My father recently visited his internist with complaints of vague chest symptoms and was referred to a cardiologist who recommended coronary CT, ultrasonography, and angiography. A cardiac workup would seem to be a reasonable course of action given that he has a history of coronary artery disease (CAD) with prior angioplasty.
However, upon further exploration, I felt that his chest symptoms were due to stress and were not of cardiac origin. He exercises regularly without symptom provocation. A few months ago our family went on a cruise, and my father would walk on the treadmill for hour-long sessions to pass time while at sea. A few years ago, my father and I completed a 22-mile hike to the peak of Mt. Whitney, which included more than a vertical mile of elevation gain. The fact that he can sustain prolonged periods of physical exertion without symptoms has not changed over the course of many years. Furthermore, I was able to elicit that his chest symptoms were provoked by emotionally stressful events, after which he would go out for a walk to alleviate his symptoms.
I practiced as an internal medicine hospitalist for about a dozen years before I transitioned into a career in health information technology and quality improvement. Given my background in both fields, I tried to explain to my father that the best care results from a course of action that includes both doing the right things as well as not doing things that provide little to no clinical value — that sometimes less is more. I argued that even though I did not have access to his entire medical record, his clinical history was simply not consistent with cardiac ischemia, so I recommended against the cardiac workup and instead suggested exploring stress reduction and stress management options. Besides, even if they found something on cardiac workup, there was no clinical correlation to justify an intervention. For good measure, I even cited reputable evidence that demonstrates no benefit for percutaneous coronary intervention in stable CAD.
A few weeks later, my father informed me that he completed all of the recommended studies, including the angiogram. In trying to understand why, I asked if his symptoms had changed — they had not. Rather, he decided to have all the procedures done out of concern that his cardiologist would no longer want him as a patient if he declined the tests. Although I was initially dumbfounded, I could understand his rationale because it can be difficult for a layperson to understand the medical literature showing that less is more, and he would be unable to intelligently defend his decision-making against his cardiologist. After all, they are just harmless tests, right?
In reading the angiography report, the cardiologist did, in fact, find a stenosis but did not intervene. Prior to the procedure, my father had told his cardiologist to not be “too aggressive” which I think was his way of balancing my conflicting advice. So to this point, he has undergone coronary CT, ultrasound, and angiography to reveal that he has a coronary stenosis that does not correlate with his symptoms. Still feeling that his symptoms were not of cardiac origin, I recommended follow-up with his internist and remarked that at least there were no complications. Then he told me that he had returned to the emergency department the day after discharge with painful constipation. I postulated that it could have been triggered by a medication or the stress of the hospital stay. Given all of the patient safety events that can happen in hospitals, it could have been worse.
Well, it did get a little worse. In a follow-up appointment, his cardiologist said he could go either way: stent the lesion or leave it alone. With knowledge of his coronary stenosis, my father was determined to get the damn thing stented, so he scheduled another procedure. In obtaining pre-procedure labs, his cardiologist discovered that his renal function had declined from a previously normal level and was most likely due to the contrast material from the angiogram. So the procedure has been postponed, and my father awaits a nephrology consult.
I am not sure if any of my guidance will influence the subsequent course of my father’s care. After all, my parents used to change my diapers, so to this day I have no credibility with them on any topic including health care. My years of training amount to no more value to them than a retrospective consultation. Ironically, I believe it is my father’s care that has been of low value and even some degree of harm. If his cardiologist was willing to not intervene on a lesion even if it were detected on angiography, then I have to believe that financial incentives had influenced the recommendations. I would have liked to see a more balanced informed decision-making process so that my father could have better understood the low value of the workup and measured it against potential consequences.
I am not accusing my father’s internist or cardiologist of any wrongdoing or malicious intent. It is indisputable that our fee-for-service models of reimbursement drive up the volume of care, often without a concomitant increase in the value of care. It’s not that our nation has bad doctors, it is that our well-trained doctors often have the wrong incentives. I was excited when the U.S. Department of Health & Human Services announced in January 2015 its goals and timelines for shifting Medicare reimbursements from volume to value. Now that I have witnessed an episode of low-value care being delivered to an immediate family member, I am even more eager for our nation to transition to value-based care.
Victor Lee is vice president, clinical informatics, Zynx Health.
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