Sunday, November 29, 2009

The High Cost of Health Care: A Personal Confession

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Who says one person can’t make a difference? This past week, I personally set back health care reform. No, I wasn’t attending a ‘tea party’ or decrying Obamacare in a venomous letter to the editor. I single-handedly bent the health care cost curve in the wrong direction. I performed an unnecessary medical test on a hospitalized patient, which exposed her to risk and cost the system money. Why did I do this? Personal enrichment? Fear of litigation? Need for a juicy Whistleblower post? None of the above.

The patient was hospitalized after a week of abdominal cramps, nausea, vomiting and diarrhea. A CAT scan of the abdomen, often ordered by reflex in the emergency department (ED), showed no abnormal findings. In the ED, her white blood count was modestly elevated, but had normalized by the following morning when I met her. My physical examination demonstrated no concerning findings.

I suspected that she was suffering from gastroenteritis, medical jargon for‘stomach flu’. Physicians, lawyers and some bloggers often prefer highfalutin terminology, rather than standard colloquial English, which works just as well. I briefly digress to give a few examples of complicated phraseology used to aggrandize the pompous professional.

Pompous Phrasing........Ordinary English

Pharyngeal injection.....................................Red throat





I advised my patient that I did not advocate additional testing, and anticipated a very brief hospitalization followed by a full recovery.

She was not satisfied with this conservative approach. She had suffered a stomach ulcer nearly 20 years ago, and was concerned that her illness was a recurrence of this condition. She wanted the scope test (EGD) of her stomach to exclude this diagnosis. I spent more time with her to explain why this test was unnecessary, and told her that she might be able to be discharged late in the afternoon. I promised to check on her progress later.

It is more typical for gastroenterologists to coax folks into colonoscopies and other intestinal delights, than to dissuade them from sampling our diagnostic bag of tricks. This patient was an exception.

I called her nurse that afternoon to inquire on her condition. She advised me that the patient’s family had visited and they all insisted that an EGD be performed prior to discharge.

Here were my options:
  • Return to the hospital for a family meeting

  • Refuse to do the procedure and see the patient on rounds the following morning

  • Resign from the case and request another consulting gastroenterologist to see her

  • Perform the procedure.

Medicine is not a perfect world and its practitioners are imperfect members of the human species. It was clear to me that if the scope were not performed, that this patient and her family would believe that an essential medical service was being denied. They would be angry. In similar instances in the past, when I had counseled patients against having tests performed that they desired, I had been falsely accused of trying to save insurance company money. I did not return to the hospital to meet with the family as I believed that discussing the futile scope test with them would be futile. As the EGD has nearly no risk, I decided that performing it would serve the greater good. I recognize that other physicians may have chosen differently.

The results were normal. I’d like to think that no one got hurt in this vignette, but this isn’t true. Health care reform took a direct hit from me and my personal integrity was grazed. I’m blowing the whistle on myself.

Sunday, November 22, 2009

U.S. Preventive Services Task Force and Mammography: Evidence-Based Medicine or Medical Rationing?


This week, the revised U.S Preventive Services Task Force (USPSTF) mammography guidelines monopolized newsprint and airtime. Was this truly Page 1 news? For a few days, mammojournalism pushed aside stories on the war in Afghanistan, double digit unemployment, Iran’s hidden nukes, the president’s foreign nation tour and the war on terror.

(Note to readers: The phrase ‘war on terror’ is now verboten in the the Obama administration. No spokesmen will utter it, except on deep backround. I unabashedly use it since it seems that our enemies are still at war with us.)

Of course, it’s not the science of mammography that is white hot – it’s the politics of breast cancer that is volatile and combustible. Medical guidelines in every specialty are revised regularly, yet no conflagration erupts in the public square, as occurred last week. When my own specialty revises colonoscopy guidelines every few years, the public and the medical community respond with a collective yawn. Not so for breast cancer,which has lobbyists and political muscle that fights to make sure that their cause remains a national priority. Even mainstream medical organizations and public advocacy groups are in their corner. Maggie Mahar writes at HealthBeat that the initial reaction from many health professionals, breast cancer survivors and advocates has been outrage and anger, with many insisting that women’s health will be compromised if these recommendations are implemented...Leading this onslaught are some key members of the cancer establishment: The American Cancer Society, The American College of Radiology and the National Cancer Institute.

First, the USPSTF was accused of being a tool of medical cost control fanatics. I agree there was bias – from the accusers, not from the USPSTF. The mammogram brigades had an agenda and weren’t going to be derailed by solid medical data. The USPSTF has earned a reputation for objectivity and caution. They do not make recommendations that are beyond the data, despite political pressure to do so. Unlike most medical societies and advocacy groups, they are skeptical and conservative, two qualities that are often lacking in the medical arena. They should be applauded for calling it like they see it. Instead, they are chastised by those who are distressed by their recommendations. However, just because we dispute the outcome, doesn't mean that the system is flawed. For example, if we don’t like a jury’s verdict, does it mean that the trial was unfair?

Preventive medicine is overrated, a heretical statement from a physician who performs screening colonoscopies. While I support mammography and colon cancer screening, their medical benefits are much more modest than the public realizes. With respect to mammography, the data demonstrating meaningful benefit to women, particularly those under 50, have always shown relatively small gains for them. This test is often portrated as a lifesaver, but this is an exaggeration. Yet, there is a juggernaut of support for annual exams behind it.

What about the downsides of yearly mammograms for average risk women in their 40s? In addition to the test’s limited efficacy in this group, here are some real concerns from overuse.

  • Radiation

  • Anxiety for patients and families
  • False postive results which lead to invasive medical care
  • Detecting cancers that may never progress.

Of course, cost is also a factor, even though the USPSTF is prohibited from considering it in their deliberations. Where is the data that yearly mammograms in younger women are cost effective? This is analogous to the PSA test in men for prostate cancer. How many men are harmed by the PSA in order to save a single life? You cannot argue that saving a life is worth any cost, as this is not how our society operates. We all know that if we lowered the highway speed limit to 40 mph, or raised the driving age to 25, that we would save lives. Yet, we do not demand these revisions. We accept low risks of catastrophic events in our daily lives.

The USPSTF revisions are being co-opted by the political right as a prelude to medical rationing. I reject this broadside, just as I do the protests from the medical left, whose enthusiasm for mammography exceeds the evidence. If rationing means that every American cannot have every available medical benefit on demand, than I am a rationer. Of course, we all know that loaded terms like rationing are routinely sanitized to make them more palatable, even if their meaning doesn’t change. Here are a few sanitization examples.

New & Improved Sanitized Descriptions

Global War on Terror morphs to Overseas Contingency Operation

Medical Rationing is scrubbed to Evidenced Based Medicine

Whistleblower is buffed into Truth-teller

Interestingly, Kathleen Sebelius, Secretary of the Department of Health and Human Services, is sprinting at top speed away from the new USPSTF guidelines. I hope she doesn’t collapse from exhaustion. I am troubled by her retreat, as are fellow medical bloggers Medrants and The Covert Rationing Blog. The Obama administration is devoting over $1 billion dollars to fund comparative effectiveness research (CER), which is supposed to use solid medical data to determine which treatments actually work. Its objective is to eliminate ineffective care, which would result in billions of dollars of cost savings. Now, the USPSTF, appointed by the federal government, has issued solid CER guidelines that our government is rejecting with alacrity and zeal. Anyone want to wager on whether CER has a prayer to succeed? The Health Care Blog notes that our government's revised CER policy is 'not on our watch'.

The USPSTF presently endorses screening colonoscopy between the ages of 50 and 75. In the forseeable future, this guideline will be revised, when new technology replaces this procedure. When this occurs, should I welcome a development that will serve humanity, or grab a pitchfork and a microphone and cry foul. One of the most intractable challenges in health care reform is to separate one’s own interest from the public interest. If there is to be any chance of success, we need to be governed by science and medical evidence. The mammography mania we have just witnessed demonstrates that we are not equal to the task. The public and many physicians are convinced that more medical care means better health, a fallacy that may take at least a decade to unravel. This is the Gordian Knot of health care reform.

Ironically, the American College of Obstetricians and Gynecologists just announced that they think we are doing too many Pap smears. Hmm, first too many mammograms and now Pap smears also? Sounds like a vast GYN conspiracy is in the making.

Sunday, November 15, 2009

A ‘Never Event’ In My Own Practice!

I have already opined on the ‘never events’ reform where hospitals would not be compensated for certain medical catastrophes that should never occur. We all agree that performing surgery on the wrong organ, or the wrong patient, should never happen. My fear is that the list of events will metastasize and will include many unfortunate medical outcomes that cannot be avoided by even the most diligent physicians and institutions, a point echoed at The Covert Rationing Blog, and elsewhere. Dr. Val, in a guest post at Health Care Law Blog argues that patient falls in the hospital, while regrettable, should not be a 'never event'. Dr. Wes, a cardiologist, irreverently suggests that the common cold may be added to the 'never events' list!

We bloggers know how easy it is to hurl opinions from our safe sanctuaries. I learned this when I wrote a post about excessive emergency room care. Folks who had never heard of me, an obscure gastroenterologist from Cleveland, were leaving comments on various websites that I hope my mother never saw. While I stand by the post, I realize now that I didn’t sufficiently consider the issue from the emergency room physicians’ vantage point.

Recently, I experienced a ‘never event’ in my own practice. I am no longer a smug blogger who is pontificating from a distance, but I am now a physician who has to explain to a real human being why something happened that never should have occurred.

Was it my fault? I don’t think so. Was I responsible? Of course. I’m the doctor.

Two months ago, an elderly man was referred to me with suspected silent internal bleeding, a medical issue that gastroenterologists commonly address. He was in his 80s and had many medical conditions. He was a very reluctant patient. To the surprise of the referring physician, he actually showed up. I gave him his options:

  • Scope examinations of the large intestine (colonoscopy) and the stomach (EGD) to search for a source of the presumed bleeding. These tests are the most accurate, but have risk. He would be advised to stop his blood thinner several days before the test. He was anxious about stopping this medication, even though the risks of briefly interrupting a blood thinner in his case are extremely low.
  • Radiographic tests of the colon and stomach. No risk, but less accurate. He could continue the blood thinner. These tests require the same cruel, but not unusual, laxative purge as required in colonsocopy. However, if a lesion is discovered on these noninvasive tests, then he may need a colonoscopy and an EGD on another day to remove it. This option is safer, but may result in the fun and excitement of a 2nd colonic cleansing.
  • Do nothing and take your chances.

He agreed to contact me in a few days with his decision. While I would have wagered handsomely that he would have selected option #3, he surprised me. He chose option #2, so I scheduled him for a virtual ‘colonoscopy’, which examines the colon with a CAT scan. He preferred this over colonsocopy because it was safer and he could continue his blood thinner. He understood that if the CAT scan showed an abnormal finding, or wasn’t a high quality study, that he would be offered the ‘enlightening’ experience of a traditional colonoscopy.

Of course, the CAT scan showed a large growth high up in the colon. I related the news to him and then offered a colonoscopy. Now that he knew for certain that he harbored an unwelcome stowaway in his large intestine, this was an offer he could not refuse. For the second time in a month, he endured the liquid-dynamite cleansing agents that we gastroenterologists casually prescribe every day. I performed the colonoscopy and removed the large lesion and submitted it to the pathologist for analysis. The patient was to see me in 2 weeks.

Days later, in advance of his appointment, our office was called as the specimen was not received by the pathology department. No need to panic yet. This was likely a clerical oversight that would soon be rectified. Not quite. After several more phone calls, I learned the truth. The nurse had discarded the specimen. Let me restate this in more familiar language. She threw it in the garbage. Why? I’m still not sure. The nurse maintains that she asked what I wanted done with the specimen and she heard me reply, “I didn't need it.” So, she obediently complied and discarded the specimen.

There have been very rare instances when a specimen has been lost, but never has this been a deliberate act. What a colossal misunderstanding! Though I cannot recall my precise words to the nurse, I am sure that I wasn't talking trash.

I was shocked at this occurrence, which should have never occurred. I have removed thousands of colon polyps and every single one of them has been sent for analysis. We never discard a specimen. The nurse should not have deviated from an unbroken pattern of medical practice. Clearly, there was a complete disconnect between her inquiry and my response. I should be relieved that she didn’t ask if we should amputate his left leg. What if I nodded ‘yes’? Would she have taken out a chainsaw?

The patient and his wife returned and I disclosed what occurred. I apologized for the event and told him that the hospital was thoroughly investigating the event to assure that such an error will never happen again. I told him that the lesion appeared benign to my eye, but I couldn’t guarantee this, or that it was completely excised. I told him that another colonoscopy in a few months was advisable. He agreed to return to see me in the office 2 months later.

I saw him last week and scheduled him for another colonoscopy. As a precaution, I will be accompanied by a retinue of trained SWAT personnel to secure the site and guarantee that the chain of polyp custody will be seamless. Should I hire a Brink's truck?

Saturday, November 7, 2009

Tort Reform for Lawyers!

The law has many privileges and protections for its own players that are necessary for the legal process to operate effectively. For example, we all accept that a judge should have absolute legal immunity for decisions and judgments made in his judicial capacity. If a judge could be sued because he ruled that certain evidence was inadmissible, for example, then the system would collapse. Immunity allows judges to decide legal issues freely, without any threat that he could be legally vulnerable. This is how it should be.

Earlier this week, the U.S. Supreme Court heard oral arguments that challenge legal immunity for prosecutors, under certain circumstances. As an aside, I learned an astonishing fact in the New York Times article that reported that …prosecutors cannot be sued for anything they do during trial, including knowingly submitting false evidence. Read this sentence again. I had to as I was sure I had misread it initially. Immunity for trial conduct was not the issue being argued before the Supreme Court this week. The case at bar was whether prosecutorial misconduct prior to trial should be protected also. Two Iowan prisoners, freed by the Iowa Supreme Court, are now suing two prosecutors for fabricating evidence against them and tainting witnesses before trial. A lower court ruled that their case could proceed. The prosecutors, who are now defendants, argue that their pre-trial activities are beyond the reach of the law and fall under the immunity umbrella.

We should be cautious before expressing outrage and demanding that lawyers’ immunity be stripped. If attorneys were vulnerable, then this could invite frivolous lawsuits against them by litigants who are dissatisfied with the outcome of their case.

Frivolous lawsuits? This phrase sounds familiar. Any physician who still has a pulse will develop a rapid heart beat just on hearing the term. While the medical profession isn’t the sole target of FLs, we have a rich and unwelcome experience with them.

The Supreme Court case is examining a concept that could relate to the medical malpractice quagmire. The reason that judges and lawyers are shielded is so they are free of extraneous distractions and fear of lawsuits. Immunity improves their judicial performance. Why should physicians be vulnerable for acts and judgments made during our official professional capacities? If physicians functioned with immunity, wouldn’t our performance improve? Why doesn't the immunity argument apply to the medical profession?

Of course, if physicians enjoyed the same immunity as our legal colleagues, we would need another mechanism to compensate injured patients. I’m open to suggestions. Although nearly any system would be better than the current one, there is no consensus on how to proceed. Tort reform is a volatile issue in the public square and in the blogosphere. Spirited and strident blog posts appear daily. Just this week EverythingHealth listed various factors that fuel medical malpractice litigation, but omitted medical negligence from the list. Shouldn't medical malpractice be the sole reason for a lawsuit? KevinMD opines in his usual measured manner, that the current tort system must be reformed, not for physicians' sakes, but for patients' sakes. On the other side of the issue, a Huffington Post blogger argues that tort reform advocates are self-serving disseminators of myths and misinformation. (Yes, the Whistleblower did comment on the sight.)

We can’t sue a teacher because little Johnny received a C- on his history test. We can’t sue a basketball coach because the team lost the championship. We can’t sue our congressman because he voted against our district’s interest. We can’t sue an army general because the military strategy failed. But, we can sue a doctor who has done his job in good faith.

Those who deride my reasoning will present arguments why we physicians are somehow different from other professions who are immune for their official conduct. Let’s see what they come up with. No matter how outrageous their arguments are, I guarantee them complete immunity. The Whistleblower is their sanctuary.