American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, November 18, 2014

The good, the bad and the ugly

I had a recent conversation with an old friend about her elderly father that encapsulates a lot of what is both great and terribly wrong with health care in America today.

Here are the basic facts: the man is in his mid-80s, retired from teaching school, and is active and vigorous, living in the community; he is cognitively intact. He has a history of coronary disease and had an intracoronary stent placed some years back. He is asymptomatic on a typical “cocktail” of meds including aspirin, a statin, and an ACE inhibitor. Over the summer, he had a routine follow-up visit with his cardiologist, who detected a carotid bruit. After a duplex sonogram and a CT angio, a high-grade unilateral internal carotid stenosis was identified, and carotid endarterectomy surgery was recommended. My friend called me to see if I could recommend a surgeon in the city where she and her father both live.

It will come as no surprise to those who know me (or read this blog regularly) that I asked about the specific advice that her father had been given and the process by which he apparently decided to go ahead with the surgery. Both the cardiologist and the vascular surgeon to whom he was referred pitched surgery as pretty much a no-brainer. Although his daughter had questions and reservations, the patient did not really see this as a “decision” to be made. His doctors had recommended a course of action and he was going to do as they said. When I pressed for details about what had been presented as risks and benefits, here is what I learned they told him. Surgery would require a 1 to 2 day hospital stay; risk of major complication was about 1%; risk of stroke without surgery was 15% over five years. Seemed like they were implying that his chances were 15 times better with surgery than without. Who wouldn’t go for that?

OK, so here’s what I think is good about this. Assuming that he had appropriate indications for his prior stent (big “if”), then this man has clearly benefited from modern cardiovascular care. He is asymptomatic, and his medical therapy has likely added years of event-free survival. He is, in many ways, a counter-example to the prolonged disability anticipated by Zeke Emanuel, which I wrote about recently. I certainly would not want to “check out” at 75 if I could be active, cognitively intact and symptom-free at 85.

So what’s so bad?

First, there was no attempt made to engage the patient in shared decision-making. Even if the evidence strongly favors a particular course of action, it is a truism that the outcomes of interest to the patient are not necessarily the outcomes that interest the physician, and neither set necessarily includes the outcomes for which reliable evidence exists. For example, if a patient is thinking “avoidance of disability” while the doctor is thinking “survival” and the evidence is unreliable with regards to either, then the conversation can’t possibly go well. Put another way, to say that 1 treatment is “better” than another without agreeing what better means to the patient is to head irretrievably down the wrong path.

Second, there is the citation of evidence that, on the face of it, can’t possibly be accurate. Even if the surgeon were accurately quoting his own track record for this type of surgery, it is not credible that he has sufficient experience in 85 year old men with coronary artery disease (and whatever particular set of other co-morbidities my friend’s father has) to formulate an accurate assessment of risk for this patient. Likewise, the quoted risk of stroke in the absence of surgery is likely an extrapolation from a mix of observational and interventional studies in populations that probably included few if any 85 year olds. Of course, physicians must make recommendations in the absence of perfect data all the time. The point is not that this uncertainty is avoidable; it is that the uncertainty should be appreciated by physicians and disclosed to patients.

The third problem is one that I have also written about: the “innumeracy” that is common among patients and physicians. Even if the numbers quoted were “right” (that is, they were the best point estimates of the risk and benefit for a population of similar patients facing a similar decision), the framing makes a big difference. Would he have agreed to surgery if the same data had been presented in a different way? What if he had been told that he had an 85% chance of making it to 90 years old without a stroke? Or if he were told that the risk of stroke was 3% per year? How about if he were told that he had a >80% chance of making it to the end of his predicted life-span 91 for a man his age without surgery or a stroke?

Finally, the ugly. I can’t help but wonder how much of this whole cascade, from the “routine” and likely unnecessary follow up visit with the cardiologist, to the multi-modality imaging, to the inevitable recommendation for invasive intervention, was driven by the unholy alignment of fee-for-service reimbursement with the well cultivated (and totally wrong) belief among our patients that more “care” is always better, and facilitated by Medicare shielding the patient from the cost of care.

The good, the bad and the ugly of American medicine. What do you think?

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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