Appropriate use criteria in echocardiography: delphic or not?

In ancient Greece, wisdom was sought by the mighty and the modest alike by consulting the Oracle of Delphi, an aged seer who channeled Apollo’s thoughts while intoxicated on the fumes emanating from a python, slain by Apollo himself and cast into the depths of the earth. Sitting on a three-legged stool astride this malodorous crevasse, this ancient Oracle, always a woman of unblemished repute, could answer such burning questions of the day as (from the King of Thera), ‘‘Where shall I colonize next?’’ (Answer: ‘‘Libya’’; second question: ‘‘Where is Libya?’’). Fast-forward almost 3000 years, and today we have our own Oracle of Delphi (in the form of the modified Delphi process used by the American College of Cardiology Foundation) to answer such questions as, ‘‘Is it appropriate to perform a transthoracic echocardiogramwhen there is a severe deceleration injury [and] cardiac injury [is] suspected?’’ (Answer: ‘‘yes’’). With the release of Douglas’s 2011 Appropriate Use Criteria for Echocardiography, the medical community has new consensus data summarizing when echocardiography is and is not appropriate to use in a host of clinical scenarios. The purpose of this commentary is to guide the reader through the possibly unfamiliar Appropriate Use Criteria process, describe the broad findings of the document and how to use them, indicate potential areas that the echocardiography community may find troubling, and suggest research priorities for the future to better define the benefit of echocardiography. The method used by the American College of Cardiology (ACC) in developing the Appropriate Use Criteria (AUC) is a modification of the Delphi process designed by the RAND Corporation in the 1950s to better predict the impact of technology on the cold war. It is based on the notion that opinions of a group are superior to the opinions of a single individual and is specifically meant to force consensus among disagreeing parties or at least define those issues on which there is no agreement. Of course, we should recall Abba Eban’s observation that ‘‘consensus means that everyone agrees to say collectively what no one believes individually.’’ As implemented by the ACC, the AUC development is a four-step process. First, descriptions of many (202 in the case of this document) clinical scenarios in which echocardiography might be used were compiled and reviewed by external reviewers for their relevance, precision, and inclusiveness (disclaimer: I was one of the external reviewers for this document, though, to be honest, not too many of my recommendations made it into the scenarios). Then, the clinical scenarios are presented to a technical panel for initial rating. This technical panel is deliberately composed of a minority of ‘‘card-carrying’’ echocardiographers, with most of the panelists coming from other specialties, including a representative from a health insurance plan. These panelists voted on a 9-point scale (1 = completely inappropriate; 9 = absolutely appropriate) without any interaction with each other. Next, the panelists were brought together for a face-to-face meeting where each indication was discussed and the group received a list of their individual scores and