I have never liked serving as a technician gastroenterologist, but I am often asked to do so. Like every other gastroenterologist, I have performed requested procedures that were reasonable, but that I would not have personally recommended if my advice had been sought. The patient referenced at the top of this post was in a different category. This was not a 'gray area' issue.This scenario raises so many questions it is hard to know where to start. The major questions that come to mind are:
This particular patient was having some minor rectal bleeding. He had already had the pleasure of a full colonoscopy this past November, when hemorrhoids were discovered. No additional testing was necessary for the current minor bleeding, as hemorrhoids were the likely culprit. The request for an EGD was nonsensical. The ordering physician had no economic conflict of interest in ordering the test; only the gastroenterologist would benefit financially. An EGD here was like ordering a foot x-ray on a patient with a sore throat.
1. Who do you work for in this circumstance?
2. What job were you hired to do?
Until it is clear what the answers are to these questions, all other discussion are essentially moot. Let us address the first question. Most economic transactions are fairly straight forward since there are generally two parties, a buyer and a seller. There may be a broker who facilitates the transaction but it generally pretty clear who the principal parties are. In a health care transactions such as described by the MD Whistleblower are extremely common and in my estimation the problem is the confusion relating to these two questions.
For a specialist who is dependent upon referrals, it is pretty clear that they are more beholden to their referring docs than to the patients who are referred. How else could you justify actually doing the equivalent of a foot x-ray on someone with a sore throat. Because of the financial structures which have evolved in medicine, physicians are only marginally beholden to patients with some specialties essentially not beholden at all.
The second question is inextricably linked to the answer of the first. If any given physician who has been pulled into the care of a specific patient is primarily working for someone other than the patient, the job they are hired to do may or may not actually provide any value to the patient. In the scenario described in this particular blog, the job the MD Whistleblower was hired to do was to reduce the exposure of the primary care MD to the legal risk of failure to diagnose. In this case there essentially no potential value to the patient. This unfortunately placed the consulting MD in a precarious position of either being a true advocate for the patient by revealing the absurdity of the consultation and alienating his employer (referring MD) or continuing to play the game.
I do not mean to pick on the GI field. The MD Whistleblower simply described a great scenario to use as a springboard. The same game happens ever day in other specialties. Overwhelmed primary care MDs send consult missiles to get patients out of their offices and relieve themselves of the responsibility of explaining the nuances of risk and the ability of testing to predict risks. Technically focused specialists are most highly rewarded for maintaining a state of blissful unawareness of anything that might prompt them to stop and convince patients that they do not need that EGD, CAT scan, skin biopsy, or cardiac catheterization.
I believe the only way out of the quandary is to educate patients to ask these two basic questions whenever they have encounters with physicians. The answer to the first question will invariably that the MD claim he (she) has been hired by the patient. It might not be entirely true, but it will at least serve as a reminder how it should work. The answer to the second question is where things will get interesting. I can imagine the the conversation regarding the scenario described above with a patient who has been educated to ask the right questions.
Patient: What job am I hiring you to do?
Doctor: Your primary care MD referred you to me to do an EGD.
Patient: Why will this be useful to me?
Doctor: It might find an undefined source of blood loss?
Patient: How likely is that to be the case?
Doctor: Vanishing small to non-existent. I will be happy to comply with your doctor's request. Is this what you want me to do?
I can also imagine the more likely conversation going like this:
Patient: I had some minor bleeding and my doctor sent me for this test?
Doctor: Yes I know. Here sign this consent for the EGD.
Patient: Can I really die from this test?
Doctor: Not really, legal makes us include this language
What it boils down to is uninformed patients will always be prey. We would like to believe that the medical profession will be driven by altruism primarily. As much as it hurts me to admit this, there are cultural elements which permeate the business of medicine that most closely resemble cultural elements more commonly associated with used car sales. We are not going to change human nature and the best defense for dealing with this is informed consumers.