Doctoring General Cardiology General Medicine Health Care

Not mastering the obvious is costing us now…

Being married to a palliative care doctor is enlightening in so many ways.

As has been noted previously, CMS (government) decided that commonly ordered stress scans and ultrasounds of the heart are much less valuable.  Undoubtedly, there are many reasons for this, but at least one is likely the notion that there are too many of these imaging procedures performed.  Obviously, we cardiologists disagree.  I am no lawyer, but it seems instructive to visualize the opposing view of any argument.

Take the case of a near 90 year old nursing home resident with advanced dementia AND a stage 4 (out of four) sacral decubitus ulcer who is now referred for hospice care.    Not such an uncommon scenario, but what is remarkable was a very recent hospitalization in which a nuclear stress study was done.  This 1000$ plus diagnostic test equivalent to 500 CXRs of radiation was deemed necessary despite a note prior by the cardiologist saying the patient would be a poor candidate for heart catheterization. 

 {Important warning:  do not do a google image search of a Stage 4 sacral decubitus unless you possess a strong stomach.   If you do dare to look, it will be obvious why heart disease would be low on the problem list.}

Of course this patient was a poor candidate for any diagnostic heart procedure.  Advanced dementia, immobility sufficient to cause breakdown of the skin to the bone and an age of 90 would argue for treatment of symptoms and care focused on enhancing comfort.

Ordering an expensive diagnostic scan on this patient is the antonym of mastering the obvious.  Like one of those choices on a multiple choice test that can be eliminated immediately.

So do the powers that determine cardiologist’s salaries think they can facilitate the mastering of the obvious?  Did we bring some of this on ourselves or are we simply standing there in the ocean thinking the upcoming wave isn’t big enough to take us down.