Ignorance And Fear In Health Care

I had an interesting conversion the other day with The Happy Cardiologist. In my discussion about the shortage of radioactive tracers for pulmonary embolism scans (V/Q) I was asked, What would I do?

happy cardiologistYesterday 03:03 PM

HH,

Agree, many tests are difficult to interpret in obese patients. Even a BNP can be falsely low. But if the BNP, troponin or RV function were markedly abnormal, then that would add more urgency to the matter due to mortality risk. If all normal, then a more wait and see approach appropriate. Just another tool to assess risk and benefit.

On another note, I was asked to see a 360#, 5'3'' diabetic patient with a history of multiple bilateral PE, for a single episode of atypical chest pain. The CT as read by the radiologist was indeterminant for possible single lobe PE, due to poor contrast timing and patient obesity and movement. The EKG as read by the machine was normal and then overread by a physician as abnormal with ST elevation in the lateral leads (it was normal). I was asked to consider a pulmonary angiogram or cardiac catheterization. The echo was completely normal, with surprisingly good images. Normal RV function. BNP <>

What would you do?

I answered that I wouldn't do anything but refer them for gastric bypass. The Happy Cardiologist concurred. But, the question shouldn't be what would I do if I was the cardiologist. The question should by why is the referring doctor, presumably a family medicine doctor, outpatient internist or hospitalist even asking you to see the patient. There are only two possible reasons:

• Ignorance
• Fear

If the doctor is ignorant, we need to pay them less for costing the health care delivery system more. More referrals cost more money. Bundled care would cost this referring doctor because more referrals means more cost to the health care system. Bundling the care would force them to think long and hard about their duties as a physician. If they are ignorant, they need to go back and train longer. Otherwise, the alternative is to bundle their care and pay them less for their ignorance.

If the family medicine doctor or the outpatient internist or the hospitalist decided to handle this situation on their own, using evidence based medicine and sound clinical judgement, they get no reward. In fact they get higher perceived risk (even though known exists). They not only cost the system less with decreased referrals and presumable fewer unnecessary testing, but they get none of the reward for their great care.

Some folks would argue this places too much incentive on the family medicine, internal medicine and hospitalist docs to not refer care. And that's exactly the point. If you have good doctors doing their jobs for which they were trained, they should be rewarded for their excellence. While those who run volume mills out of a need to financially survive, or out of ignorance should not. Right now, fee for service rewards the doctors who run volume mills either out of ignorance or by pretending to practice great medicine. With bundled care, the doctors doing their job well would be rewarded. All the rest would suffer (those taking advantage of fee for service).

If the happy cardiologist was not referred a patient out of ignorance, the only other alternative is out of fear. Perhaps the referring doctors don't feel like taking all the risk for making a medical decision that leads to a bad outcome. I refuse to play this game. Asking another doctor to give me their opinion will always be out of ignorance on my part, not out of fear. If I wanted to spread the risk, I would be asking for a subspecialist on every single patient I see, for every single new or old medical problem. Playing the risk game is what created irrational standards of care. So many doctors practice out of fear, they have created standards which can't be achieved. It is a horrible way to practice medicine. The solution to fear based medicine is not to do more of it (which is obviously not working) but rather to do less. To establish lower community standards. Standards based on doctors, not lawyers.

This consult request by the Happy Cardiologist is a microcosm of what's wrong with our health care delivery. The great doctors who do nothing shoulder all the risk from irrational standards where many cardiologists would just cath this patient and collect their $500 for passing go. Those who don't, and instead practice sound clinical cognitive based medicine, shoulder all the risk and none of the financial benefit.

And because of that, we get exactly what we pay for. Expensive, irrational health care that no one can afford.