The Call

Still trying to stay one step ahead of the snapping alligators, so here’s another older post, hopefully worth your time — Dr. Bob


Damn!, I hate these calls…

Lying on my desk, clipped to a yellow manila binder, is a single sheet of paper. Its pleasant color format and sampled photomicrograph belie the gravity of its content:

Adenocarcinoma, Gleason grade 9, involving 60% of the specimen.

How do you deliver a death sentence?

Your first impression of Charlie is his sheer mass: 50 years young, healthy as a horse, built like a tank, a former football player turned popular coach at a local high school. He arrived at my office after seeing his family physician for an acute illness, with fever, chills, and problems urinating. His doctor had diagnosed a urinary tract infection, placed him on an antibiotic, and drew a PSA–a screening test for prostate cancer. It was markedly elevated: over 100, with normal being less than 4. I grumbled to myself as I reviewed his chart: Those damned primary care docs shouldn’t draw PSAs when patients have prostate infections — it just muddies the waters.

PSA (prostate specific antigen) is a test which measures a protein in the blood stream released by prostate tissue. It has greatly improved early detection of prostate cancer in the 20 years it has been in widespread use — but it is not, strictly speaking, a cancer test. It is noisy — often abnormal in other conditions, including benign prostate enlargement (BPH), inflammation, and prostate infection. It is virtually always elevated in the presence of an acute prostate infection — often markedly so — and can take months to return to normal. The high PSA alarms the patient, however, who is told he may have cancer. But most do not — and Charlie looked like a classic case of infection.

His history was typical, and his response to antibiotics appropriate, so this seemed at first glance like so many other similar cases I had seen. His prostate exam was alarming, however: rock-hard and irregular, unlike the typical soft, boggy texture of an infected gland. Experience and training kicked in, and I knew exactly what we were dealing with: a relatively uncommon form of prostate infection called granulomatous prostatitis. I had seen dozens of cases — always alarming on first exam, with very high PSA values — and always responding to long-term antibiotics. Charlie was started on a one-month course of high-powered, high-priced bug exterminator, and came back for follow-up after its completion.

He was feeling better, and his PSA had dropped markedly, to 45. His prostate exam also seemed improved, but still quite abnormal. I remained quite confident in my diagnosis — after all, cancer doesn’t get better on antibiotics — but was unwilling to wait much longer to know for sure. I scheduled a prostate biopsy, reassuring him after its completion of my optimism that the results would show only infection.

The report was a blow to the gut. I sat silently, staring at it, in stunned disbelief.

In the age of PSA screening, most prostate cancers are detected at an early, curable stage — although their slow-growing nature makes treatment less important in very elderly patients. The chances for cure at diagnosis are determined by an estimate of the size and aggressiveness of the tumor. Size is determined by exam, ultrasound findings, and total PSA values; aggressiveness by the Gleason score — a value indicator (between 2 and 10) of the aggressive appearance of the cancer cells under the microscope. Higher is not better: Gleason scores of 9 and 10 indicate rapidly growing cancers which tend to spread early and are difficult — if not impossible — to cure. Charlie had drawn a pair of deuces in a high-stakes poker game: large volume, high-Gleason score cancer. The statistics were dismal: he would likely be dead of cancer in 5 years, regardless of treatment. And as cancer deaths go, this one’s not pretty: pain is a huge management problem in many, as the cancer infests and erodes the spine and long bones, breaking even the strongest of men. One learns to hate this disease before very many such cases have been seen.

And now I had to call him with his biopsy results.

The actual call will be brief: I will inform him that, unfortunately, the biopsy has shown cancer, that additional tests will be needed to determine its extent and the best way to manage it, and arrange for a follow-up visit in the office. The real bad news will be transmitted then, face-to-face, with more than enough information for its gravity to sink in. To do this — without robbing hope — will require more inner strength than is readily at hand.

But for now, I simply need to tell him he has cancer.

The word cancer encapsulates the deepest fears and anxieties of man, embodying in one small word pain, suffering, loss of control, hopelessness, dependency, death, the fragility of our dreams and hopes, and our uncertainty about the hereafter. To inform a patient that he has cancer is to shatter the illusion, the daily denial that death may yet be outmaneuvered, forestalled, kept on hold for some future date of our own determining. It is an illusion which dies hard — surprisingly so, as we alone among all creation are cognizant of its inevitability and certainty.

Perhaps the cruelest wish a man might be granted — were there some bottled genie passing out such favors — is knowledge of his own future. Yet, in some small measure, that power has been granted to me, and others of my profession. Not in any specific manner, of course — not of days or years, details or circumstances — but in knowledge deep enough to see the broad strokes: shadowy figures through rippled glass, of pain, and loss, and shattered dreams, of desperate grasping at the frail straws of fading hope, as the drumbeat of mortality pounds ever louder toward its dark crescendo.

Patients receive the call in different ways. Most accept it with seeming stoicism, and little expressed emotion — yet it is not hard to imagine — and sometimes to sense — the tight grasp of fear that grabs the throat and grips the heart. When wives are listening, the fear is more immediate, more palpable, as voices tremble with panic despite every effort to control it. A million questions will arise — but almost never on the initial call. On rare occasion, there is a casual indifference to the news — prompting reflection on what strength of spirit — or dense denial — such men possess.

I often wonder how I would receive the call. As a Christian, I am confident of a life hereafter, eternal, spent in the presence of Him who loves me. Some call that arrogance, or self-righteous; it is not. God alone knows better than I the darkness of my heart, the depravity that makes me uniquely unsuited to be in the presence of the Holy One but for one moment, much less eternity. But I have been adopted — an unworthy child by an unspeakably loving and merciful Father, who only asks submission to His tender guidance and direction, and transforms a lost fool into something useful, something cherished, someone with purposes aligned — though poorly so — with His own.

But the call of death — so confidently faced from the comfortable vantage of good health and cheap grace — will strike fear into my heart when it arrives, for far smaller challenges have brought dread in larger measure. There will be the fear of the ordeal, the journey of suffering, the loss of things now treasured but instantly made worthless. There will be the pain of watching the loss of those close to me, struggling to make sense of a relationship, undervalued while unthreatened, yet now more precious while counting down inexorably to its end. I know – -by the tutor of past and bitter experience — that faith will sustain me and mine through it all. But one cannot know what that day will be like — nor should we wish to ever know.

But for Charlie, the battle will now be enjoined — the weapons and wherewithal of modern medicine in all-out war against its implacable foe. Perhaps by some miracle or unexpected grace he will be given a reprieve, a window to revalue and reassess life’s course, its priorities, its purpose. For even when we are cured, we are healed to face death again: Lazarus, once risen, will revisit the stony crypt. Yet the Voice which called him forth calls us also, beckoning toward a painful light from the cold terrors of death.

How difficult to be the herald of another’s mortality — it is a burden no man should have to bear. Some will deliver it through the steely detachment hammered hard by years of training; some avoid it altogether where possible, through choice of profession or abdication of responsibility. But for those who must speak this hard truth, may there be grace and wisdom, empathy and compassion.

May it be also for me.

A Life Not Long

Another older post, as my friends at the IRS seem to be demanding an extra dose of torture this year.


A link from Glenn Reynolds hooked into something I’ve been ruminating on in recent days: the endless pursuit of longer life.

Here’s the question I’ve been pondering: is it an absolute good to be continually striving for a longer life span? Such a question may seem a bit odd coming from a physician, whose mission it is to restore and maintain health and prolong life. But the article which Glenn linked to, describing the striking changes in health and longevity of our present age, seemingly presents this achievement as an absolute good, and thereby left me a tad uneasy — perhaps because I find myself increasingly ambivalent about this unceasing pursuit of longer life.

Of course, long life and good health have always been considered blessings, as indeed they are. But long life in particular seems to have become a goal unto itself — and from where I stand is most decidedly a mixed blessing.

Many of the most difficult health problems with which we battle, which drain our resources struggling to overcome, are largely a function of our longer life spans. Pick a problem: cancer, heart disease, dementia, crippling arthritis, stroke — all of these increase significantly with age, and can result in profound physical and mental disability. In many cases, we are living longer, but doing so restricted by physical or mental limitations which make such a longer life burdensome both to ourselves and to others. Is it a positive good to live to age 90, spending the last 10 or more years with dementia, not knowing who you are nor recognizing your own friends or family? Is it a positive good to be kept alive by aggressive medical therapy for heart failure or emphysema, yet barely able to function physically? Is it worthwhile undergoing highly toxic chemotherapy or disfiguring surgery to cure cancer, thereby sparing a life then severely impaired by the treatment which saved that life?

These questions, in some way, cut to the very heart of what it means to be human. Is our humanity enriched simply by living longer? Does longer life automatically imply more happiness–or are we simply adding years of pain, disability, unhappiness, burden? The breathlessness with which authors often speak of greater longevity, or the cure or solution to these intractable health problems, seems to imply a naive optimism, both from the standpoint of likely outcomes, and from the assumption that a vastly longer life will be a vastly better life. Ignored in such rosy projections are key elements of the human condition — those of moral fiber and spiritual health, those of character and spirit. For we who live longer in such an idyllic world may not live better: we may indeed live far worse. Should we somehow master these illnesses which cripple us in our old age, and thereby live beyond our years, will we then encounter new, even more frightening illnesses and disabilities? And what of the spirit? Will a man who lives longer thereby have a longer opportunity to do good, or rather to do evil? Will longevity increase our wisdom, or augment our depravity? Will we, like Dorian Gray, awake to find our ageless beauty but a shell for our monstrous souls?

Such ruminations bring to mind a friend, a good man who died young. Matt was a physician, a tall, lanky lad with sharp bony features and deep, intense eyes. He was possessed of a brilliant mind, a superb physician, but left his mark on life not solely through medicine nor merely by intellect. A convert to Christianity as a young adult, Matt embraced his new faith with a passion and province rarely seen. His medical practice became a mission field. His flame burned so brightly it was uncomfortable to draw near: he was as likely to diagnose your festering spiritual condition as your daunting medical illness — and had no compunction about drilling to the core of what he perceived to be the root of the problem. Such men make you uneasy, for they sweep away the veneer of polite correction and diplomatic encouragement which we physicians are trained to deliver. Like some gifted surgeon of the soul, he cast sharp shadows rather than soft blurs, brandishing his brilliant insight on your now-naked condition. The polished conventions of medicine were never his strength — a characteristic which endeared him not at all to many in his profession. But his patients — those who could endure his honesty and strength of character — were passionate in their devotion to him, personally and professionally. For he was a man of extraordinary compassion and generosity, seeing countless patients at no charge, giving generously of his time and finances far beyond the modest means earned from his always-struggling practice.

The call I received from another friend, a general surgeon, requesting an assist at his surgery, was an unsettling one: Matt had developed a growth in his left adrenal gland. His surgery went deftly, with much confidence that the lesion had been fully excised. The pathology proved otherwise: Matt had an extremely rare, highly aggressive form of adrenal cancer. Fewer than 100 cases had been reported worldwide, and there was no known successful treatment. Nevertheless, as much for his wife and two boys as for himself, he underwent highly toxic chemotherapy, which sapped his strength and left him enfeebled. In spite of this, the tumor grew rapidly, causing extreme pain and rapid deterioration, bulging like some loathsome demon seeking to burst forth from his frail body. I saw him regularly, although in retrospect not nearly often enough, and never heard him complain; his waning energies were spent with his family, and he never lost the intense flame of faith. Indeed, as his weakened body increasingly became no more than life support for his cancer, wasting him physically and leaving him pale and sallow, there grew in him a spirit so remarkable that one was drawn to him despite the natural repulsion of watching death’s demonic march.

Matt died at age 38, alert and joyful to the end. His funeral was a most remarkable event: at an age in life where most would be happy to have sufficient friends to bear one’s casket, his funeral service at a large church was filled to overflowing — thousands of friends, patients, and professional peers paying their respects in a ceremony far more celebration than mourning. There was an open time for testimony — and such a time it was, as one after another took to the lectern to speak through tears of how Matt had touched their lives; of services rendered, small and large, unknown before that day; of funny anecdotes and sad remembrances which left not one soul of that large crowd untouched or unmoved.

A journey such as his casts critical light on our mindless pursuit of life lived only to live long. In Matt’s short life he brought more good into the world, touched more people, changed more lives, than I could ever hope to do were I to live a century more. It boils down to purpose: mere years are no substitute for a life lived with passion, striving for some goal greater than self, with transcendent purpose multiplying and compounding each waking moment. This is a life well-lived, whether long or short, whether weakened or well.

Like all, I trust, I hope to live life long, and seek a journey lived in good health and sound mind. But even more — far more indeed — do I desire that those days yet remaining — be they long or short — be rich in purpose, wise in time spent, and graced by love.

Lancet Speared

Remember the Lancet study? You know, the one which came out days before the 2006 election, reporting that the Iraq war had caused about 655,000 excess civilian deaths — a number about 20 times larger than most other estimates? It was widely reported in the mainstream media, echoed by politicians and pundits who were quick to use it to further damage the Bush administration politically and heighten opposition to an already unpopular war. It was also widely cited in Europe and the Middle East as evidence of American brutality and callousness in the execution of the war. Because it was published in a prestigious medical journal, those who were skeptical of its findings were left arguing about arcane epidemiological and statistical flaws which virtually guaranteed that no one would listen. The idea that a medical journal would publish a document almost purely political in nature was, of course, pooh-poohed by all the right people.

The National Journal has been quietly investigating this study, looking not only at its methodology, but its authors, participants, and the financial backing for its research, and has published its findings in a detailed review. It is must-reading for anyone who wishes to see how deeply the “scientific” literature can be co-opted and corrupted by politics and bias.

Just a few of the NJ’s findings:

The authors of the Lancet study followed a model that ensured that even minor components of the data, when extrapolated over the whole population, would yield huge differences in the death toll.

The Iraqi scientist recruited to oversee the researchers conducting field surveys in Iraq, Riyadh Lafta, had been a child-health official in Saddam Hussein’s ministry of Health when the ministry was trying to end the international sanctions against Iraq by asserting that many Iraqis were dying from hunger, disease, or cancer caused by spent U.S. depleted-uranium shells remaining from the 1991 Persian Gulf War.

Lafta was quoted as saying, “God has picked these clusters [sample groups]. If God wants me, he will take me.” Roberts, one of the study principals, who recruited Lafta, also quoted him as saying, “I know no one [who] perceives themselves so humbly to be a tool of God’s destiny…. He sees his science as synonymous with service to God.”

The study’s authors have repeatedly refused to provide the surveyors’ reports and original data which supported their findings.

Virtually everyone connected with the study has been an outspoken opponent of U.S. actions in Iraq.

A substantial portion (about half) of the funding for the study came from the Open Society Institute created by George Soros.

The Lancet editor who agreed to rush the study into print before the 2006 election, with an expedited peer-review process and without seeing the surveyors’ original data, also makes no secret of his leftist politics. At a September 2006 rally in Manchester, England, he declared, “This axis of Anglo-American imperialism extends its influence through war and conflict, gathering power and wealth as it goes, so millions of people are left to die in poverty and disease.”

This, and much, much more can be found in the National Journal’s article. Take the time to read it, and think about it the next time some “unbiased” medical or scientific article is cited for political purposes.

This is, by the way, the Lancet‘s equivalent of TNR‘s Beauchamps meltdown. And don’t expect to hear about this on CNN later this week. (HT: Brutally Honest)

The WSJ has picked up on this as well: The Lancet’s Political Hit.

CAT Scams

The Wall Street Journal reports on a recent New England Journal of Medicine study which concludes that doctors are over-utilizing CT scans, exposing their patients to excessive, and potentially harmful, radiation doses:

Doctors are ordering too many unnecessary diagnostic CT scans, exposing their patients to potentially dangerous levels of radiation that could increase their risk of cancer, according to Columbia University researchers.

The researchers, writing in this week’s New England Journal of Medicine, conclude that in the coming decades up to 2% of all cancers in the United States may be caused by radiation from computed tomography scans performed now. Children face the most danger, they said.

In ordering CT scans, doctors are underestimating the radiation danger … In many cases, the researchers say, older technologies like X-rays and ultrasound that expose patients to lower radiation doses or no radiation at all would work just as well.

Since CT scans were introduced in the 1970s, their use has grown to an estimated 62 million annually. An estimated four million to five million scans are ordered for children, Mr. Brenner said. Adults receive scans for diseases of the stomach, colon, breast and other areas. Children most often are scanned for appendicitis. It has become a favored technology because it provides detailed information about patients’ bodies, is noninvasive and typically is covered by health insurance.

While the scans save lives, the authors say, doctors are leaning on them over safer diagnostic tools because they underestimate the levels of radiation people receive from the scans.

The authors measured typical levels of radiation that CT scans emit. They found levels they say were comparable to that received by some people miles from the epicenters of the 1945 atomic blasts over Hiroshima and Nagasaki, Japan.

There can be little doubt that CAT scans, as well as other expensive medical imaging studies, are overutilized in medicine today. There is also no doubt that the overutilization of CAT scans in particular, with their ionizing radiation, does expose patients to significantly more radiation. It may be worthwhile to pause and think about why so many CAT scans are being performed.

Hint: It’s not because doctors don’t know that CAT scans deliver more radiation.
Continue reading “CAT Scams”

Health Wonk Review

Welcome to the September 6, 2007 edition of health wonk review.

I discovered, to my considerable surprise, that I had been tagged to host Health Wonk Review. To be honest, I have no idea how that happened (I’ve never submitted a post to the review, and didn’t volunteer). The submissions rolling into my inbox over the past few weeks were therefore confusing, and it was only a day or two ago that I had the dawning realization that I was on the hook. But being a can-do kinda guy, I rose to the challenge, so here it is.

Thankfully, the Blog Carnival folks made life easier by assembling all the submissions in one place, making the job immensely easier.

So the long and short of is: this will be neither clever, nor fancy, nor terribly erudite — but there’s some great stuff in the submissions, so check them out:

Shaheen Lakhan presents Medicare Begins its “Never Pay” Category posted at GNIF Brain Blogger.

Karen Halls presents How Do I Avoid Drinking Too Much Alcohol? posted at Addiction Recovery Blog, saying, “If you are trying to prevent yourself from drinking too much alcohol at social gatherings, here are a few ways that you can keep your alcohol intake under control.”

Henry Stern, LUTCF, CBC presents No Docs in This Box posted at InsureBlog, saying, “Retail medical clinics are popping up all over. They’re an inexpensive alternative to a full-blown practice or the ER, but “traditional” providers are crying foul. InsureBlog’s Bob Vineyard explores the hypocrisy.”

Warren Wong presents How To Overcome Fear And The Obstacles It Creates posted at Personal Development for INTJs, saying, “Are there things you are afraid of? Here’s how to overcome your fears, permanently, and overcome all the obstacles that fear creates.”

Alvaro Fernandez presents Brain Fitness Program 2.0, MindFit, and much more on Brain Training posted at SharpBrains, saying, “Review and commentary on several New York Times articles related to “brain training””

Shahid N. Shah presents Make sure your online SaaS vendors are appliance-capable posted at The Healthcare IT Guy, saying, “Shahid over at The Healthcare Guy provides some sage advice on how you should not count on “software in the cloud” for your mission critical healthcare IT needs without a backup plan. With big outages from Microsoft, Skype, eBay, and PayPal recently making headlines it’s a great time to make sure you’re protected.”

Jason Shafrin presents What are the Major Clinical Pathways to Disability posted at Healthcare Economist, saying, “This post reviews an NBER working paper discussing findings regarding how the elderly move from healthy to disabled states. Hopefully, this data can be used to aid health service providers on how to better prevent and treat disabilities which occur in old age.”

Richard Eskow presents Medical Justice League of America posted at The Sentinel Effect, saying, “Richard Eskow examines “Medical Justice.” a new service group that provides “gag order” forms to dissuade patients from reviewing their docs online, and also promises to “relentlessly” fight med mal lawsuits.”

Michael D. Horowitz presents What are the real savings in medical tourism? posted at MedTripInfo, saying, “An analysis of the costs of hip replacement in Costa Rica demonstrate that Americans can save 80% or more by going there.”

Dean presents Top Ten Fast Food Meals That Make You Fat posted at Mr. Cheap Stuff, saying, “Avoid these fast food meals.”

Daniel Goldberg presents On Epstein v. Relman (& Public Health Policy) posted at Medical Humanities.

David E. Williams presents Abusing the orphan drug law to rip off customers posted at Health Business Blog. Questcor Pharmaceuticals has announced “a new strategy and business model for H.P. Acthar Gel(R).” Translation: the company has obtained orphan drug status for a product that has been used for decades –including for the orphan indication of Infantile Spasms– and is raising the price 20-fold, from about $1000 per vial to $20,000 per vial.

Anthony Wright finishes up with a submission which snuck in this morning:

Small Business of California, Unite!

A spotlight on a poll of small business owners, showing that they are not reflexively opposed to health reforms, as they are sometimes portrayed. The scientific poll casts some doubt on “membership surveys” of some national organizations.

And a last minute shameless plug: for those interested in an in-depth look at the insanity which poses as our health-care system, check out The Maze — a multi-part series of posts on our billing and coding system, federal and third party carriers, and thoughts on fixing this mess.

That concludes this edition. I may have missed a few submissions, due to the last-minute scramble — my apologies for any such oversights.

Submit your blog article to the next edition of health wonk reviewusing our carnival submission form.

Past posts and future hosts can be found on our blog carnival index page.

Technorati tags:

health wonk review, blog carnival.

Swindler’s List

“I have here in my hand a list of two hundred and five (people) that were known to the Secretary of State as being members of the Communist Party and who nevertheless are still working and shaping the policy of the State Department”

Senator Joseph McCarthy, in his famous accusations about Communist influences in the U.S. government, had a list. A secret list. And he wasn’t revealing his sources.

Fortunately, we’ve come a long way since those dark days. No longer do senators keep secret lists with which to malign the reputation of those who displease them.

The only ones with such lists today are the health insurance companies.

The Wall Street Journal reports the following:

New York Attorney General Andrew Cuomo demanded last week a “full justification” of the rankings that Aetna Inc. and Cigna Corp. have rolled out in the state. He warned the companies that the ratings are confusing and potentially deceptive, in part because insurers don’t disclose how prone to error their rankings are. The move follows rankings lawsuits by doctors accusing insurers of libel, unfair business practices and breach of contract in other states.

Health plans say the designation of preferred doctors is meant to aid patients by calling attention to the best physicians. To that end, UnitedHealth Group Inc., for example, is rolling out a system called United Premium Program. Aetna gives select doctors an “Aexcel” label in its plans. And Cigna launched its Cigna Care Network in at least parts of 26 states and Washington, D.C., early this year.

Sounds pretty benign, doesn’t it? Your health plan publishes a list of “best doctors” based on their interest in keeping you healthy, and promoting their new emphasis on quality. It’s all in the best interest of their customers, after all. Whatever could be the problem with that?

As you might guess, there’s more here than meets the eye:

…critics accuse insurers of concentrating more on cost than quality when handing out the preferred labels. Data from health claims are commonly used to produce the ratings. But the information, while standardized and widely collected, is prone to error, Mr. Cuomo and physicians say. Medical conditions can overlap and doctors’ offices vary in how they assign billing codes to care … Mr. Cuomo warned that rankings based on claims data can be badly flawed, and said insurers have conflicts of interest because of financial incentives to contain costs.

Of course the insurance industry has taken great pains to ensure that their quality rankings are fair and balanced:

An Aetna spokeswoman said the company consults with physicians in developing the ratings. Aetna considers its rating system transparent and posts the criteria and other details about it on the company’s Web site.

UnitedHealth also calls its system transparent, and said it had sent Mr. Cuomo a 25-page response but declined to make it available.

A Cigna spokesman said the company measures doctor performance by “what we believe is the best data available.” However, the measures “represent only a partial assessment of a provider’s quality and cost efficiency” and shouldn’t be the only reason patients pick a doctor, he added.

The emphasis above is mine, BTW — more on that in a minute.

Now, color me skeptical about such claims from insurance companies; having dealt with them first-hand for nearly 30 years does leave one with a certain hardened cynicism about their motives. But being a fair-minded type of fellow, I decided to check out some of their transparency claims. So I moseyed on over to Aetna’s web site, used my considerable influence as a physician to register, and started snooping around.
Continue reading “Swindler’s List”


Michael Cannon over at Cato takes issue with my conclusions regarding pay-for-performance — the federal and third-party steamroller which is the health care bureaucracy’s latest ill-considered idea for reigning in health care costs. In pay-for performance, guidelines for quality (read: less expensive) care are established, and those physicians who color between the lines get paid more (or, more likely, don’t get paid less).

Dr. Bob argues:

1. “High quality — while not invariably more expensive — is often so.”
2. “[B]y and large,” the guidelines that physicians are supposed to follow “don \'t exist — except in a few relatively straightforward areas of medicine.”

I agree with those statements, but I disagree with their conclusions.

Though the first statement is true, it is also true that a lot of the expensive stuff that doctors deliver is not high quality. For 30 years, researchers at Dartmouth Medical School have found it very easy to demonstrate that some doctors do a lot more expensive stuff than other doctors do (e.g., specialist consultations, hospital stays, etc.). But they have found it very, very hard to find any evidence that that extra stuff makes patients any healthier or happier. Thus, a lot of the expensive stuff that doctors do isn \'t high-quality care.

Though the second statement is true, it is also true that where evidence-based guidelines do exist, patients still don \'t get the “high-quality” care that the guidelines recommend. According to Elizabeth McGlynn and her colleagues, patients receive such recommended care only about 55 percent of the time. (I put “high-quality” in quotes because not every patient should receive what the experts recommend. But it would be a stretch to say that 45 percent of patients are outliers.) Even when evidence-based guidelines exist, doctors don \'t follow them.

Quality suffers both because physicians don \'t do enough of what they should, and do too much of what they shouldn \'t.

Michael makes some good points here, but is looking at the forest while missing some very big trees.

There is little question that a substantial amount of medical care, much of which is very high-cost, is performed with little measurable benefit. I would emphasize here the word “measurable.” For example, a patient who comes in with blood in the stool will generally be advised to have a colonoscopy, which is an expensive procedure. In many cases, the colonoscopy will be normal, and therefore, in retrospect, be unnecessary. The patient, however, will receive the reassurance that he or she does not have cancer, and more appropriate treatment for the bleeding problem will result. This is an important outcome, but difficult to measure in purely economic terms.

Furthermore, in those cases where cancer is detected, this finding will lead to much more care, which is often quite expensive. This situation points out another flaw in our current enchantment with the cost savings of preventive medicine — particularly by those who believe it will somehow magically save us millions of dollars to spend on the uninsured. The economics of most screening programs make little sense, for the screening generates a large number of expensive follow-up tests, and in many cases the initial symptom or abnormality proves to be a false positive.

The second issue about ordering expensive studies speaks to another favorite solution of the cost-cutters: primary care. The knowledgebase of medicine has grown exponentially in the past 50 years, with increasing numbers of specialties being spawned to master it. The specialist, dedicated to a single subset of medical knowledge, must still spend substantial effort to remain current in his or her field of specialization. The primary care provider, however, must attempt to master, at least to some degree, a substantial amount of the knowledge in multiple specialties in order to make wise decisions about evaluation and treatment in his or her patients.

In my experience, it is the primary care physician who often orders expensive studies inappropriately. I have seen patients who have come to me, having had an MRI (costing well over $1000) to diagnose a scrotal hydrocele — a benign condition which is almost always harmless, and should be easily diagnosable by physical examination, or much less expensive ultrasound. The point here is not to denigrate the primary care physician, but simply to point out that it is becoming virtually impossible for the primary care provider to achieve mastery of the many complex subspecialties of medicine. Education can of course resolve some of these problems, but this is likely to grow worse as medicine becomes increasingly more complex. The primary care provider is under substantial pressure to keep patients away from expensive specialists– which can prove to be a false economy in many instances.

The last tree in the forest is a giant Sequoia, which is our current liability system. It is very difficult to estimate how many of the expensive, unnecessary studies are driven by our current malpractice system — but it is unquestionably huge. In a perfect world, we would weigh the risks and benefits of diagnostic studies, and order expensive studies or treatments only where the benefits substantially outweigh the risks. In the real world, every physician mentally plays out the scenario of failing to do an expensive but low-yield study, and having to answer for this decision — entirely rational at the time — under the cynical cross-examination of a plaintiffs attorney in a courtroom. Measuring this impact is extremely difficult, and its effect is minimized in the extreme by the trial attorneys, but it is in fact a huge financial black hole in our health care system. Unfortunately, tort reform alone will not solve this.

The institution of rigid pay for performance guidelines will also introduce new legal opportunities for second-guessing sound medical decision-making. There will certainly be instances — the percentage of which will depend on the quality of the guidelines — where physicians will need to make recommendations which fall outside of these guidelines, in order to provide high-quality care. Such decisions will provide rich fodder for Monday morning quarterbacking by attorneys. Furthermore, anyone who believes that such guidelines, studiously followed, will provide protection against malpractice, should stop smoking that funny tobacco and to seek treatment immediately.

I think third-party P4P, where insurers reward providers for high-quality care, is a fine idea – provided the patient gets to choose her insurer.

This last point which Michael makes regarding third-party payers instituting quality guidelines needs a reality check. The simple fact in every physician’s experience is that insurance companies have no interest whatsoever in quality care, except as a marketing tool. For third-party payers, quality = low-cost. Our local Blue Cross provider recently sent out letters to patients, indicating that a number of physicians in their panel had been dropped from one of their large plans because they did not meet “quality standards.” Turns out, the only standards applied were financial and not medical, and physicians had no knowledge of or access to the so-called standards. The carrier has as a result found themselves in court defending a class action suit for defamation of character. Expect to see much more of these sort of shenanigans as pay for performance becomes more common.

The best way to assure quality in healthcare is a high level of transparency in our medical system — something which is currently impossible due to the current liability environment — combined with placing the decision-making process regarding care back in the hands the patients, by making the patient the purchaser of healthcare rather than government or the insurance carriers.