Wednesday, August 07, 2013

The teachable moment

Tweets are flowing about George W. Bush's annual stress test and the resulting angioplasty and stent insertion.  Why? Because the care provided to our last President is inconsistent with current evidence-based medicine recommendations. Indeed, hospitals would risk non-payment from the government and private insurers for the type of treatment received by Mr. Bush.

Here's a full description from Burt Cohen's Stent Blog.  He links to a number of tweets from people, including Eric Topol, who says:

Relative to Pres Bush, here are the @ACCinTouch recommendations against stress testing

Burt Cohen notes:

Was a CT angiogram necessary?

This test is not currently covered by Medicare or most insurance providers for this indication, mainly because it’s considered one of those “over-used unnecessary tests.”

He follows:

Was a stent necessary?

Or could Bush’s coronary artery disease have been managed with optimal medical therapy. 

Noting the absence of public comments about this from many prominent health care experts and commentators (Dr. Oz, Sanjay Gupta, Atul Gawande, Don Berwick, ex-Surgeons General, AARP, Brian Williams, the American College of Cardiologists), a friend summarizes:

You and me, and everyone who gives a hoot about the health care system talks of the adult conversation and the teachable moment.  Look in the mirror.  I would call what we have in front of us a whopper.  

If W did indeed have a screening stress test, mind you--in an incredibly fit, teetotaling, non-smoking Texan, then who will be a immune from over testing and misuse of resources?

We have a root cause of system ills right in front of us, but the A in RCA, i.e, the analysis caboose, has seemed to decoupled from the engine.
Indeed, where are the mainstream media and the advocates?  Are you afraid to challenge this type of care because it involves a member of the country's ruling class?  In doing so, do you implicitly advocate a two-tiered system of care for the country? One where the rest of us pay for "royalty" to receive a more costly level of care than the rest of us?


Victoria Haliburton said...

From Facebook:

Individual differences, situations, needs are possible good reasons. Stupidity and stubbornness and a money-driven system are possible bad reasons. I'd like to see what a Canadian doctor would recomend to him but too late now.

Anonymous said...

Well said in your last paragraph, but it must be noted that you said 'more costly', not 'better'. In fact, Mr. Bush may have been exposed to harm in all this extra care, in the form of a potential surgical complication, or the need for blood thinners due to the stent, misinterpreted tests, etc.
So it's not that he's royalty and therefore got the cream of our health care system. More likely, he got care from doctors who really were treating themselves, not him - because they were trying to cover themselves from any future blame for not doing 'everything' - precisely one of the main causes of poor care in this country today.

nonlocal MD

massmotorist said...

I'm always puzzled by the way medicine is treated so differently from every other industry. I'm interested in your thoughts on this, Paul.

If a field contains known safe practices and many unsafe ones, why are there not mandatory regulations governing these practices?

I don't mean that in the sense of general guidelines, voluntary recommendations and bulletins, or medical journal articles. I mean that in the sense of mandatory regulations prohibiting known poor medical practices and prescribing specific evidence-based treatments in certain situations and proscribing others. I mean medical inspectors coming into a hospital in the same way a bank inspector would, and reviewing a random selection of patient files for compliance, and reviewing hospital procedures for process improvement, with licensing sanctions for noncompliance. A government agency with general supervisory authority over the practice of medicine, that regulates doctors and hospitals the same way the USDA regulates meat packing and the FDA regulates pharmaceutical manufacturing.

It seems to me that the problem with the medical industry is that medical professionals want to think of themselves as individuals constantly solving unique and complex problems. They each base their assessments on anecdotes and personal experiences without consulting any evidence. The fact is that 80% of care could be done more efficiently by a nurse or medical assistant with a computer - input all symptoms, circumstances, and patient information, get a list of possible diagnoses, choose the most likely one, get a list of most effective treatments (based on solid statistical evidence), present options to patient.

Naomi Kaufman Price said...

On Facebook:

On the one hand, unnecessary if indeed it was used as a routine screen, etc. On the other, he could have had symptoms we know nothing about -- not as if he released his whole record. Even if the latter, stent seems like a pretty fast-draw solution. Unless, of course, things were much worse than "advertised." Even "incredibly fit" etc. folks drop dead of heart attacks -- not unusual to read of one happening during a run, race, rowing, etc. I just don't want to rush to judgment on so little information.

Paul Levy said...

If you are public figure releasing some information, you have an obligation to put the entire thing into context--especially here where it sends a poor message.

Paul Levy said...

Dear massmotorist:

On your point "It seems to me that the problem with the medical industry is that medical professionals want to think of themselves as individuals constantly solving unique and complex problems."

Exactly right, but not WANT to think, rather are TRAINED to think. As noted by the Lucien Leape Institute:

“Medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care.”

“The medical education system is producing square pegs for the delivery system’s round holes,” said Dennis S. O’Leary, MD, President Emeritus of The Joint Commission, a member of the Institute, and leader of the initiative. “Educational strategies need to be redesigned to emphasize development of the skills, attitudes, and behaviors that are foundational to the provision of safe care.”

Neville Sarkari MD, FACP said...

A couple of thoughts. First, as noted above we don't really know the entire story.

Second, the "best care" according to guidelines and the "safest medical care" and the most cost-effective medical care are not always the same thing. They could be three different approaches. Screening guidelines are built with the statistical best outcomes of populations in mind. Physicians are sitting across from individual patients making decisions. If that patient wants to make a decision that he/she can afford to pay for, should that be disallowed because it is not the most cost-effective? Or even the "safest" in terms of side-effects?

Finally, look at what happened to Tim Russert who was receiving "medical therapy" for his known coronary disease. If you're the physician taking care of a high-profile client, that's a pretty poor outcome for you. Bad things can happen unexpectedly, but our court system doesn't do much to help physicians, either in terms of the process or often the outcomes. Not to mention the press when your high-profile patient drops dead at the office. Does that justify the stent intervention, perhaps not, but currently in our system it was a choice the patient had.

All that being said, I haven't really read much about this case and have no strong feelings either way. That's because I don't know the true details and I wasn't sitting with the patient making decisions. But, I have been in that situation many thousands of times, and it's not an easy one. Certainly not as easy as looking backwards at the case and preaching about guidelines later.

Dr. Berwick has talked about giving patients the "care they really, really want." What if this was the care he really wanted, and he can easily write a check to get it?


e-Patient Dave said...

Where are the advocates? Well, I for one hadn't heard a peep about this yet. I'm guessing I have the opposite of "way too much time on my hands." So thanks for this post.

My thoughts: these days people are correctly calling for more personal accountability on the part of patients. It's one aspect of "patient engagement," and it's always clear where the onus sits: the [named] patient. Has the parallel happened here? Has the cardiologist in question been called out by the ACC to defend him/herself? Seems to be a clear issue of medical professionalism.

Bob said...

As to Bush's stent: "guidelines" apply sometimes and sometimes not. I'm all for them, but lots of times they are not appropriate for an individual case. We see it all the time. "Guidelines" have to apply to everyone, from a nurse practitioner in the Mississippi Delta, to a private doc in Scarsdale. Yet, a practitioner with a very reliable patient in one place can do things that can't be done in a clinic setting with less skillful practitioners.

Also, many times a broad study has to ignore many individual patient medical characteristics. So "in general" stents might not help - but that could be because a lot of practitioners are placing stents when they shouldn't, and the studies can't detect that.

Or take the case of the PSA test. It is currently recommended against. But if you look at it, there is lots to be recommended for someone like me - if the result is low, great. If higher, we can make careful choices. But the hoi palloi? Neither practitioners nor patients can be trusted to make thoughtful decisions. So in this case, I'd say that blanket recommendations shouldn't apply.

Or look at recommendations for Hep A vaccines. Years ago they were not recommended because on a population basis, the risk/reward didn't look too good. But for someone with money, paying the extra $200 or so for vaccination was a valuable expenditure - it's just that the government didn't want to spend the money for the whole population. That's a clear case where general recommendations don't apply to individual situations.

For those who are levelers, this is unequal care. But do we really want to reduce the level of care for people with money to achieve equality? It's one thing to raise the bar for everyone, but lowering it doesn't make sense to me.

There was a book on Russia about 15 years ago. An older woman heard the young cry, "Nobody should be rich!" She said, "I remember when we said, 'Nobody should be poor!'"