Sunday, April 3, 2011

Medical Turf Wars: Truth vs Turf

Prototype 'BS' meter. 

So many folks express views that are obviously self-serving, but they try to masquerade them as altruistic positions that benefit some other constituency. These attempts usually fool no one, but yet these performances are common and ongoing. They are potent fertilizer for cynicism.

Teachers’ unions have been performing for us for decades. Their positions on charter schools, school vouchers, merit pay and the tenure system are clear examples of professional advocacy to protect teachers’ jobs and benefits; yet the stated reasons are to protect our kids. Yeah, right. While our kids are not receiving a top flight education, the public has gotten smart in a hurry on what’s really needed to reform our public educational system. This is why these unions are now retreating and regrouping, grudgingly ‘welcoming’ some reform proposals that have been on the table for decades. This was no epiphany on their part. They were exposed and vulnerable. They wisely sensed that the public lost faith in their arguments and was turning against them. Once the public walked away, or became adversaries, established and entrenched teachers’ union views and policies would be aggressively targeted. Those of us in the medical profession have learned the risk of alienating the public. Teachers have been smarter than we were.

The medical profession is full of ‘performances’ where the stated view is mere camouflage. For example, there is a turf war between gastroenterologists (GI) and anesthesiologists whether GI physicians can safely administer the drug propofol to sedate our patients before colonoscopies and other glamorous procedures. This drug may be familiar to ordinary readers as it was involved in the death of a superstar pop music legend in 2009. GI doctors insist that with proper training we can safely administer this drug to our patients. Indeed, there are numerous scientific publications that support this view. Anesthesiologists have pushed back hard and they have prevailed. “It’s too dangerous,” they warn. “No one can use this drug unless you have advanced anesthesia training,” Of course, the only physicians who have ‘advanced anesthesia training’ are anesthesiologists. I’m not claiming that my anesthesia friends don’t have a legitimate point. But, let’s be clear. Their position is not merely an effort to protect patients, it is also meant to protect their turf. See the equation below for a mathematical depiction of this issue.

Protecting(Turf) = $$$

Gastroenterology, my specialty is in the game also. This is transparent when our GI professional societies issue ‘guidelines’ for recommended GI procedure volumes and training for obtaining hospital privileges. For example, if these societies, who are dominated by academic physicians who work at medical schools and teaching institutions, issue procedure volume standards that are unreasonably high, this will serve to siphon procedures toward their medical centers where they work, and away from community gastroenterologists like me. In other words, if I do 20 procedures a year, but the ‘guidelines’ state that at 40 cases annually are required for competency, then I may be denied hospital privileges for this procedure and must then refer these patients to an academic center. The argument, of course, is to protect patients, but I suggest that there may be an unstated agenda. Interestingly, these medical centers and academicians do not issue ‘guidelines’ and volume standards for treating patients with cirrhosis, Crohn’s disease, irritable bowel disease or gastroesophageal reflux (GERD)? Why does my procedure count matter so much, but my case load for specific diseases doesn’t? Is it really only about safety?   Perhaps, physician readers will offer views on this point.

National leaders in gastroenterology are very concerned about surgeons and other physicians performing endoscopic procedures, which represent a major proportion of our incomes. Of course, we don’t want untrained physicians performing colonoscopies. But, there is a turf issue at play here also.

Everyone is grabbing for a piece of turf. Politics is so rife with turf protection that it is nearly impossible to divine what someone is really thinking. So much of what these guys and gals say and do have little to do with the merits of the issue, and plenty to do with elections and self-preservation. Wouldn’t it be nice if all of our elective representatives were equipped with a B.S. (barnyard epithet) meter that could distinguish truthfulness from turfulness? Could our best engineers design such a device? I doubt it. After 2 or 3 sentences, the needles would all snap.


  1. The combination of Fentanyl and Versed give very satisfactory conscious sedation for about 98% of my patients, and other 2% that truly need propofol are easily screened ahead of time.

    The reason propofol is used by gastroenterologists is $$$: it takes me as long as 6-8 minutes to properly sedate a patient using Fentanyl and Versed. Propofol sedates the patient in 15-30 seconds. Propofol patients wake up quicker, too. With propofol you can move 'em in and move 'em out.

    The truth is, because reimbursement for endoscopic procedures has plummeted so low, in order to remain solvent, the endoscopist has to generate huge numbers of procedures and this can only be done with propofol sedation.

    So yes, it really is a money issue.

    You fiberoptic colleague.

  2. You forgot how GI docs have opened their own path labs to grab the technical fee for the biopsy along with hiring a pathologist to read the specimen at way below market price. How come you guys feel that it is your right to take half of the pathologist profession fee for you own pocket when you had absolutely nothing to do with reading the biopsy????

  3. Dr. Kirsch,

    I find your silence deafening. No comment on how GI docs, as well as others, have reduced pathologists to a commodity.

  4. It was dealy, not deafness. Our practice does not collaborate with pathologists. We send out our specimens to an outside lab, and receive reports back. I accept your point and have certaintly targeted my own specialty - and myself - throughout this blog for our excesses.

    So, has my 'deafness' been cured?

  5. No, it hasn't. Why do YOU use propofol instead of conscious sedation?

  6. We use propofol, administered by nurse anesthetists, for patients with compromised pulmonary function, sleep apnea, anxiety, prior difficult exams under standard conscious sedation and on patients who take pain medications. I presume this list is similar to yours.

    Has my hearing been restored?

  7. Yes, your hearing has been restored.
    Thank you for your response.

  8. I don't know how I got turned onto your blog, but I'm grateful. It's a terrific read, and I'm encouraged by your unusually broad and critical view of healthcare issues. Would you mind if I linked your blog with mine?

    Jeff Kane MD

  9. Jeff, feel free and welcome to the blog. Look forward to your views.

  10. "We use propofol, administered by nurse anesthetists, for patients with compromised pulmonary function, sleep apnea, anxiety, prior difficult exams under standard conscious sedation and on patients who take pain medications."

    So if you reserve propofol for high risk patients, why would you want to deny them access to anesthesiologists? Help. I'm confused. How did this become a turf war?

  11. We do use nurse anesthethetists. However, I believe that GIs with training could safely administer Propofol. There's ample literature support for this. Anesthesiologists have cried foul on this, and it's not just about patient safety.

  12. Reminds me of the turf wars when the GI docs would fight to exclude family physicians and general internists from colonoscopy privileges or training.

    It won't matter soon. Both the Propofol and the colonoscopies will soon be done by midlevels.

  13. Actually, I don't think we'll be doing colonscopies then.

  14. Interesting perspective on TURF wars. I can see why some people are so interested in protecting their livelihood. Especially when new technology comes it, it can really be a game changer.

    Look what happened to CV surgeons when Cardiologists decided to do the stenting, cath imaging, angios, etc

  15. @medallic, thanks for the comment. Wait 'til comparative effectiveness research gets underway. That will be the 'Mother of All Turf Wars'!

  16. Last comment should have been addressed to @medholic, iPad autocorrect goofed!