"Shadows" are now less valuable…

Another huge day for cardiologists today.  CMS, or medicare or the government or whoever has decided that cardiologists who read images are making too much money. Nuclear scans and echocardiograms (ultrasound) are being arbitrarily cut by up to 40 percent. These scans form the backbone of a cardiology office.  Although they require a substantial initial investment of capital and maintaining a ‘quality’ lab requires expensive human capital these images are still lucrative.

The CEO of the American College of Cardiology says that “they are basically killing the private practice of cardiology.”  Really?

Cardiologists are so mad that their professional society, the ACC, is suing the federal government.

I guess the main question is whether cutting imaging reimbursement is good for patients?

What would my old mentor Dr Fisch think?

It is 1994. On the fourth floor outside the renal ICU in a bland room with a long table in front of a wall adorned by nothing in particular we sit surrounding the late Dr Fisch–the resident to the left, the fellow to the right and the students behind, always in that formation.  Old fashioned EKG’s are passed form left to right, the resident calling out the interpretation with a hopeful tone.  A grunt and passage to the right if correct, a peer over the impossibly thick glasses if wrong and in many cases a drawing of vectors to explain the error. Dr Fisch is a world famous expert in interpretation of these ancient, now 25 dollar EKG recordings. He is old, stern, but yet comes to work at age 75 to show us. We are tentative, except Staci, who in her short third-year medical-student white coat grins at him and he is disarmed.  But yet, on Thursdays our sessions are cut short at noon for ECHO conference.  We get antsy as the clock nears 12 noon; there is free food from drug reps – a tradition which has passed the same way of the VCR tape – and Dr Fisch says with the meekest of grins “you are off to study those shadows again, aren’t you.”  He is not a believer in shadows or nuclear scans.

So is it bad that fewer scans will be done?

There are indeed stories of non-symptomatic patients who were discovered to have terrible heart disease by nuclear scans.  Consider this though: a single nuclear stress test, ordered ubiquitously, exposes a patient to the same dose of radiation in 500 chest x-rays. Additionally, they are wrong up to 20-30 percent of time and worse yet, when wrong, they are  often “false positives,” which lead to cardiac catheterization and another 500-cxr dose of radiation and the potential risk of serious complications.

So naturally, one wonders how expensive nuclear stress tests could be reduced?  Here’s where being a master of the obvious comes in to play.  Judgment. There is a role for these tests, in certain situations with clear goals, a priori considerations and knowledge of their limitations. A common unthinking scenario is “patient Jane Doe is here with chest pain, we will just get a Nuc.”  Hopefully, the “just get a nuc” will be replaced with sound clinical judgment.  Of course, the problem herein is that a time consuming careful evaluation, examination and clinical judgment is increasingly poorly compensated and the concept of not ordering tests exposes one to potential liability.

Will suing the US government help matters? This master of the obvious is not optimistic.

My concern, maybe yours too, is whether these forthcoming changes will limit availability of access to cardiac care before a major cardiac event. Combine less access with our continually worsening lifestyle choices and it is easy to foresee rough seas ahead.

Once again, we will make due with less, as Thoreau said we should.