Where do I begin. I love this on so many levels.
Now. Here goes.
Yet the irony is shocking.
I received in my mail today word of a new program being offered through my full service hospital.
The letter said the following:
Dear physician,
I would (like) to take the opportunity to inform you of an exciting new service being provided by Hospital X. We will be providing a variety of screening opportunities for members of our community, both at the Medical Center campuses and in our newly acquired mobile screening vehicle.
The screening services currently being provided include:
Carotid Ultrasound
Abdominal Ultrasound (AAA)
Peripheral Artery Disease (ABI's)
Ejection Fraction Echocardiogram
Bone Densitometry
Cholesterol
Triglycerides/Glucose
Blood Pressure
Those procedures requiring a physician interpretation will be reviewed by a cardiologist or vascular surgeon, who is credentialed in the identification and treatment of specific disease processes being screened for.
Participants will recive the results of their screening in a letter mailed to their homes. Anyone with a result that indicates there is area of concern is encouraged to see their primary care physician. In addition, we will notify the patient's primary care physician immediately if we determine the patient has a "critical value" associate with one of our screening procedures.
I am enclosing a copy of the participant result letter so that you are aware and familiar with the format, should a patient present to your office with this information. In addition I am enclosing a copy of the brochure we are distributing in the community.
Signed,
Director of Cardiovascular Services.
This offer has SOO MANY ANGLES one could take and think about.
In my normal style of picking things apart, I have come up with several, in just a few minutes of thinking about it. So here goes, I will try to discuss them as I see fit. This is going to get wordy.
#1. It's A Damn Sexy Program.
The brochure was very pretty. Colorful. Full of excitement. A picture of the impressive giant big rig 18 wheeler mobile facility with the fancy hospital logo and a catchy phrase. Definitely the work of professional marekteering.
Here is a partial view of the very pretty brochure going out to my community and all the docs as well.
Now. Here goes.
On the surface, I am in 100% agreement that my hospital has every right as a viable business to market this program. This is how TRUE market economies at work.
100% CASH paying customers, who under their own free will, are willing to make a decision to plunk $70 or more to get screening tests, that as far as I know, have never been recommended to the general public (except for blood pressure and diabetes screening and cholesterol) in the absence of any verifiable indication.
As far as I know, there is simply no class I indication (the highest level of evidence) to screen the general public for ANY of these technology offers.
The hospital has every right to market this service to anyone who wants to pay it, CASH only.
As a screening service, this is a CASH only business. It will generate the income that the people are willing to pay. And I am 100% OK with that.
The physicians who will interpret these tests come from a pool of physicians who meet strict criteria to make clinical interpretations, as established by my hospital.
In a land of hospital competition, this new service takes technology, which people respect and accept as the gold standard of care, to the people. It takes my hospital's name to the people.
Hospital marketing is all about technology. It is a brilliant marketing technique for spreading the hospitals name. Not the technology itself, because, it's old school technology.
Who has the latest version of what scanner or treatment modality. The stuff that is purchased for the small percent of the population, but builds the status symbol of the hospital overnight.
Look at the prices and the marketing technique:
A HEART PACKAGE with screening EF ECHO (the technology part) and the cholesterol, blood sugar, blood pressure and risk profile (the more important stuff) for $70, cash.
A VASCULAR PACKAGE which includes such things as carotid screening, AAA (abdominal aortic aneurysm) screening, and peripheral artery disease screening (the technology components) and cholesterol, blood pressure and glucose (the more important stuff) and profile screening for $135, cash.
A STROKE PACKAGE with carotid ultrasound (the technology part) and cholesterol, blood pressure, and blood glucose and profile screening (the more important stuff) for $70, cash.
An ESPECIALLY FOR WOMEN PACKAGE with bone densitometry screening (the technology part) ,and heart risk assessment, cholesterol, blood pressure, and glucose (the more important stuff) for $50, cash.
Now. I look at this service and I think to myself.
WHAT A GREAT WAY TO GET PEOPLE SCREENED FOR THE MOST COMMON LIFE THREATENING AND EXPENSIVE DISEASES OUT THERE.
diabetes
hypertension
hypercholesterolemia.
The power of the free market is that my hospital has found a way to market, in my book, completely unnecessary screening, using boring (to doctors), but fascinating to the lay person technology. Echo, ultrasound, and doppler.
This stuff is nothing new. It is some of the oldest health technology out there.
It doesn't have words like stealth MRI, or Positron Emission Tomography.
So they market it as packages of health.
Your heart package.
Your stroke package.
Your vascular package.
Your women package.
I contend that what they are doing is 100% ethical and legal. These are cash paying customers who agree to spend their hard earned dollars on a $135 cholesterol, blood pressure and glucose check.
My only simple concern ethically, is that this program does not get marketed using fear tactics.
"Get your carotids screened, or fear a stroke"
"Get your triple A screened, or fear sudden death"
As far as I know, and some outpatient docs can assist me, the only possible indication to do any of these screening technology tests are a AAA on elderly folks (and I'm not sure what the current guidelines are for that).
That's why this is a CASH only program . Because there is no indication for the test. And no insurance will pay for it.
On a population basis, with the general public, there is simply no reason to be doing these tests. Without an indication, I am not aware of any study showing a cost-benefit analysis.
What it brings people is peace of mind.
For $135 and some pretty boring technology.
If your primary care doctor ordered an echo for "screening" no insurance would pay for it. Your doctor must have an indication.
Chest Pain
Passing out
Abnormal exam
Something that indicates there is a reason they ordered the test.
If they wrote screening as the indication, and sent you to the hospital to get it down, it would not get done until you presented a viable reason. Nobody would get paid. Not the hospital nor the cardiologist reading it.
You simply can't use "screening" or "rule out" as an indication for a test, and expect to get paid.
So, put forth clearly, an asymptomatic person who wants to get their neck arteries checked has every right in the world to have that done, for peace of mind.
But the only one that will pay for it is you, the one requesting the test. You. And that's why it's CASH only. And that's why I have no problem with this program.
They have found a way to bring people into the preventative medicine, and making it sexy at the same time.
I contend that vastly more benefit will come from one month of the screening of cholesterol, blood pressure and diabetes than all the positive echos and ultrasounds that will be read out in an entire year of the program.
#2. For Technology, It's Actually Quite Cheap. For Preventative Health, You Primary Care Doc Is Less Than 1/2 the price.
The benefit of the technology component is actually quite cheap. That price only includes the screening version of the test. The quick and dirty aspect. So it isn't the big shebang with all the bells and whistles.
But none the less, as far these these tests go, the price is actually quite cheap because it also includes the physician component/fee.
I can't think of any think else in medicine where you could get a vascular surgeon's opinion on anything for under $70. So if you really want "peace of mind", which is what these tests sell, the price point is actually quite attractive.
GO for it
If you went to the same hospital, with a formal carotid ultrasound with a real indication, your insurance would be charged doctors fees, and facility fees that pays for the rent and the ultrasound tech. I can assure you, the cost would be well north of $70, probably by several hundred dollars, once you include the docs fee and the hospitals fee.
So $70 is a steel. But the question is, what are you paying for.
Is it worth it? Well? Is peace of mind worth $70 +$70+$135+$50. Over $300.
You could get an exam by your primary care doc, a blood sugar check and a blood pressure check, and possibly even a cholesterol check for a $30 copay.
Even cash price you would get a full exam at probably 1/2 the price. The associated preventative labs is where the money is. THAT is the value of this program on a population basis.
So, is the technology component worth the money? Well. On a population basis. No.
Not even close.
That's why these screening tests aren't done on a population basis.
It's as if I recommended that for $70, you should have a heavy metal screen. It is simply not done on a population basis.
There simply is no clear cut current indication to screen for these tests on a population basis.
So it comes down to fear.
Fear of the patient.
Fear of wanting to "know for sure"
The grandmother of my wife asked me last year if she should get this done. It's the fear of not knowing.
It's that fear that will drive people to spend $200-$300 on CASH technology tests that they don't need.
It is engrained in our culture.
But to that end, since it is a cash proposition, the hospital and the public have every right to engage in unneeded testing since only the patient is responsible for the cost. As long as the hospital does not market the program on the basis of fear, I think everything is ethical and pure. It would make me feel better if the brochures actually stated that this technology testing is not recommended by any primary care or specialty society on a population basis. That would actually increase my respect for this cash endeavor even more.
#3. Does it exacerbate inequality to access?
I am a strong believer in the ability of the market place to create a WIN-WIN. Happy docs, happy patients. In this program, you have a cash only market where the patient and the hospital are both winners because the patient gets what they want at a price acceptable to them. But it also raises the following point. If this service is only available to the cash paying customer, is it fair that those unable to pay for it are left behind?
Yes it is.
The free health for all camp would state it should be available to everyone regardless of ability to pay. If it's available to those who can afford it, it should be available to those who can't.
That is the current mentality of the Medicare National Bank. Regardless of ability to pay, Medicare is available to all folks over 65 and a few disabled and a few dialysis patients.
All patients are essentially created equal with the same low level ring of service. Volume mentality with no incentive to provide better service from our docs. Waiting in the office for 2 hours to see your doc? Tough shit. Go find another doc taking medicare.
With the cash paying customer, it is overt rationing of a service that could not possibly be paid for for every single person in this country.
The question of whether it is necessary is a moot point. If somebody wants to spend their hard earned money on a service that is needed or not needed, that is their right.
This is an example of a service. A service not available to the insurance paying group. That's what cash paying customers bring to the table. The patient expectations for service.
Whether the testing is necessary or not really makes no difference, since the patient makes the decision to spend their money.
#4. A Potential Loss Leader for a Back End Cash Cow.
I have no idea whether my hospital will make money or loss money with this endeavor. I don't have an MBA. But I can see this program from several different angles.
If a positive test is achieved, a referral to a cardiologist or a vascular surgeon potentially may lead to the much more lucrative heart cath or vascular surgery DRG collection at the hospital. I'm sure that some where along the way, an actuary for the hospital ran some numbers.
How many screening echo's need to be done to generate a postive cash flow from a medicare DRG for a heart cath or a carotid endarterectomy?
I can't imagine any hospital, mine included would enter into a major community project without the bottom line in mind.
These screening tests come with big DRG's (diagnosis related groups) on the back end.
If a patient gets admitted to my hospital to get an intervetion (procedures pay gobs of money), then the back end value of a front end money losing service may be justified.
In a big way. Strip away the "community benefit" and look just at the number. The money numbers.
Maybe my hospital makes a ton of money without any referrals. Maybe they don't. I have no idea.
I can assure you that a screening chest xray isn't one of the offered "lung packages" because an abnormal chest xray would not garner the type DRG payments on the back end, and may actually lose more money on the front end.
Which makes me ask the question.
Why isn't there a Lung package?
Spirometry and a chest xray for $70. It would make sense that if we are screening your heart and your blood vessels that with 20% of the population smoking, a lung package would certainly be in the publics best interest.
I am sure every hospital in the country that runs these screening programs have looked at the data retrospectively to see what kind of ROI (return on investment) they get on the back end interms of filling up hospital beds with AAA repairs, CEA (carotid endarterectomy) and heart cath or CABG (coronary artery bypass graft).
I still contend that the major community value of this entire program will come from the screening done on the primary care front (blood pressure, cholesterol, glucose).
The rest is a pure gravy train.
#5. I Can't Afford My PCP
The AARP always goes ape shit when a bill to allow balance billing is entertained in the House of Bought Votes (Congress). Yet, here we are. A program, which my grandma paid similar money last year. A $100 for peace of mind.
On a population basis, a complete waste of money.
But it's cash. And it's fear of the unknown. And that drives people to spend their money.
The argument that balance billing will decrease access to care is hogwash. WE have folks spending $70-$300 for piece of mind that their arteries, which have no clinical indication of disease, are disease free.
But technology rules the day. The primary care doc is left in the dust. Struggling to keep their heads above water with every decreasing payments.
While their patients spend $100 on a worthless endeavor into technology.
Now, I ask you, our payment system is set up to give access to the lowest economic denominator. It is set up to create access for the poorest of poor.
Yet the wealthy and even not so wealthy, who are able to go buy their worthless $300 vascular cash scans take advantage of the same system.
I contend that balance billing would allow those with the means to pay, to allow the doctor to voluntarily subsidize those who couldn't.
In the current system of payment, equal payment for all social classes, the rich are making access for the less afluent less available, by not paying for fair share, and instead taking advantage of the rules which establish payment rates based on the lowest economic class.
Balance bill and the market will equalize itself. I don't doubt that for a minute.
#6. Placing Inappropriate Responsibility on a Primary Care Doc Who Didn't Order The Test
I was told that screening tests don't need a physician's order. Yet, as I understand the current program at my hospital , if an abnormal test is obtained , the patient will be "encouraged" to notify the patient's primary care physician, and a "critical" value will be notified to the primary care doc's office immediately.
While, in practice, the right thing should be done for the patient. I see several problems with placing further burdon on a doc that didn't order the test and has no knowledge of the order for the test.
Placing a primary care doc on notice that they are responsible for an abnormal, or even slightly abnormal test result that they didn't order, is risky, in my opinion.
Take for example. None of these tests, these screening vascular technology tests, come with a clear cut normal/abnormal results. Circle the winner mentality.
There are many shades of grey.
An EF on a echo can be normal, low, kinda low, too thick, too thin. Left side bad, right side bad, both sides bad.
An ultrasound of your neck arteries, same thing. Normal, kinda abnormal, but not really, a bit abnormal but nothing to do about it, really abnormal.
Same with leg ABI
Same with a AAA.
There are many shades of grey.
There are lots of shades of grey that when presented to the PCP will require them, for medico-legal purposes, to order a complete standard full court test press.
A full blown echo.
A full blown carotid
A full blown leg vascular exam
A full blown AA evaluation.
This is where the real money is. Where they can now also collect the facility fee, the specialist can read the full test all over again and collect an insurance fee. This is the test that can costs several hundred dollars, by itself. And it's paid for by you and me via third party payers.
And it is all courtesy of the low cost screen that is not recommended by any professional society, but the patient wanted for peace of mind.
The vast majority of the time, nothing will need to be done. The formal echo, carotid, leg doppler and AAA eval will all still be slightly abnormal, but not need any intervention.
The hospital has now achieved an exponential collection of revenue from that cheap screening test which is not recommended by any professional society.
Yet, now the primary care doctor is put in the vicarious position of
If I am presented with a slightly abnormal screening test, and do nothing, I could be sued. The patient will be fearful and I will have to refer them to get the formal test and to see a specialist, most likely the one who read the original test.
And that specialist will recommended yearly screening.
It is amazing how a screening test on a cash only system now became a yearly screening test on an insurance basis, which will increase all of our costs without an improvement in health, on a population basis.
That, I have a problem with.
But the primary care doc will not take the fall They will not hold onto an abnormal, even slightly abnormal screening test, because a screening test is an incomplete test.
And if a patient has a stroke and had a slightly abnormal screening test, and no formal follow up was done, the basis of negligence could be established and that poor primary care doc gets their ass sued.
All because the patient decided to get a test that they didn't order.
I contend that an abnormal test result no matter how abnormal should be interpreted by the specialist who reads it and they should be responsible for the abnormal test result and follow up.
That's good medicine.
And it should be up to them to contact the primary care doc with their recommendations. Since they are the ones collecting the professional fee.
In the current set up, the specialist collects the professional fee, the hospital collects the screening fee, and the primary care doc collects the liabilty.
And the primary care doc collects all the liability, for free.
Placing the burden of responsibility on a doc who didn't order a test and didn't read it is simple not good medicine. No matter how you slice it. And it's even worse when they collect the liability for free.
#7. Primary Care Needs A Professional Marketer
It has become painfully obvious to me that if a program can achieve success for a service of worthless technology (and by worthless I mean not recommended for screening by any professional society) and bundle it with lifesaving primary care intervention (glucose, cholesterol, blood pressure), and get away with charging $70-$300, it has become painfully obvious to me that primary care, in general, needs a professional mareketer to come in and give the public an attitude adjustment.
The clear and present value in their service is being overwhelmed by forces much greater, with deeper pockets and greater savy that has been able to convince a population that MORE is BETTER. In this case, FREE does not equal MORE. Which is amazing, because Ms Medicare will complain that their copay at their primary care docs office is too much, but will gladly spend a couple hundred bucks CASH on unnecessary tests.
Only in America.
Happy Hospitalist, how would a full test to follow up a slighly abnormal screen in an asymptomatic patient be billed?
ReplyDeleteFor example, what diagnosis would be used if a screening echo was suggestive of mildly decreased ejection fraction, but the patient had no signs or symptoms of cardiac disease?
Interesting post.
I disagree only with your take that there is no ethical problem with this. In fact, you proceeded to outline all the ethical failings of the program quite eloquently. However you slice it, marketing tests that are not recommended is quackery, even if it is legal. It's the downside of your utopia of a truly free market in medical care. The only place in American health care that operates under actual market principles is woo.
ReplyDeleteHow about if it offered Reiki along with blood pressure, glucose and cholesterol and called it "Energy screening"?
"If I am presented with a slightly abnormal screening test, and do nothing, I could be sued. The patient will be fearful and I will have to refer them to get the formal test and to see a specialist, most likely the one who read the original test."
ReplyDeleteplease. it is no different than your inpatients who come in with diabetes that you don't refer to an endocrinologist, or heart failure who you don't refer to a cardiologist. if an abnormal test result is discovered, they probably need to engage the health care system anyways-being pre-sick and all.
when you say nothing, obviously you don't mean watchful waiting and observation with lifestyle modification, right? :)
Hmmm... not sure I agree with Dino that ultrasound screenings for low risk populations = woo. The way I see it, a 1:10,000 risk of something is not sufficient to justify the cost of screening for it on a population basis. But if an individual wants to pay cash to rule out that risk for himself personally... then let him (especially if there's no radiation or known side effects involved). However, a better use of his money would be to eat more veggies and join a gym.
ReplyDeleteI agree with HH that scare tactics are an ethically questionable part of this - people should be given a sober explanation of their risks (and how unlikely they are to have problem X), and then be offered the screening if they still want it (for peace of mind purposes).
It is my ethical responsibility to inform the patient and help them decide what is appropriate for themselves. Just like it is appropriate for the used car salesman to help the patient find the right SUV. Just like it is the ethical responsibility of the counter girl at Mcdaonalds to get just the right Double Shake, Double Cheese, Double fry for the #450 customer....
ReplyDeleteSorry, how does one sell uncertainty again? What is the going price on Responsibility? Or does all this fit under my Professional Umbrella escape clause I got when I got the MD and the monopoly? Jeez, I hope so. I gotta go meet with my broker.
I think that part of the problem with this arises in the predictive value. The reason we do screening tests in certain populations is that the positive/negative predictive value of screening tests varies depending on the prevelance of disease in the specific population (and the characteristics of the test, but let's say we hold the test constant). So, how many patients are going to undergo unnecessary heart caths due to an apparently abnormal echo ef, and then end up having a perfectly normal heart? I suppose this is mostly a concern when the diagnostic test/gold standard is an invasive test, or perhaps a very expensive test, but still....
ReplyDeleteMichael Rack, I use F/U abnormal_____ all the time as an indication in hospital patients and I've never been questioned. In the case of an abnormal screening echo. Follow up abnormal Echo. Follow up abnormal carotid. etc...
ReplyDelete#1 Dinosaur, I disagree. Using that line of argument, a service oriented doctor (my new word for Concierge), who markets his time for cash price and 24 hour access for extra money. One could argue that the service is not required to get medical care. But the patient is willing to pay for it because they want the service.
As long as you have a willing cash paying customers who have been informed freely, they can spend their money how ever they like.
If somebody wants to spend their money on Energy screening, it is not my place in life to judge how they wish to do so. As long as they are not spending my money (aka tax dollars).
If somebody choses to buy a lexus even though a Honda is adequate I have no business caring how they spend their money.
Anon: you are missing the point completely. For example. a carotid screen may signify placque. But when i get formal carotid reports due to an indication such as an aucultated bruit, or a stroke, I get a report that indicates 1-39% blockage, 40-59% blockage, 60-79% blockage or 80-99% blockage. As part of the report I am told about antegrade flow throught the vertebral arteries.
It is not simply normal or abnormal. Would I refer an asymptomatic patient with stenosis of 1-39% to a vascular surgeon? Of course not.
But that is based on a formal study. A screening study may say plaque. It may not signify clinical significance. It may not indicate the need for further evaluation. But it very well may need further evaluation. So not doing a formal study would leave liability in the primary care doc wondering, is this abnormal screening test abnormal enough to warrant a full formal test? And the answer will always be yes, because a screening test doesn't give you all the necessary information.
They only problem with the inpatient arguement, is that my population is selected to include sick people. These screening tests are being done on the general public. Now, if the echo, and dopplers were ONLY being offered to folks with known cardiovascular risk factors, that's a COMPLETELY different situation, because then, you are dealing with a much more bang for your buck. There is no reason in the world the general public needs a screening EF.
None.
Now, if this mobile lab would sell you a complete Echo or complete carotid for a CASH only price of $70, then that a hell of a steel, because it comes with much more important clinically relevant information.
As a patient I totally disagree with you on ethics. If your ethics tells you that it's OK to order any test a patient in his or her ignorance is willing to pay for, than you are also saying selling snake oil is also ethical (it can also have some benefit due to placebo effect).
ReplyDelete1. You totally ignore the potential harm associated with false positives of some of the tests. There is not a single word in your post about risks of unnecessary tests. A quick search of the USPSTF website said "harms likely to outweight benefits" for, for example, PAD and AAA. Here is what USPSTF says about screening healthy women for AAA:
Because of the low prevalence of large AAAs in women, the number of AAA-related deaths that can be prevented by screening this population is small. There is good evidence that screening and early treatment result in important harms, including an increased number of surgeries with associated morbidity and mortality, and psychological harms. The USPSTF concluded that the harms of screening women for AAA outweigh the benefits
So according to you because a woman is willing to pay, it's OK to order a test which (after considering false positives) is likely to harm (and even kill) more women than it may save? Is the brochure sent to people includes ANY information about risks of these tests?
2. Most people don't know enough to understand why a test is recommended or not. Most people don't know that having this extra test may not be beneficial to them. I saw one of a similar brochures in my community - it was from a newly opened radiology lab and it specifically listed AAA, PAD and echo. Each test was accompanied by a nice description of how serious a condition might be, of course, omitting the probability an otherwise healthy under-65 person may have it.
As most Americans have heard for years message "just be tested", why wouldn't they believe reading this ad that they absolutely need this tests. So they'll be spending their money on something they don't really need but were convinced by "expert" authors of the ad that they do. How is this different from a fraud?
3. Tests lead to more tests. Every test has false positives. Even if patients pay for the original test from their pocket, they will not for the follow-up. This will lead to extra health care costs for everyone.
The main issue for me, though, is the potential harm. I am amazed that you consider a medical ad from doctors encoraging people to do tests that are more likely to harm than benefit them ethical.
If you think overtesting is harmless, look up testing for neuroblastoma in Japan that failed to save a single kid, but killed and harm quite a few. Sure for most people this testing will have no effect, but when you consider a 1000 or 10000 people, these extra people who are harmed will add up.
diora using your broken logic, it should not be ok for a Lexus dealer ship to sell a big expensive SUV to a cash paying customer because the exhaust fumes will lead to excessive green house gases and result in more harm.
ReplyDeleteIt's not my role to control how other people spend their money.
If you read my postion with calm sensibility, you will see that I said that a cash paying customer has every right to purchase any health care they want. It is not my role to control how other people spend their money.
I stated that those offering the service should not do it based on fear and that I would respect the hospitals offering these population screening tests more if they indicated that these screening tests are not recommended for population screening by any primary care or specialty society.
And by the way, I didn't say I would order the test as you imply. It is the patient ordering the test. Remember, the screening test is being taken to the public and it is not a medical doctor ordering it. It is the patient ordering for themselves.
I categorically stated I don't believe in the benefit of population screening for these unnecessary tests, but I am not going to stand in the way of something that is not illegal.
That would make me a cop.
And I have no desire to be the lay person's cop.
They are big boy's and girls who can spend their own money.
Would I order it myself? Hell no.
I was actually quite suprised that a patient can order their own screening test. If I went to the lab where I had my thyroid drawn and asked to have a cholesterol drawn, they told me they would need a doctor's order.
So I was shocked to see that you don't need a doctors order to get these screening technology tests
#2. It's not fraud because there is no law against It. If you think it's illegal, take it up with your legislature. As long as it's legal, just like cigarettes, the ultimate self harm legal activity, the right to engage in the activity can't be denied. Is it ethical to sell these tests based on fear? No. And I said that. Is it ethical to sell them based on false pretense? No.
I wouldn't sell them, But I won't keep some else from doing a legal activity with their own money.
#3. You repeated what I said. These test will lead to more tests. I agree.
You must be new to my blog. I never said overtesting is harmeless. I am infact quite the opposite. I believe in less is more.
But I am not going to treat the public like little children. If they understand what they are getting for their money, they are free to do what ever they want.
I realize that you wouldn't order the tests - although, yes, I am new to your blog.
ReplyDeleteMy issue, however, was with your saying that it is ethical for the doctors who were responsible for the brochure to encourage ignorant and unsuspecting public to have the tests that are more likely to harm them (personally - unlike your example about Lexus) or even kill them than to help them all the while claiming that the test is life-saving. Your example of harm resulting from Lexus is not relevant - we aren't talking about harm to the environment here but the harm specifically to the buyer. Nor is a Lexus dealer telling the buyers that the car may save their lives and they may die without it. Also, most people know that SUV uses more gas. Very few people know that taking these tests may harm them, most believe they may save their lives. Now if a Lexus dealer was telling buyers that buying an SUV as opposite to Honda Civic would save their lives with a scary information about danger of driving smaller cars (all the while forgetting to mention the higher risk of SUVs), your comparison would've been valid. I'd imagine if a Lexus dealer put out such an ad quite a lot of people would take exception. Also, people normally don't associate ethics with car dealers.
Yes they are big boys and girls who can spend their money. The problem is that they are being mislead by the brochure authors into thinking they need the test. For years and years some of your collegues were sending a message that more testing is better - in newspapers, in some articles on the web and on TV "housecall" shows. Younger people grew up with these ads. Naturally they are very likely to believe what they read, especially since the brochure has "expert" authors with MDs after their names. As I said I got a similar brochure (actually a flyer) in the mail. Obviously, it went straight to my garbage can, but the information there was extremely convincing. Each of three tests - AAA, PAD and echo if I remember correctly - had a little square describing why we should fear the particular condition and describing how a test can save lives. Legal - yes, ethical - I doubt it. Oh and where does "first do no harm" and "informed consent" fits into this picture?
If the brochure had a little asterisk near non-recommended tests with fine print saying that "this test is not recommended because the harms may outweight the benefits" and "only 1/10,000 people will benefit from the test" (not sure about actual number), then the ad would be ethical because yes, grown-ups can make their own informed decisions. Sure outside of the area of medical care they can make uninformed decisions as well, but as the authors of the ad are doctors, they should at least ethical inform of the risks.
If they understand what they are getting for their money, they are free to do what ever they want.
Absolutely. The problem is - they don't understand what they are getting for their money; they have no background to understand it and the authors of the brochure don't seek to inform them; quite the opposite.
diora, you should do yourself a favor and go back and read my blog entry. You spout many inacurate assumptions that are clearly not true in my entry.
ReplyDeleteFor starters, doctors aren't responsible for the brochure, the hospital is. The the basis of your attack fails in the wrong assumption of your first sentance.
Because of this wrong assumption, the rest of your argument is not debatable. It's just inaccurate.
It's also obvious to me that you failed to absorb my blog entry when I clearly stated I would have more respect for the program if they stated on the brochure that this technology testing is not recommended by any primary care or specialty society.
Go back and read it. It's clear as day.
Your assumption that having this test is unethical without full consent of risks and benefits simply doesnt hold water.
Using that same rational of broken logic, I would need to have a grocery store list all the possible illness I could contract by buying spinach in their grocery story.
I would need McDonald's have informed consent explaining all the possible medical illness I could be exposed to by eating their Big Macs.
I would need every liquor store cashier explain the risks of consuming alcohol and rattle of every possible accident or medical disease I could get from drinking. In fact I would have to assume you consider selling beer to an alcoholic unethical because the store selling it would be doing harm.
I would have to assume that a store selling cigarettes would be unethical due to the harm they are causing, and not explaining to each and every customer all the possible medical conditions associated with smoking.
I would have to assume you believe every possible store that sells processed foods are unethical because of the risk of all associated medical conditions.
The expectation of harm does not rise to a consent requiring level. Nor does it rise to the level of of these screening tests.
I do not need informed consent for every possible test I order in a hospital. Nor should a patient expect it. Lab tests, xrays, CT scans. There is no informed consent required for CT scans, even though they carry a small chance of secondary cancer years from now. I do not need informed consent to obtain a chest xray, even though a nodule may lead to a biopsy of a benign finding which could result in procedural complication and death.
I would need informed consent if the procedure itself, such as a biopsy, carried with it risks of immediate complications or morbidity or mortality.
You are confused.
If you believe that every single possible test/xray, and lab required informed consent, the medical system would grind to a hault. And that would be a far greater travesty for the population than being explained the 1 in 10,000 chance of a bad outcome.
Sorry, your argument simply doesn't hold water.
Are these tests necessary on a population basis?
No.
Do I defend the publics right to obtain them if they want to pay for them?
Yes.
The things you are talking about - e.g. that cigarettes are bad for - are common knowledge. Anybody who hasn't heard about anything you mention from TV or radio probably lives on another planet. The fact that tests have risks isn't common knowledge; the fact that finding something early isn't always beneficial isn't common knowledge; the actual chance a healthy 40 year old can have one of these condition isn't common knowledge.
ReplyDeleteYou seem to be missing this point. The brochure provides deliberately misleading information. I also find it hard to believe that no MD who works for the hospital read the brochure, not given so many articles by the doctors supporting lung cancer screening.
Would the same people who are willing to pay for the tests still be willing to pay if they had been told that their risk of a condition they are being tested for is 1/10000? Want a bet?
And if you know probability theory than you know that if a risk of false positive after one test is 10%; the risk of having at least one false positive in 10 years of testing is way over 50% (close to 75%). Since I don't know the rate of false positives for each of these tests nor the rate of complications for more invasive tests that follow, I cannot quantify this risk. But even if it is 1/10000 after single test, it'll be more than that after 10 such tests.
No you aren't required to ask for informed consent for tests. But ethically you should at least in cases when the benefits don't clearly outweight the risks. I'd imagine if you ask your patients if they are interested to know it, many will say yes. Besides, the subject isn't what you do, the subject is the ad. Drug company ads are required to have the list of side effects, however small these risks might be. How the tests are different?
I'd be curious to hear ethicists' opinions on this issue.