Sunday, July 11, 2021

Why I Cancelled a Colonoscopy

This morning, as I wrote this some time ago, a patient came to my office for a colonoscopy.  I sent her packing.  Here’s what happened.

In our Ambulatory Surgery Center (ASC), in my prior private practice, we introduce light into dark spaces every day.  This is where we perform colonoscopies and upper endoscopies.  We have a program in place where referring physicians can have their patients contact our ASC and schedule a procedure without seeing us first in the office for a consultation.  Obviously, we have to have a vigorous screening process in place  We do not want to meet a person for the first time for a colonoscopy and discover that he has complicated medical issues and is dragging an oxygen tank behind him.

Our screening system works extremely well, but it is not perfect.  On occasion, it misfires  The patient arrived at our office at 7:00 a.m. after a 45 minute drive.   She had ingested the required purge,  often the highlight of the experience.  I hadn’t seen her for years.  She was suffering from severe pulmonary disease, smoked cigarettes and used supplemental oxygen at night.  Clearly, this was not an appropriate patient for our out-patient facility.  Our nurse anesthetist and I conferred and agreed that we should not proceed because of safety concerns.

I explained to the patient, her husband and her daughter our reasons for cancelling the case.  It was a long conversation.  At first, she was disappointed for all of the obvious reasons.  She had endured a day of a clear liquid diet followed by ingesting our prescribed liquid dynamite to cleanse her colon.  She and her family had taken an early and long drive.  After she had ventilated her transient exasperation, she quickly came to understand that our sole objective was to protect her.

Why am I sharing this vignette?  Every doctor could relate similar anecdotes.  I share this typical scene from our practice, which I offer as an example of sound medical judgement.  We did the right thing and protected a patient’s health.  We considered the risks and benefits of the procedure and sedation, and chose safety.  Doctors (or patient) shouldn’t try to get away with stuff.

When the Medical Quality Police evaluate me, as is being done by our hospitals, insurance companies and the government, how will they measure our performance this morning?  They won’t and they can’t. So much of the good work that a doctor, a policeman or a teacher does, can’t be measured.  I work with great nurses every day, but there is no formula that exists that can measure what they do.  What has happened is that these professions are now assessed by box-checking bureaucrats who are charged with measuring all kinds of silly stuff that doesn’t matter.   Do I get any credit, for example, when I advise a patient that he doesn’t need a colonoscopy or a CAT scan?  Ask your doctor about this issue during your next appointment, but bring some Maalox with you because your physician’s esophagus will start sizzling.

Medical Quality Measuring Device

Look up Pay for Performance on this blog and elsewhere to find out more about this scam.
Incidentally, there’s happy ending to the woman whose case we cancelled.  Since she was prepped for a colonoscopy, we sent her to the hospital where I did the case safely later in the day. 

How do you define a high quality physician?  If you are able to define it, how would you measure it?

2 comments:

ALAN L BUCHMAN said...

We have a system that is beyond dysfunctional. We and are predecessors are all to blame. We are incentivized to do things to patients, not for them. Procedures are often over-reimbursed while thinking is usually under-reimbursed. We are not paid for reviewing records, which is why some centers seem to prefer to repeat procedures rather than scan through 1000 pages of medical records to find the previous endoscopy report or zinc level. Bonuses are based on RVUs, which are mostly generated by procedures. We've allowed MBAs to run medicine, many of whom know little about medicine but a lot about cutting costs. Initially, efficiency is improved but they often fail to recognize whereupon inefficiency starts to increase because of cost cutting. Clinicians and their business partners try to maximize revenue while payors try the opposite - much like lawyers in arbitration where each side starts at a point where they know their position is unacceptable. Where is the patient in all of this?? What is needed are fully integrated systems - but even then the right pocket will complain that the left pocket is getting too much money. Doctors are at least partially to blame here. They/we didn't want to be involved so much in the development of billing systems - or even EMRs for that matter (which is why they are not as user-friendly as they should be) because (the collective) we stuck our heads in the sand. It is unfortunately too late to scrap teh billing system in order to bill by complexity of thinking rather than by time or by procedure. That's where the patient really suffers. Physicians are paid for doing - but not necessarily for doing the right thing. Payors have problems too. There are things that are paid for that never should have been and there are things not paid for that should be - and there are also those that try to game the system. This is why our health care system stinks, but I think many of us do the best we can within these constraints.

Michael Kirsch, M.D. said...

Alan, thanks for your thoughtful and expansive comments. If you have been a Whistleblower reader for some time, you know that I largely agree with you. The fee-for-service model, which was my primary method of reimbursement for most of my career, misaligns physicians’ and patients’ interests. Currently I am on salary which I think is a much better model as long as the salary is fair. As you might expect, the definition of what constitutes a fair salary is rather elastic. Additionally, there is a zero sum element to this game in that paying some specialists more will likely come at the expense of others within the medical arena - causing an internecine conflict. With regard to the issues you raise, I think we are headed toward higher ground as value based pricing is gaining a foothold in the medical landscape. I agree as well that EMR’s were developed with billers and coders - not physicians - in mind. Astonishingly, we do not have a universal EMR which was the original promised included with the seduction many years ago.

There are many moving parts in this 4 dimensional chess game. Tug on one thread and their may be unintended effects in other regions of the tapestry.

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