The stent problem and the overuse of medical procedures

In 1911, George Bernard Shaw famously wrote “All professions are a conspiracy against the laity”.

One hundred years later, in 2011, I write “the MBA has done more to harm the public through bottom-line hospital administration than have many dread diseases.”

As an example, the continuing saga of this stent, that stent, the other stent placed into as many coronary and other arteries as often and as fast as possible does show some signs of waning.

One of my favorite journalists, Maggie Mahar, has been writing about the stent problem as well as many other overuses of TOL (technology for lucre), in columns and her book, Money Driven Medicine, for many years.

And Dr. Nortin Hadler, a professor at UNC in Chapel Hill has a number of books that document the mass misbehavior of American medicine at large for many years.

The problems conclude that the overuse and misuse of medical procedures is so widespread as to now be accepted as “conventional wisdom” and institutionalized as “standard of practice.”

The academic medical centers are the worst because they posture as presenting the best medical science while practicing as the largest generator of the most revenue for their institutions.

And they thereby teach the students and residents to emulate them, doing with great competence loads of procedures that don’t need to be done at all.

Here’s my take on how different actions such as those Maggie, Nortin, and I are advocating here would save vast sums of money.

And, for the best science on use of stents that should best inform the decisions for you and your patients, look yourself to the clinical trials called RITA-2; BARI-2D; OAT; and COURAGE.

Don’t continue to be entrapped by the AMMM, the American Medical Marketing Machine.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Originally published in MedPage Today. Visit MedPageToday.com for more cardiology news.

Comments

http://www.hospitalimpact.org/index.php?s=true+north&sentence=AND&submit=Search Thomas Dahlborg
Excellent article and very much in line with noted healthcare journalist Shannon Brownlee: “more medical tests and treatments do not necessarily lead to better overall outcomes.” In her 2007 book “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer”, Brownlee elaborates on that opinion, noting that one of the main motivators behind such behavior is that doctors, oftentimes “are paid for how much care they deliver, not how well they care for their patients.”
This is something that I know about all too well.
Some years back, I was analyzing medical expenses in the state of Maine, broken down by community. As the process went forward, notation was made that the medical expenses in one community–more specifically for cardiac services in one particular market–were markedly higher than in the other communities.
Long story short, there was NOT a substantial improvement in outcomes for patients in the community with the higher medical expenses. And as I dug deeper into the data, I determined that the use of nuclear stress tests in that one particular community was significantly higher than in the other communities, and as such, was determined to be the key driver of the increased expense. Additionally, it was determined that only one high-volume physician practice in that community had the capability to perform said nuclear stress tests, meaning the practice was leveraging that ability to receive higher reimbursement for the treatment of patients with cardiac issues.
The financial misalignment in our broken healthcare “system” has significantly and adversely impacted the health of individuals and communities AND perversely impacted how care is delivered.
Now add to the perversity of our reimbursement model the conclusion by the Institute of Medicine and others that only between 15 and 50% of medicine is based on valid science and and Dr. John Ioannidis’ claim that many clinical studies’ conclusions (even “gold standard’ studies) are misleading, exaggerated, or flat-out wrong and we truly have a huge challenge before us.
We have much work to do. Time to eliminate ego and truly adapt and optimize our “system”.
Thank you,
Tom

http://myheartsisters.org Carolyn Thomas
Tom – “time to eliminate ego”?!? Please tell us how!!

pj
If and when the economy collapses, that will be enough of a shock to the system to deflate some egos….
Pride will have to succumb to financial reality sooner or later.
http://www.hospitalimpact.org/index.php?s=true+north&sentence=AND&submit=Search Tom Dahlborg
Dear Carolyn,
In my organization we have addressed ego and other challenges and barriers to an optimal healing environment at the cultural level. To do so we have implemented Circle Process.
Circle Process is a model of governance based on a combination of the ideas Christina Baldwin presented in her books, Calling The Circle and The Circle Way, the teachings of Paula Underwood, and guidelines on Relationship-Centered Care by the Fetzer Institute.
Some features of Circle Process in my organization include:
•Rotating leadership: We level the playing field. All titles, experiences and gifts are as important as another’s. Leadership shifts according to the needs of the organization. We continually find the resources needed to accomplish our goals exist within the group.
•Shared responsibility: Each person asks what he or she needs and offers what he or she can. It is based on the trust that someone will come forward to provide what the organization needs.
•Consensus decision-making: Voting by consensus, which doesn’t always mean unanimous, where it is important to hear all the points of view and vote when everyone present is able to agree on the action.
•Covenants, agreements and decisions are revised as goals of the group and the group itself changes.
Value of the Circle
Feedback from some of our practitioners:
“We have found that Circle Process is healing our multidisciplinary wounds, and it provides the momentum to nurture the physiicians and other caregivers professionally.”
“The experience of Circle has enhanced the care I provide for young children and their parents. The experience of being loved, honored, and sometimes challenged in Circle has deepened my ability as a healthcare provider as it allows me to get to the root of issues, to meet people where they are, to trust there is a larger process at work, and, to walk with people in a way that calls out their own intrinsic ability to solve problems, see what’s there, and ultimately, to heal.”
“The simple guidelines of Circle Process create a structure that allows the caregivers to practice how to be more present with themselves and others.”
“This increases our confidence, courage, trust and connects us more strongly with a sense of meaning in our work. That deepens our practice in many ways.”
The culture of the organization itself was developed along these lines and has created opportunities in a safe place to address ego and other barriers to the larger goal(s) of healing: “Shining light on the issue rather than burying the issue in the shadows.”
So this is one approach/process/philosophy that is working for one organization.
I am sure there are many others.
I hope this is helpful.
Tom

stitch
When I went back to my 10th medical school reunion (less than 10 years ago) I was somewhat surprised to find that our student lounge had been converted into a simulator room. That’s the way medicine has been going for a number of years. Simulators have significant benefits, but a huge disadvantage is that they take medical students away from the bedside, pretending that this kind of training is equivalent. Students then come to look at patients as “cases” to be approached, with a bent towards technology, and not as human beings with human concerns. We forget that everything we do has consequences – even just ordering what we think of as “simple” blood tests.
If we train a generation of physicians to think of themselves as technicians, and continue to let mid-levels do the work of actually interacting with patients, should we be surprised at this outcome?
http://www.medical-rights.com/ Jerricho Cotheri
Excellent article. It is true that prescription drugs should be controlled efficiently that so people do not affect the damage they cause side effects.
Ed
One of my personal favorite text is “Beware the Healthcare Bubble.” And I love Mahar’s book, but not so much her overly partisan blog. It seems to me she damages her reputation with the blog.
I’m an independent voter but I tend to agree most with the libertarian point of view. In healthcare though I favor a fully socialized medicine approach because I have seen healthcare from the inside, and in my opinion, it can’t be cured within today’s framework.
I hear the howls from those who say that socialized medicine doesn’t work elsewhere, and they are likely right.
I do not believe that “free market” or “government provided” healthcare are intrinsically right or wrong. I do believe that the right approach is to cycle between the two approaches. Once free market has gone out of control and become a hindrance, switch to socialized. As socialized becomes a bureaucratic nightmare and becomes a hindrance, the free market will creep back in and the cycle renews itself.
This is a decade or more type of fix rather than a short term band aid, so I don’t know if it can be done, at least in today’s dysfunctional government. But cycling between free market and socialized healthcare would, in my opinion, be a systematic fix which would stand the test of time.
Perhaps we need to fix DC before we try to fix healthcare, but that is a tall order.
Don Howard
Many of the Doctors have unwittingly or otherwise become the instruments of Insurance, Pharmaceuticals and Mega Hospitals. The Docs lost control and no longer are able to practice medicine rather they work as factory workers for the above institutions. As a non peofessional in medicine I can only suggest that the Doctors who are sick of this should form a coalition, decentralize and become generalists who can perform all but the more serious condition within their offices. This is nothing new-this is what was going on before Medicine was hijacked by big business. Good luck to those who are trying to get out.
http://www.myheartsisters.org Carolyn Thomas
Dr. Lundberg, I applaud your blog article, “How to Rein in Medical Costs, RIGHT NOW”, which should be required reading for those responsible for the “overuse and misuse of medical procedures”.
But alas, as eminently sensible as these suggestions seem, your pointers are likely lost on those very people. There is simply too much money to be made.
Consider the latest scandal surrounding the stent-happy cardiologist Dr. Mark Midei of Maryland. Court documents allege that some of Midei’s patients were told they had blockages in the 90% range, even though a subsequent review of their records shows blockages of 10% or less.
Yet even after being notified after the fact in writing by authorities that their coronary arteries had actually been less than 50% blocked (clinically meaningless and not an indication for stenting), many of Midei’s stent patients didn’t even seem to care. One such woman, in fact, told the Baltimore Sun:
“No one can ever tell me that I didn’t need that stent. I feel like [Dr. Midei] saved my life.”
For many patients like this woman, MORE really is MORE.
These folks appear to believe that undergoing a medical procedure is better than watchful waiting. Undergoing a procedure is better than popping a pill. Throw in any procedure involving the heart, and the doctor will virtually have carte blanche – and then hailed as a life-saving hero even by patients told that they did not actually need the cardiac procedure in the first place.
As a 2008 heart attack survivor who is now sporting my own stent, I can tell you that the Midei scandal, as well as the equally stent-happy Mehmood Patel of Louisiana (convicted of health care fraud last year and sentenced to 10 years in prison) has many of us stentees (is there such a word?) feeling confused and suspicious.
More at “Cardiologists Accused of Implanting Stents That Weren’t Necessary” at The Ethical Nag: Marketing Ethics For The Easily Swayed at: http://ethicalnag.org/2010/09/29/cardiologists-implant-unnecessary-stents/

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