Dr John M

cardiac electrophysiologist, cyclist, learner

In the Prime post up over at the Courier-Journal: The difficulty of judging others

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Judging other doctors is tough. You are torn. On the one hand, as a member of the profession, it’s hard to read stories of misdeeds of fellow cardiologists and remain neutral. You want to call out the foul. You want to set the record straight. That doctor did wrong. Justice needs to be done. I am not like that, and neither are my buds. You are especially sensitive to the perception that doctors take up for their own. You are scared that if you don’t stop the bad kids from misbehaving, the whole class will be punished.

But on the other hand, this whole human doctoring thing is pretty fragile, isn’t it? You have a lot of thoughts in your head. Things like, how perfect am I? Do I respond to financial incentives? Have I always made the best decision for my patients? In hindsight, could another doctor be critical of decisions I made in real-time? The word righteous’ worries me. And not to introduce religion into a medical blog, but it would be deeply disingenuous not to admit that one can wonder about the existence of Karma.

That tension was why I had originally decided to let the most recent story of  doctor-misconduct rest. But this one hails from Kentucky. The alleged misdeeds made the front cover of the Courier-Journal and was also covered in the USA Today.

You have heard the storyline before: Cardiologists, perhaps conflicted by financial incentives from their hospital, performed unnecessary cardiac procedures on hundreds of patients over many years. A lawsuit involving more than 280 plaintiffs is ongoing. A little city in rural Kentucky is now in the national news.

I changed my mind about posting some thoughts. It is a local story. The breakdown of trust is one of the reasons why we have a healthcare crisis.

I hope you want to read more. It’s published on the In the Prime Blog over at the Courier-Journal.

The title of the post and link are: When doctors break the public trust.

JMM

“Choosing Wisely”–A great name for a great plan.

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Cycling Wednesday has to be postponed this week. There is indeed a more pressing and relevant health matter that has come to light today. I am talking huge news; a story ripe with optimism and hope.

Let me tell you about a possible paradigm-changing idea in the seemingly hopeless matter of controlling runaway healthcare costs—a topic that has far-reaching implications, not just for healthcare, but for our nation’s economy and vitality.

The news:

Organizations of doctors have decided to embrace common sense in the practice of Medicine. Led by the American Board of Internal Medicine Foundation and joined by many other medical societies, the Choosing Wisely movement aims to promote care that is…listen to this…

  • Supported by evidence,
  • Not duplicative,
  • Free from harm,
  • Truly necessary.

Nine medical groups—with more coming on board soon—were asked to compile a list of 5 misused or overused tests. The American College of Cardiology listed these ground-breakers:

  • Cardiac imaging should not be performed routinely in patients without symptoms or high-risk.
  • Cardiac imaging should not be performed for routine follow-up in patients without changes in symptoms or signs.
  • Cardiac imaging should not be performed prior to low-risk surgery.
  • Echocardiograms should not be done to follow-up non-symptomatic patients with mild valve abnormalities.
  • Patients with heart attack treated with emergency stenting should have stents placed only in the culprit vessel.

These are not misprints. The leaders of American cardiology have gone on the record against nonsensical and wasteful–but some say ‘thorough’ testing. Wow!

As a minimalist and (budding) master-of-the-obvious clinician, these proclamations of common sense make my heart sing. But that’s not all. Choosing Wisely isn’t just about smarter Cardiology recommendations. (Although, if implemented, these heart recommendations alone would greatly reduce unnecessary healthcare costs.) Other medical societies have weighed in with equally ‘epic’ suggestions:

  • Radiologists recommend performing fewer head imaging studies for headaches and fewer chest CTs in the initial evaluation of suspected lung blood clots (PE).
  • Family doctors urge doing fewer MRIs for low back pain and prescribing antibiotics less aggressively for uncomplicated sinusitis.
  • GI doctors call for less repeat colonoscopies after an initial negative test, fewer CT scans of the abdomen and titration to the lowest dose of medicine to treat reflux.
  • Internists repeat the call for fewer MRI scans of the low back, avoiding head-imaging tests for simple faints, and echo the ACC recommendations to not do routine stress tests in low-risk patients.

This stuff is huge. We all know healthcare costs are spiraling out of control. Most agree that the reforms argued in front of the Supreme Court last week don’t address the issue of controlling costs. Government regulation tries to limit costs by covertly (or overtly) inserting itself in the doctor-patient relationship.

Effective healthcare reform will not come from the government.

Doctors must design and implement healthcare changes and reforms. Call us what you will, but we are the experts in medical diagnosis and treatments. We know what works and what doesn’t. We must be allowed to practice Medicine–not just follow protocols, or test and treat just to cover our butts. The corollary here, of course, is that we must be allowed to be human. What my favorite cyclist, Fabian Cancellara, says about cyclists holds true for doctors too: “We are not cyborgs, only men.”

That our thought leaders are now proclaiming–and social media is amplifying– the values of clinical judgment and targeted thoughtful diagnostic and therapeutic interventions represents a monumental sea change. Malcolm Gladwell writes about small yet obvious ideas that come to stick. I think Choosing Wisely has a chance. I hope it sticks like super glue.

Gosh…Writing about this feels so good. Not just because my approach to the practice of Medicine has come back in vogue, but because I care so much about the human aspects of our profession. Because it matters so.

If only I had thought to name my blog, Choosing Wisely.

JMM