Friday, February 22, 2008

Ripoffs or Reticence?

Couple of months ago I read an article about a guy who did a three or four simple un-fixes to his Subaru, took it to a bunch of repair places, and reported the results. Bottom line: only about twenty percent found the problems and provided the appropriate and easy repairs. The others suggested all manner of unneeded and very expensive work, and missed some things. Not a surprise.

The article analogized to medical care: experts who have a stake in providing the care and charging for it may not always be trusted to give the best advice. It's not an entirely specious proposition. I was reminded of it recently.

I get ongoing comments on posts from long ago; most particularly the gallbladder series. "I'm so glad to have found your blog," they say, and then proceed to tell me their saga of problematic diagnoses and/or recommendations, and they ask my advice. At some level it's flattering, until I realize they're probably pretty desperate to trust some guy on the other side of their computer whom they don't know from a bag of groceries.

Anyhow, I try to help when I can, within the parameters of my disclaimer over there on the right. Recently there was a description of a symptom complex that was quite typical of gallbladder pain, with confirmatory ultrasound which even showed some thickening of the organ's walls -- pretty much diagnostic of active problems. Her gastroenterologist had her scheduled to have upper endoscopy to "rule out ulcer," and then she'd be sent to a surgeon. Her question was less about the need for the scoping than about how to approach the upcoming surgical consult. (The preceding link is worth checking out, by the way, because the doc appears to be using an invisible scope and looking at a lampshade.)

So here's where it gets complicated. Unlike a Subaru, the human body doesn't have a shop manual. Doctors sort through incomplete, conflicting, and inadequate data (because all of our tests are fallible) in order to come up with a diagnosis and recommendations. On the one hand, I can't judge from afar the need, in this case, for endoscopy; on the other, from the little info I had, it seemed a waste of time and money, with at least a small amount of risk.

I didn't say anything.

In my series on the appendix, I told the story of a call I got from a family doc, asking me to see a young man he suspected of having appendicitis. A twenty year old with a day and a half of abdominal pain, starting near his belly-button, moving to his right lower quadrant, he now had point tenderness, associated with loss of appetite, nausea, fever, and an elevated white blood count. Which did I want ordered, I was asked: ultrasound, or CT scan? If ever there was an appendicitisoid duck ("if it walks like a duck, quacks like a duck, has feathers and feet like a duck, it's a duck"), this was it. But here's the point: in this case, the doc had no financial stake at all in the imaging studies he'd have ordered. (I operated with no further tests, removed a hot appendix, and the guy lived happily ever after.) So yeah, it's complicated: it's not just about self-interest, at least in the purely financial sense.

I've been referred many patients over the years, all teed up by their docs and expecting an operation. For a variety of reasons, it wasn't an intergalactic rarity for me to tell them it wasn't needed or advisable. I can say with near certainty that I never did an operation where I let monetary considerations tip the scale. But I'm sure nearly all docs would say the same thing about any procedure, even the ones that did. Is it conceivable that an ulcer could cause severe colicky right, upper abdominal pain, intermittent, radiating to the shoulder blade, and not be related to the proven gallstones and gallbladder wall-thickening? I guess it is, although she might also have been struck by lightning on her way to the test.

If the patient were seeing his/her family doc instead of a gastroenterologist, would s/he have been referred first for endoscopy before an appointment to a surgeon? I'm guessing not. If the patient were seeing a surgeon who did endoscopy, would that procedure more likely be done, pre-operatively, than if it was a surgeon who referred such patients to a gastroenterologist? And if not, would there be any back-scratching involved? I'll defend my profession vigorously, and I'll argue as hard as possible that caring for humans will never be subject to binary decision making. But in this I can't claim we, as a group, are pure as a virgin's smile.

I am.

Were it possible, liability-wise, and avoiding-being-burned-at-the-stake-wise, it'd be interesting to consider an on-line business wherein one provided prospective (as opposed to working for lawyers) second opinions or general guidance through a problem. Obvious preclusive limitations and dangers and presumptions aside, I bet it'd be eye-opening.


Anonymous said...

Perhaps I'm naive, but I don't think it's very prevalent. Increases in income would be marginal unless you're a total sleaze doing all manner of unnecessary things (which will get you nailed eventually). And there are few people for whom those marginal increases in income are worth the hit to their self-image (because we do enjoy thinking of ourselves as wonderful human beings).

Ironically as reimbursement goes down and people become more desperate to keep making payments on their oversize mortgage I think it may become a bigger problem.

rlbates said...

Dr Sid, another good post. I try hard to be that "ethical" surgeon who has the patient's best interest at heart and not my mortage or even my phone bill. I hope I manage to do so 100% of the time, but I don't know. Anyway, you say it much better than I ever could. Thanks

Sid Schwab said...

anonymous: I think your point about the future effects is a good one. Also, I'd say my title, "ripoffs or reticence," speaks to the dilemma: it's not necessarily dishonest. It's about the fact that, for various reasons (which might also include subconscious -- or conscious -- profit motive) many docs seem less willing to make a call without covering even the most unlikely possibilities.

ramona: from what I can tell about you, I'm guessing you're most definitely a 100%er.

GDad said...

So, my shoulder has been hurting lately...

I am the alpha geek in my family. Everyone asks me to diagnose computer problems based on ill-remembered symptoms days after the fact. I can only imagine trying to diagnose medical things from far away.

JP said...

I take it there is no internal auditing process, random or otherwise, by which doctors' orders (for tests, medication, etc.) are reviewed for the "primum non nocere"?

SeaSpray said...

Interesting post and it would be interesting to know the outcomes of your proposal.

Sid Schwab said...

JP: short answer: no. There are some indirect mechanisms, such as data that's gathered by insurers, medicare, etc, comparing one doctor's costs per specific disease management to another's. And there are various audit committees in hospitals: indications for procedures are reviewed. Still, it's less than uniform, nor always effective. I think it's an area that needs addressing, along with "best practice" standards, as ways really to manage health care costs. But it's far from simple, and I barely scratched the surface in this post. On a national scale, I'm not even sure it's entirely possible.

jean said...

a very interesting post.

having had classic gallbladder pain and tests that found "sludge" but no stones in my gallbladder, i had a test that revealed a borderline 33% ejection fraction. this was nov. 2006.

may 2007, having another episode of pain and nausea, i discussed this burning pain in the middle of my chest. the surgeon did an endoscopy, found h. pylori, which was successfully treated.

nov. 2007, another bout with nausea and pain, this time ejection fraction was down to 22%.

gallbladder out, dec. 2007.

happy tummy, happy patient :).

Anonymous said...

What IS it with docs thinking classic gallbladder symptoms are ulcers? Mine spent fifteen minutes trying to tell me that I had an ulcer and needed endoscopy, when I knew with complete certainty that it was my gallbladder. As a student with no health insurance, I was not about to have tests that I knew I didn't need. I insisted on ultrasound, they found gallstones, I had it taken out the next week, and it's been happily ever after for two years.

I've found that the positivity/negativity of my experience with doctors is very much based on whether they believe me when I tell them I know what's wrong. Interestingly, they believe me more often now that I have health insurance.

jb said...

Maybe it's been done, but I haven't seen it. Compare workups done for a given symptom (e.g., epigastric pain) in a fee for service situation with a prepaid situation (Kaiser/VA/military) where all the staff is on salary. Look at outcomes. Also must look at liability issues- in how many depositions was a doc asked why she did not get that CT/endoscopy/cardiac catheterization. That will get you the answer, if the study could be done properly. I suspect that the ultimate answer will be that there is some, but not a lot of, stuff done purely to pad the docs' pockets. Trying to eradicate all of it will lead to more counterproductive Stark laws, and overall quality of care will suffer.

Anonymous said...

I think a lot of the unnecessary stuff is ordered not so much from greed but ignorance, fear and plain tiredness. I'm an orthopedic surgeon and can't tell you the number of patients who show up with things like MRIs for ruptured achilles (um, simple clinical exam tells you all) or knee arthritis (weight bearing plain films cheaper and more useful) but also the number of patients who are convinced they NEED an MRI for something that is just not diagnosed or helped by an MRI. You can either make a stand and waste a bunch of time or give in. I tend to waste a bunch of time because I'm constitutionally incapable of not convincing someone they are misinformed and am in a small town where there isn't the competitive pressure to make a buck seeing 45 people a day but I think a lot of people give in. Especially primary care docs who get most of their pay from seeing as many people as possible and don't really know whether one would help or not or have to keep the regulars happy.

Sid Schwab said...

anonymous: I think that's a very accurate characterization of a very important dynamic.

anabellasmommy said...

Hey Dr Sid,
I posted a couple weeks ago about my gallbladder with the ef of 29%. Gi reffered me to surgery with a dx of biliary dyskanasia(sp) I see a surgeon this week, any advice of questions I should ask that I may not be thinking of??

Sid Schwab said...

mommy: I wrote in another post here about biliary dyskinesia. In my experience those who get a good result from surgery are those who have very typical gallbladder symptoms, and whose HIDA is definitely abnormal, and in whom the injection of CCK reproduces their symptoms. I don't recall your symptom pattern, and your previous comment wasn't in this thread. 29% is marginal, so for me to be confident, were you my patient, I'd want to know the other two factors were pretty clear. I guess the main issue to address with the surgeon is what her/his definition of biliary dyskinesia is and where s/he thinks you fit. What, in his/her experience, are the chances of a good result?

Having just heard from someone about a nasty response from a surgeon when asked some questions provided by another surgeon, I'd recommend tact. And don't quote me!!