Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

An episode of low-value care delivered to my father

Victor Lee, MD
Physician
October 30, 2015
410 Shares
Share
Tweet
Share

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.

Image credit: Shutterstock.com

Prev

A cancer patient who had bad luck with clinical trials

October 30, 2015 Kevin 4
…
Next

Test your medicine knowledge: 48-year-old woman with type 2 diabetes mellitus

October 31, 2015 Kevin 0
…

Tagged as: Cardiology

Post navigation

< Previous Post
A cancer patient who had bad luck with clinical trials
Next Post >
Test your medicine knowledge: 48-year-old woman with type 2 diabetes mellitus

Related Posts

  • Why health care replaced physician care

    Michael Weiss, MD
  • How social media can help or hurt your health care career

    Health eCareers
  • Can the Maternal CARE Act fail moms? 

    Sonal Patel, MD
  • More physician responsibility for patient care

    Michael R. McGuire
  • Health care needs more physician CEOs

    Alexi Nazem, MD
  • Denying payment for emergency care: a physician defends insurers

    Michael Kirsch, MD

More in Physician

  • The heart of a Desi doctor: Balancing emotions and resources in oncology

    Dr. Damane Zehra
  • The Iranian diaspora’s fight for liberty: Overcoming challenges in the largest women’s rights movement of our century

    Montreh Tavakkoli, MD
  • The harmful effects of shaming patients for self-education

    Maryanna Barrett, MD
  • The power of self-appreciation: Why physicians need to start acknowledging their own contributions

    Wendy Schofer, MD
  • Skydiving and surgery: How one doctor translates high-stress training to saving lives

    Alexandra Kharazi, MD
  • Don’t be caught off guard: Read your malpractice policy today

    Aaron Morgenstein, MD & Laura Fortner, MD
  • Most Popular

  • Past Week

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
    • The heart of a Desi doctor: Balancing emotions and resources in oncology

      Dr. Damane Zehra | Physician
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • The heart of a Desi doctor: Balancing emotions and resources in oncology

      Dr. Damane Zehra | Physician
    • Safe sex for seniors: Dispelling myths and embracing safe practices [PODCAST]

      The Podcast by KevinMD | Podcast
    • Overcoming Parkinson’s: a journey of laughter and resilience

      Cynthia Poire Mathews, FNP | Conditions
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • Maximize sleep efficiency with stimulus control

      Pedram Navab, DO | Conditions
    • The Iranian diaspora’s fight for liberty: Overcoming challenges in the largest women’s rights movement of our century

      Montreh Tavakkoli, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 25 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • How This Doctor Found Purpose After a Devastating Injury
  • House Lawmakers Squabble Over HHS Budget
  • Infant Formula Crisis Exposed FDA and Industry Failings, Lawmakers Say
  • Building Vaccine Trust Among the General Public
  • Is It Business as Usual for the Drug Industry?

Meeting Coverage

  • Phase III Trials 'Hit a Home Run' in Advanced Endometrial Cancer
  • Cannabis Use Common in Post-Surgery Patients on Opioid Tapering
  • Less Abuse With Extended-Release Oxycodone, Poison Center Data Suggest
  • Novel Strategies Show Winning Potential in Ovarian Cancer
  • Children Do Well With Fewer Opiates After Surgery
  • Most Popular

  • Past Week

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
    • The heart of a Desi doctor: Balancing emotions and resources in oncology

      Dr. Damane Zehra | Physician
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • The heart of a Desi doctor: Balancing emotions and resources in oncology

      Dr. Damane Zehra | Physician
    • Safe sex for seniors: Dispelling myths and embracing safe practices [PODCAST]

      The Podcast by KevinMD | Podcast
    • Overcoming Parkinson’s: a journey of laughter and resilience

      Cynthia Poire Mathews, FNP | Conditions
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • Maximize sleep efficiency with stimulus control

      Pedram Navab, DO | Conditions
    • The Iranian diaspora’s fight for liberty: Overcoming challenges in the largest women’s rights movement of our century

      Montreh Tavakkoli, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

An episode of low-value care delivered to my father
25 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...