Little progress in improving US overtreatment crisis…

I tweeted yesterday that the US healthcare delivery system remains broken. With only 140 characters, there was little means to expand. Let me tell you a story and then you be the judge.

The patient was elderly and had multiple chronic medical problems, including the chief complaint of debilitating orthopedic issues. I was asked to perform a procedure that specifically addressed one of the many problems–a heart arrhythmia. The procedure is one of the simplest that I do. It takes about 30 minutes, causes little pain, and I am well-compensated for doing it. When done in selected patients, this procedure can provide incredible benefit. And there is science to back it up.

The patient was ready, and all I had to do was do the damn procedure. It would have been so easy. On paper, it was justifiable.

But I didn’t feel right about it. The effects of the procedure would be permanent. The risks of making things worse were real. There was a possibility of benefit, but it in my mind, the likelihood was modest. It was a pure judgement call. No right answer. I just didn’t like what I was about to do. (I fear making the elderly worse; they are a fragile lot.)

I tried not to show it, but my brain was flailing with the decision to express doubt. The patient’s doctors are excellent; they thought the procedure (that I do) would help. They knew the patient well, but we had just met minutes ago. My internal estimate of the correctness of my decision was 90%/10%. (I always assess my level of certainty with decisions. You do too, right?)

It would be disingenuous to omit this thought: “Oh boy, Mandrola, you might get in trouble for over-thinking and not doing the procedure.”

So I tried to explain my doubts. Picture the scenario: The patient was hard of hearing; the family member had a notebook and was trying to transcribe my every word–to explain why I didn’t feel so cheery about doing a procedure that I was expert in, and that other doctors had recommended.

It took more than an hour to get through this. It wasn’t just the time spent, I had to get it all down on paper. And then there was the matter of communicating with the other doctors.

Here is the broken part: I burned a tremendous amount of time and emotional energy walking this thin line. A note chronicling that time earns less than a quarter of what the procedure would have paid. Not only that, if I don’t include, in the e-note, pages of irrelevant medical nonsense, I could be held liable for fraud. That’s tragically ironic, because I just saved the patient and medical system from a potentially harmful and expensive procedure. (Don’t forget, there was a 10% chance I was wrong.)

As a procedural clinician, not giving in means everything to me. But I notice the temptation, and conversations like these make running on time a fantasy. Fortunately, it is easier for me than most doctors. I am a veteran here in the local healthcare system. I have capital, and the energy and risk-aversion to burn it. Many–likely most–doctors aren’t in the same position. They want to do the right thing, but the pressure to do more, not less, is too great to overcome. Plus, our healthcare behemoth has been defaulting to delivering more care for so long, it is reasonable to think that most doctors and patients have come to expect it as normal. Like a flat earth and the benefits of non-statin cholesterol-lowering drugs.

Right-minded people point to the problem of misplaced financial incentives. The US model favors doing. That’s a big part of the problem for sure. But it’s way more than just dollars. And one has to be careful with incentives: it’s possible to induce too little care–remember the HMO experiments.

Real (I won’t say meaningful) improvement in the over-treatment crisis will come only when patients and doctors wholly accept the merits of discussing the option of no treatment or conservative treatment. This is the key. We are all believers in doing more.

It’s pointless to write about problems without offering a possible solution. I have a simple one that might appeal to policy makers and medical educators alike.

May I suggest that doctors avoid the word ‘need’ in the exam room. If we stopped saying patients needed stuff, we might be able to open our minds to the benefits and harms of the disease versus our treatments. If patients were never told they needed something, they too, might be allowed to consider their options.

I once wrote about the most overused word in cardiology. I believe it more than ever.

Changing the need culture might be safer than messing with dollar incentives.

JMM

6 comments

  1. John – I hear you loud and clear. You’ve explained the perspective from the view of a procedure doctor (YOU are of course MUCH MORE than just that – but you like other specialty practitioners do a lot of highly compensating procedures).

    Similar ethical dilemmas arise for a medical doctor. For example, it takes much longer to explain by providing true informed consent all the pros and cons of ordering a test (say a screening mammogram, colonoscopy, PSA in a healthy asymptomatic subject) – than simply writing the order. To not treat a likely viral URI (when you are >90% certain the infection is not bacterial) takes a lot more time to explain to the patient why antibiotics are not only not indicated, but potentially harmful. And to do either of the above requires much more documentation (and risk of second-guessing by chart checkers, if not frank question of your competence) – than would be needed if your note simply said screening test – statin for primary prevention of elevated cholesterol (despite this being a low-risk patient), treatment of “bronchitis” … Ironic when many of these decision points that have developed over time as “Guidelines” are in fact financially motivated and lacking in discussion on the important issues of NNT (Number-Needed to Treat) for potential to Benefit vs potential that the intervention may result in Harm (radiation exposure; false positive test leading to unnecessary surgery that doesn’t improve outcome; antibiotic or statin side effects – not to mention cost, increased doctor visits and propagation of the “patient” role). It sometimes (or more than sometimes) takes more time to “do the right thing” – with that “right thing” sometimes resulting in more work, more risk (of “malpractice”, and less reimbursement). Most clinicians DO want to do “the right thing” – but that is not always easy. The system is less than optimal …

  2. As a physical therapist I am sometimes asked to provide treatment that I judge to have little or no value for a patient. In most cases I take the time to explain this to those involved and try to offer other options. But over the years I have developed a rule that if I am the only one who feels that the treatment would not achieve the goal, that is, the patient, the referring physician, the patients family, sometimes even the payer believe otherwise, I defer. Because physical therapy rarely causes harm, am I less guilty of moral compromise than cases where harm is more likely? If it is just the money, is it okay?

  3. “Plus, our healthcare behemoth has been defaulting to delivering more care for so long, it is reasonable to think that most doctors and patients have come to expect it as normal. Like a flat earth and the benefits of non-statin cholesterol-lowering drugs.”
    Dr. Mandrola, as someone who takes a “non-statin cholesterol-lowering” drug (Welchol), I’m unsure of the meaning of your statement. Are you saying N-S C-L drugs don’t work or DO work?

    To cold for me to ride some I’m reading your blog !

  4. It’s very hard to say “no” especially if a patient has been referred to you for a specific procedure. I’m an anesthesiologist, and for us all the decisions of rightness or wrongness have already been made, and we have not, generally, been involved in the conversation. I’ve done a hundred cases I didn’t agree with. You can’t cancel the case because you disagree with the reason for it or the utility of it. I tried once.

  5. Excellent article, and great Grand Rounds presentation on Friday!

    Trust is the glue that holds the system together, and it’s in precious short supply these days.

    Don’t expect to be applauded for doing the right thing. I’ve balked at one too many PEG consults, and they simply do not come my way anymore.

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