Pipe Dreams

draindoctorI truly enjoy the practice of medicine.  The challenge, the complexity, and the constant evolution, combined with the opportunity to continually, positively, and substantially affect people’s lives should lead to an exciting career.  However, the economics of medicine as a business have sapped much of this enjoyment for everyone involved.

As the government strives to save healthcare dollars, the hospitals and insurance companies gear up their high priced lobbyists to guide the outcome.  Thus, too often it is the third wheel, the overworked, under-organized, and often politically inexperienced doctors who bear the brunt of the changes.  As those changes accumulate, they place a greater and greater psychological, mental, and physical toll on our nation’s physicians.

Thus it is that many of my friends, who have been brilliant physicians, have left the field for careers as diverse as real estate or fashion designing.  I must admit that at times I have considered leaving as well.  Of course, the problem is that having spent a large portion of our youth training to be physicians, most of us are ill-equipped to be anything else.

When I was considering what else I was at least partially qualified to do, I felt that as an interventional cardiologist, a natural fit may be to train to become a plumber. Of course, leaving my practice and going back to school would likely require going into debt, but that is the same situation most medical school graduates find themselves in.  Unfortunately, there are so many plumbers out there, and so much competition that I would need a truly unique business model to differentiate myself from the rest and be successful.  And so it is that I present to you, my valued readers, my seven point business model for a successful plumbing business:

1)  I pledge to be available to treat a plumbing emergency within thirty minutes of being called. Any time, day or night.  I will never charge extra for after hours work.  If you have a clogged drain, I promise it will be open within 90 minutes after calling me.  This holds true even if you can’t or won’t pay me.

2) Once I have fixed something in your house, I pledge to be available or have a similarly qualified plumber available at all times, 24/7/365 for any plumbing related questions you might have.  At no charge.

3) Feel free to use your plumbing any way you like.  Flush a diaper or two.  Pour Dran-o down if it gets clogged.  Leave the shower running and the drain stopped.  I will fix it.  And if it’s an emergency, see point #1.  Because every person has a right to working plumbing.

4) I will personally take responsibility for all the work I do, and help bear responsibility for anything else that goes wrong anywhere in your house with any system (electrical, HVAC, etc).  After all, houses are complicated, and everything interacts.

5) In an effort to make sure plumbing services are available to all homeowners, I and the other plumbers in the area will pledge to accept the same fee schedule as each other, which we will allow the government to set at what it deems fair and adjust it yearly.  This holds true even if our costs for tools go up, and the government decides to cut our fees 30% a year.

6) I will only charge you a small portion of your bill.  You may designate a benefactor of your choice to pay the rest.  I will take full responsibility to collect the remaining money from said benefactor.   Even if they refuse to pay or underpay significantly, I will absorb that loss rather than come back to you for the difference.

7) If I feel, in my professional plumbing opinion, that you need a new faucet but the benefactor you choose only wants to pay me to repair the old one, I will either a) replace the faucet at my own expense or b) if I fix the faucet, I will take full legal responsibility should it fail again and flood your entire house.   I will allow the benefactor the right to tell me at any time what they would and would not like to pay for, even after the work is done.

You know, on second thought, maybe I won’t change to plumbing after all. It doesn’t seem different enough.

State of the Heart

heartThis year, I availed myself of the opportunity to once again attend the Annual Scientific Sessions of the American College of Cardiology in San Francisco.  It was a special year because a former mentor and current friend from my Cedars-Sinai days, Dr. John Harold, was inaugurated as the incoming president of the ACC.

The meeting was an opportunity to reconnect with old friends, and to learn a lot about the state of the art in cardiology, as well as explore some of the current challenges.

Too much of a good thing?

The cardiology community has anxiously been awaiting JNC-8 and ATP-4 for some time now.  These expert consensus statements  will serve as updates to our guidelines on the treatment of high blood pressure and high cholesterol, respectively.  Nobody knows yet (except the writers) what the recommendations will be, but certain themes are beginning to emerge.

One of the themes that I saw emerging quickly was the idea of “overtreatment”.  While the well intentioned writers of previous guidelines recommended very strict control of blood pressure, for example, a plethora of recent data has suggested that lower may not necessarily be better.  In fact, there is now a preponderance of data suggesting a “J shaped curve” for blood pressure control in cardiac risk reduction; meaning that as blood pressure goes lower than a certain “sweet spot”, cardiac risk may actually increase.  This may be especially true in the elderly.  There are many theoretical reasons to have believed in this relationship, but the interesting findings is to show that we begin to see it even at “normal” readings.

Ends don’t always justify the means

Similarly, cholesterol control has often focused on getting bad cholesterol (or “LDL”) down by any means necessary.  The most effective method of doing so has always been HMG-CoA reductase inhibitors (“statins”), but many adjunctive therapies exist that also lower LDL.  The problem is that while these therapies lower LDL, they have not been shown in any large-scale way to significantly reduce cardiovascular risk.

These meetings held particularly bad news for Niacin, a popular B vitamin, which failed in its second consecutive large-scale clinical trial to have benefit.  CETP inhibitors, another promising new therapy, fared no better (so far) though they simultaneously lower LDL and raise HDL (good cholesterol).  Combine these findings with the findings that statins benefit even those with low cholesterol levels who have had heart attacks, and you have fairly convincing evidence that statins reduce risk over and above their ability to lower cholesterol.  Thus, I believe the newer recommendations should focus on statin therapy rather than LDL reduction, with the addition of adjunct cholesterol medications only in cases where statin therapy is impossible or insufficient.  For those concerned about adverse consequences of statins, it has been conclusively shown that for most people on statins the benefits clearly and massively outweigh the risks.  In addition, newer therapies to counteract the muscle aches with statins are showing more and more promise.

Another reason that LDL lowering may not track risk is that we are focusing on the wrong endpoint.  Most cholesterol particles contribute to the deposition of cholesterol in artery walls, with the notable exception of HDL.  Thus, measuring LDL is only measuring a subset of these harmful  particles.  I am hopeful we will see a shift in our guidelines towards increased recognition of “non-HDL cholesterol” as a primary goal of treatment, so we can be sure to address risk at every possible level.

The future is now

The past two decades have seen tremendous changes to healthcare delivery and economics.  While it is convenient to blame “Obamacare” for many of these changes, the fact is that there is plenty of blame to go around for both political parties, from SGR adjustments, to Medicares C and D, to the PPACA.  The upshot of all of these changes is the attempt to achieve substantial cost savings to Medicare by cutting physician reimbursement–this is a rare area of agreement for both political parties.  Physicians have long warned that this would lead to future reductions in physician accessibility, and that future has now arrived.

The same story was heard and overheard time and again at this conference.  Physicians leaving medicine to pursue other careers.  Physicians leaving insurance based practice to go to “concierge” or cash practices.  Physicians fretting over making ends meet in the era of unfunded mandates and regulations combined with almost continuous cuts to reimbursement.

I think much of the public doesn’t realize that the average physician in practice is basically a government employee.  We work for no money upfront and then petition the government or another agency to please pay us whatever it thinks our work (already completed) was worth.  As most private insurances are pegged to Medicare rates, however, every cut in government spending translates into a direct cut in our reimbursement.  At the same time, mandates such as electronic health records and insurance pre-authorization for every activity increase our bottom line significantly.  This is not a model for a successful business, and is the main reason that  more and more doctors are abandoning the field completely (one of the best doctors I trained with is now in the fashion business).  Many of those that stay are forced to cut overhead by cutting accessibility or services offered, or worse yet forced into gimmicky side businesses and unnecessary testing.

It has now gotten to the point that the most popular seminars and symposia at this conference were not so much about medicine as about business–cutting costs in an era of declining reimbursement.  It is an unfortunate truth that many of the most promising innovative technologies and treatments at this conference may never become available because of an economic climate which deters access, innovation, deliberation, or collaboration.  We can only hope that going forward, our legislators are able to wriggle free of the iron grip of the insurance and hospital lobby, and recognize the engine that makes health care run, the physicians.

Notes from the Heart…

Having just returned from the American College of Cardiology Sessions in Chicago, my mind is swimming in the latest and greatest in cardiac care and treatment.  I arrive at my place of work armed and ready to apply these principles to caring for my patients.  What I learned, however, surprised even me.

As an interventional cardiologist, I firmly believe in the power of simple interventions, such as balloons and stents which I use routinely, to impact the length and quality of life.  But, in the end, everyone knows that these therapies close the barn doors after the horses have left.  They are helpful, but if you need them, then in many ways you have waited too long.

What impressed me most was the emphasis in the cardiology community on prevention, and some of the new and impressive research that is looking at non-medical interventions.  Here are some of the latest and greatest news, in layman’s terms:

  • Meat is Murder? Much has been made of the recent paper in Archives of Internal Medicine on red meat consumption being linked to early mortality.  While impressive, it still remains one article.  At the ACC however, a host of supportive data was presented which bolsters this paper, and transforms it from an interesting single study to a major cog in a big wheel of diet modification.  While I am most definitely NOT ready to advocate a vegan lifestyle, I think a universal recommendation opting for greater incorporation  of plant products into our diets with fewer meats is absolutely appropriate at this point.  I was impressed not just with the breadth of research, but of the quality and scientific rigor which went into many recent studies in this field–something that had previously been sorely lacking.
  • Size Does Matter.  A major boost for obesity surgery at this meeting was the study looking at its effects on diabetes.  While it was well known that bariatric surgery (particularly the gastric bypass) could improve the state of control of cardiac risk factors, this study compared it to medications, and it came out better.  This is no surprise, really.  By treating the underlying cause (truncal obesity) of insulin resistance, you will achieve better results than by masking or compensating for the insulin resistance that causes Type II diabetes.
  • Blood pressure drugs got you down? Not to worry, for too much longer anyway.  A simple, catheter based treatment called “renal denervation” which affects the various complex neural pathway causing hypertension has shown very promising results at treating hypertension with minimal side effects.  Its use as a routine treatment is still years off, but look for a fast-track approval process for patients with very severe high blood pressure beginning sometime in 2013.
  • Stents are not the work of the devil.  Over the past five years, oversimplified analysis of the COURAGE trial had led many to feel that coronary stenting had no role in the management of blocked coronary arteries causing chest pain.  A recent major study (FAME II) was stopped early, however, because stents showed so much benefit.  The difference? In the second study, the operator had to objectively prove a stent was necessary first.
  • Neither are surgeons.  As interventional cardiologists such as myself take over everything from clogged arteries to aortic valve replacement, many prematurely mourned the death of the field of cardiac surgery.  Not so.  Recent registry data showed that in many patients good old bypass surgery led to better outcomes than even the newest stents.  In addition, newer questions have been raised about the outcomes from minimally invasive (catheter based) aortic valve replacement.  These need to be answered before rapid, widespread adoption of this procedure.
  • Don’t believe the hype: I have received countless phone calls already this week asking for the newest cholesterol medication which promises to be a “wonder drug.”  This is truly shocking to me, because usually when I want to start cholesterol medication, I am met with a lot of resistance.  To top it off, the newest drug is an injectable medication studied in only a small fraction of the patients that the other therapies have been studied in.  This medication may indeed have an eventual role in management of severely high cholesterol, but its rapid demand reeks of pharmaceutical company influence in everything from clinical trial design and presentation, to the timing and tone of press releases.  High cholesterol is a big money industry, and let’s get something straight: these companies are only interested in selling you their product.  If you happen to get better while using it, well that’s OK too.

Medicine continues to change on an almost daily basis, and cardiology changes faster than most other fields.  These are but a few of the new and exciting perspectives that I gained at the annual American College Conference.  And I’m sure by next year, they’ll all be wrong again.

We Are the 99.

The recent “Occupy Movement” has highlighted the fact that though a group may be in the majority, it does not follow that its rights are necessarily respected. Specifically, the movement refers to the “99%,” those of us in the population outside the top 1% financially who are victims of a broken system. This post, however, is devoted to another 99%–one which is much less well known.

I am referring, of course, to the percentage of doctors who will be sued for malpractice.

According to a recent study published in the New England Journal of Medicine, 99% of physicians practicing in “high risk” specialties (such as Internal Medicine, General Surgery, OB/GYN, and yes, Cardiology) will face a malpractice suit before the age of 65. But that’s just high risk specialties. In “low risk” specialties (such as dermatology, ophtalmology, and psychiatry) that number drops to a paltry 75%.

These numbers serve to illustrate a point that practicing physicians know all too well–the malpractice system in this country is badly broken. After all, a good indication of a problem might be when a “low risk” specialty has only a 75% chance of being sued. A system in which between 75-99% of providers of any service will be sued is necessarily a system laden with skewed incentives, unrealistic expectations, and held hostage by outside forces.

Not all doctors of course, deserve the benefit of the doubt. There are bad doctors out there who put profits or personal gain ahead of patients, and deserve to be sued (sometimes repeatedly). But if we, as a society, have reached the point where we honestly believe that 75-99% of our healers fall into this category then we have truly lost any semblance of trust and civility.

If we choose to believe that the vast majority of our doctors are not incompetent and negligent, then it stands to reason that many, if not most, of these lawsuits are unnecessary, without merit, or frankly frivolous. While 75% of low risk specialists will be sued, only 19% will eventually pay claims (ie, lose or settle). Much of the remaining 56% of suits are likely, when examined, frivolous or at least without merit (not all, because as everyone knows, even people who are right can lose lawsuits).

These lawsuits, while perhaps not costing the physician in actual indemnity, carry with them a significant cost to the physician and the population. The practice of “defensive medicine” (tests ordered to prevent a lawsuit, or whose primary use is to defend ones’ self during a lawsuit) has become so commonplace that the term is now obsolete. The reason is that the legal standard for malpractice is based on the “standard of care” (what one’s peers would do in a similar situation). Defensive medicine has become the new standard of care, and thus any practice of logical, pragmatic (non-defensive) medicine is at risk for malpractice exposure.

This may explain why estimates of the costs of “defensive medicine” by lawmakers (who are coincidentally mostly lawyers) vary in the 1-2% range of health care expenditures, whereas an analysis of a survey of doctors who are actually practicing puts this number at 34%. Whereas the lawmakers may use “standard of care” as their baseline (the legal definition), doctors would tend to identify defensive medicine as testing which pragmatic, logical medicine obviates the need for. In my own personal observations, the latter number is clearly more accurate than the former. If doctors would truly be allowed to practice based on clinical accumen and physical examination, the use of CT scans, MRIs, and nuclear stress tests (all very high ticket items) would decrease by orders of magnitude… Importantly, with little discernible difference in outcomes.

The issue of “standard of care” (the legal standard for malpractice) has gotten so bad in fact that doctors have been placed in virtual no-win situations, making one wonder how even 1% ever escape being sued. For example, a doctor has been successfully sued for screening a patient for prostate cancer, and recommending treatment of the cancer which resulted in complications. The complaint? That most medical studies and societies have shown no benefit in screening for prostate cancer. A doctor has also been successfully sued for not screening a patient for prostate cancer, leading to a delay in diagnosis. The complaint? While screening has never actually shown a benefit, it is clearly the current “standard of care.”

How should this misuse of the American judicial system be righted? Much smarter minds than mine have tried and failed at this endeavor, though admittedly most of the failures were due to politics rather than policy. The answer, however, lies with incentives (as it does with all aspects of human behavior). Remove the incentives for unnecessary lawsuits and increase the penalties for frivolous lawsuits and the problems should correct itself.

While the rights of the plaintiff must be protected, the rights of the physicians cannot be ignored. Compensation for the legal fees or “closure of practice” losses (opportunity cost for weeks of sitting in court) of the prevailing physician would be a start, but would admittedly discourage those of limited means from seeking compensation for true loss. The most important move would be the transfer of all malpractice proceedings from jury trials to arbitration courts. Currently, malpractice trials are low on fact and objectivity (qualities we prize in our physicians?), and high on emotion and loss. Juries, usually medically unsophisticated, fall trap to the same smooth talking snake oil salesmen that convinced the plaintiff to sue in the first place, and for that reason often side with the plaintiff inappropriately (leading to a large number of physicians and insurers to settle out of court so as to “not risk it”). An arbitration court made up of three or more judges trained in medical malpractice (though, importantly, not medicine) would allow fair proceedings based on objective evidence and help even the playing field.

However it is achieved, a fundamental reworking of the malpractice system is mandated in order to control medical costs and allow for accessibility to medical care. This article in the New England Journal serves to highlight in the strongest and starkest terms the extent and severity of the problem, there can be no more ignoring or denying it.

We are the 99, and we demand a solution.