feel better if . .

8 Anecdotal care (I have an example to demonstrate to what end I practice this way).

9 operations are fun.[8]

The emotional appeal of interventional therapy is frequently so strong that rational contemplation is denied. Others have documented the inclination toward aggressive therapy equable when well-informed clinicians become patients.[9,10] Physicians and patients repeatedly feel better trying "something" rather than waiting; interventional conducts are powerful and seductive for those desiring action. Tradition creates a "catch-22" situation, where the practice pattern perpetuates itself because it is impossible to change the "standard of care" without contradicting it. That procdure are "fun" is apparent to greatest in number of us who perform them, and thus, we must be uniform more careful to employ them merely when clearly indicated.

Medicolegal/Financial

10 Fear of lawsuits.[12]

11 Financial rewards for procedures

12 Ne to maintain adequate numbers for hospital privileges.

Many believe that medicolegal and financial make anxiouss are the most important reasons for aggressive management of postinfarction patients. The fear of lawsuits is real and influences practice names While monetary rewards are able motivaters, we feel that standard of value drives only a few physicians to perform interventional steps Salaried physicians may also overutilize invasive procedures; this may ruminate the "fun" aspects of performances medicolegal concerns, or the ne to maintain an adequate bulk of procedures for retention of hospital privileges.

Denial

13 The practitioner doesn't know the data.

Lack of knowledge regarding the issue of postthrombolytic management may be the least important of the reasons listed, as widespread lay and professional pres coverage has been given to this specific topic. In other clinical situations, however, a lack of knowledge may be a major reason for differences in practice style

Many different factors can be given to explain differences between clinical practices and recommendations based relating to controlled trials. The rife efforts to address the medicolegal theory and remuneration may not be enough. To change the "art" of medicine in consequence of the "science" of randomized trials, attention to all of these issues is urgencyed to change practice patterns and help us "practice what we preach."

REFERENCES

[1] Ros J Jr Gilpin EA, Madsen EA, Henning H Nicod P Dittrich H et al. A decision scheme for coronary angiography after acute myocardial infarction. Circulation 1989; 79:292-303

[2] Candell-Riera J Permanyer-Miralda G Castell J Rius-Davi A, Domingo E Alverez-Aunon E et al. Uncomplicated first myocardial infarction: strategy for comprehensive prognostic studies. J Am Coll Cardiol 1991; 18:1207-19

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