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Sunday, June 6, 2010

Conspiracy of silence

I always enjoy the Sunday posting from the MD Whisteblower.  Today, he wrote a piece on unnecessary medical testing, particularly issues revolving around referrals for imaging and diagnostic procedures. He describes a particular scenario where a patient presented with minor rectal bleeding :

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 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.
This scenario raises so many questions it is hard to know where to start. The major questions that come to mind are:

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.

1 comment:

  1. Chauncey McHargue M.D.June 7, 2010 at 2:07 PM

    I think the failures here are multiple and compounded and not simply an issue of pursuing self-interest on the part of a technical specialist such as a gastroenterologist as in the example cited by MDWhistleblower. And much of the problem lies with education, not just of patients but particularly of physicians. In the extreme case of a physician not merely assenting to performing an unnecessary procedure but doing so knowingly out of financial self-interest that is a personal failure and a failure of academic medicine to select ethical candidates for medicine, inculcate ethical standards in their graduates and, do the unthinkable, dismiss those from programs who do not adhere to the fundamental ethical precepts of medicine. How often has a dean or program director ever had the courage to do that.

    Those physicians who unthinkingly perform a procedure inappropriately requested by someone outside their specialty are frequently just reflecting the training environment from which they graduated, where grousing about ignorant generalists was easier than educating them if educable and confronting them if not. If a specialist has reason to demur on performing a requested procedure he should have been taught throughout his training on how to finesse such situations, educating others and reassuringly taking on the liability for the decision to forgo intervention. That is part of the job as well.

    If physicians were acting in concert with their education, training and ethical indoctrination and utilizing appropriate communications skills (which they probably are not taught), the conflict of interests and confrontations posed by MDWhistleblower would rarely occur and educating patients to ask such critical questions about the necessity of procedures would be obviated. One has to ask too whether, given the gaussian distribution of intelligence, can the majority of patients really be expected to meaningfully judge the validity of a consultants response to those questions above. In the current reimbursement environment and legal climate, it is also in many physicians self-interest to forgo procedures as the opportunity cost for the time allotted, especially to Medicare beneficiaries, could be much more productively spent on better insured or fee-for-service patients.