Judicious use of complex medical procedures

by Shanti Bansal, MD

In the cardiac catheterization lab one Tuesday morning, I encountered a situation that made me reflect on a bit of 18th-century British history.

At that time, the British government was overburdened with prisoners. A plan was hatched for sea captains to transport many of them to Australia. Due to poor conditions, up to one third died on the voyage. Politicians and clergy members desperately urged the sea captains to improve the conditions, but survival rates changed little. But then an economist suggested paying the captains for every prisoner who made it to Australia rather than for each one who boarded a boat. Survival quickly improved to 99%.

Back in the catheterization lab, there were no British prisoners — just a slim, gray-haired man with bristling facial hair lying on a stretcher in front of me. With his chart in hand, I greeted this Mr. Johnson and asked him how he had come to the attention of Dr. Attending, an interventional cardiologist.

“I was seeing him for my cholesterol,” Mr. Johnson replied, “and then I started to get a little short of breath after going up a few flights of stairs. He ran some tests, and next thing I know I’m here. I’m sure that any blockages they fix will prevent the next big heart attack, so I’m not worried.”

I perused a note written by Dr. Attending: “Mr. Johnson, a 75-year-old gentleman, remains highly symptomatic from shortness of breath. Since this may be his anginal equivalent, I will recommend a cardiac catheterization for further evaluation and treatment.”

Struck by the disparity between the clinical situation and the note, I nevertheless passed the consent form to Mr. Johnson, who signed it. He was whisked away to the catheterization lab, and with Dr. Attending by my side, we began the procedure. The catheter engaged the left-main and then the right coronary artery easily and accurately. The contrast illuminated the arteries like glow sticks on a sobering night. The right coronary was totally occluded.

“Well, this is clearly the cause of his shortness of breath!” Dr. Attending exclaimed. “We need to fix it!”

In the ensuing hours, we deployed a balloon pump to push blood over the diamond drill of the roto-rooter. It cut through the cemented plaque with hydraulic precision along the tracks of countless coronary wires. After the procedure, Mr. Johnson was admitted for a brief stay in the ICU and, later, to the hospital floor. When I saw him walking about in his standard-issue navy blue slippers, I asked him how he was doing.

“Good,” he said. “Still a bit short of breath though. I’m happy to be going home today.” The case left me feeling uneasy.

Did our complex medical procedure decrease Mr. Johnson’s risk for morbidity or mortality? If not, did we improve his quality of life? Has caring for patients become more about the journey than the destination? Can we instead give physicians and health care providers incentives to focus on outcomes, as the 18th-century British sea captains eventually received? In the 21st century, my experience with Mr. Johnson’s care read like the script of a MasterCard commercial:

Complex medical procedure plus hospitalization: $63,535.00

Outpatient follow-up: $56.50

Navy blue hospital slippers: $5.50

Judicious medical care: Priceless

Shanti Bansal is an internal medicine physician who blogs at CardioExchange , a NEJM Practice Community.

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  • Dr. J

    A different lens to look at this case through is that of the consumer-patient. Mr. Johnson wants a cath, he’s sure that it will prevent the ‘big one’. He is incorrect, but he is sure, and he is a consumer. So, he gets what he wants.
    Although it is possible that the patient in this case did not get an adequate explanation prior to his procedure, I personally think his thinking pattern fits the vast majority of patients I see who tend to believe that the most technical solutions are also the best solutions.
    The ideas of independent and autonomous consumer-patients and of gatekeeper physicians who protect rare medical resources are at opposite ends of a spectrum. The way to meld these paths is not to impose the financial implications of the decision on the doctor, rather to impose it on the patient. No one is more invested in the health of a particular patient than the patient them self.
    What the author suggests is an economic solution to the problem of resource allocation, the creation of a market. Where the solution fails is in imposing the market not on the most interested group (patients) but a surrogate (doctors).

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      I agree 50%.
      Why does Mr. Johnson want a cath? Surely he did not come up with this idea on his own (unless he is a physician himself). Someone “recommended” a cath (as the attending note shows), and it seems that the same someone is going to get paid for performing it.
      We don’t know the content of the conversation between these two prior to the event, so it’s hard to tell if Mr. Johnson made an informed decision, or if he made a partially informed decision.

      On the other hand, patients are not, or should not be, regarded as cargo on a physician’s ship. So paying physicians for outcomes, and I am not sure what those could be, is not fair to either physicians or patients, because it assumes that a particular set of outcomes is universally desired by patients, and it assumes that patients are inert cargo (or some sort of prisoners).

    • Isabel

      Why do we need doctors & nurses & all that training if the patient can show up and tell us what they want? Why not just go to the supermarket instead? What about standards of care and appropriate treatment? In CMS’s eyes, if you bill Medicare for a service or provide a service that is not needed, it’s fraud! You might consider raising the bar a little. It doesn’t take much to explain to a patient what the standard of care is & stick to your guns. Does the same apply to the patient who thinks they need Oxycontin or a higher dose of Xanax? How about some Valium? Or better still….Fentanyl?

  • anonymous

    When I was in training, it was emphasized that the 99% or 100% blockages were not the main problem because these built up slowly enough to have compensatory collaterals. It was the 20% or 30% occlusions that tended to fracture off and lodge in smaller distal arteries, causing the sudden MI. During this time, endovascular ultrasounds (which I imagine would exponentially increase the cost of a cath) were all the rage. Is this still the case now, or has the pendulum swung again?