Doctored (14 page)

—Vikenty Veresaev,
The Memoirs of a Physician,
1916

A middle-aged man collapses with a heart attack. Paramedics arrive, and they do all the right things: give him an aspirin to chew, place nitroglycerin under his tongue, and administer oxygen through a face mask. Then they take him to a local hospital that doesn't perform angioplasty to open blockages in the coronary arteries. Angioplasty is the best treatment for a heart attack if performed expeditiously by experienced doctors. Instead, the man receives a clot-dissolving drug—a thrombolytic—which in his case doesn't work.

By the time the man is transferred to our hospital for angioplasty, it is too late. He is already exhibiting signs of heart failure. At this point there is little reason for us to open his blocked coronary artery because the part of his heart that is fed by the artery is already dead.

The story of this patient is one we encountered almost every day my first year at LIJ: a heart attack victim taken by ambulance to a community hospital that isn't equipped to perform angioplasty. If the man had been brought to LIJ, which has cardiac catheterization available twenty-four hours a day, the damage to his heart could have been averted, adding years to his life. But it would have required a degree of coordination and oversight that many ambulance fleets in New York and across the country lack.

We discussed many such cases at hospital meetings on how to shorten door-to-balloon (D2B) time, the time between hospital arrival and balloon angioplasty for patients having heart attacks. In 1971, Eugene Braunwald, a cardiologist at Harvard Medical School, proposed a radical hypothesis: “Time is muscle.” He postulated that acute myocardial infarction is a dynamic process and that cardiac injury could be reduced by expeditious intervention. Many studies since then have demonstrated that shorter D2B time is strongly associated with survival. However, a large number of heart attack victims are still not being treated within the guideline-recommended D2B time of ninety minutes or less.

When I started as an attending, several published studies had sparked a vigorous debate over how acute heart attacks, the quintessential medical emergency, should be treated. With a million cases in the United States every year, acute heart attacks are a major public health problem, and how this debate is eventually settled is bound to have important public health implications.

When heart muscle is deprived of blood, it goes through what has been termed the ischemic cascade. Initially the muscle, stunned by a lack of oxygen, goes into a sort of hibernating state. Cells swell as sodium and calcium flow in through suddenly porous membranes, creating havoc with the cellular machinery. At this point the damage is usually reversible. But with prolonged oxygen deprivation for many minutes, cells start to die.

Studies comparing angioplasty and thrombolytic drugs have shown a clear advantage for angioplasty if it is performed by an experienced cardiologist in a high-volume catheterization lab within three hours of the onset of symptoms. Death rates after thirty days are lower by almost 50 percent. Also, angioplasty results in an open coronary artery 90 percent of the time, compared with 54 percent for thrombolytics. Moreover, angioplasty drastically reduces bleeding complications, especially in the brain.

But whether these advantages could be maintained in the real world, where delay in getting patients to catheterization labs is inevitable, had been an open question. Then a Danish study published about a year before I started at LIJ notched a major victory for angioplasty. In the study, about fifteen hundred patients who were admitted to community hospitals with acute heart attacks were randomly given immediate thrombolytic treatment or transferred by ambulance to angioplasty centers up to a hundred miles away. Even with the delays, angioplasty resulted in a 40 percent reduction in death, recurrent heart attack, or stroke after thirty days. The data were compelling enough that the study was stopped early by a data-monitoring committee.

In a related study published in
The Journal of the American Medical Association
, about five hundred patients at eleven community hospitals in Maryland and Massachusetts were randomly assigned to receive thrombolytic therapy or angioplasty. Angioplasty has traditionally been performed only at hospitals with cardiac surgeons on duty, in case there are complications, but these relatively small hospitals had none. In following up, the study found that even without surgical backup, angioplasty reduced the occurrence of heart attacks and strokes in the next six months by almost 40 percent and shortened hospital stays for the original visit by an average of a day and a half.

The net result of these studies was that LIJ was doing more outreach to try to get ambulances to bring patients with acute heart attacks directly to the hospital for angioplasty. At the same time, we were trying to reduce D2B time to less than an hour. But I quickly learned that coordinating ambulance fleets on Long Island is a gargantuan task, in part because a large number are privately owned. However, as my colleagues at hospital meetings pointed out, paramedics had already learned to take trauma and burn victims to specialized hospitals. Heart attack victims deserved no less, and many more lives were at stake.

*   *   *

My first year as an attending was packed with all sorts of such meetings. Once a month my cardiology colleagues would convene over chicken marsala and baked ziti and talk about the faculty practice plan. Rajiv would often bring up his “Queens strategy”: finding a way to tap into the borough's large ethnic population—Russian, Greek, South Asian—which suffers disproportionately from diabetes and heart disease. “Out here on Long Island, we practice more preventative care,” he'd say. “Patients are on the right meds. But in Queens it's a different story.” He'd gripe about the hospital's refusal to accept Healthfirst and other low-paying insurance plans commonly carried by Queens patients. He'd warn that cardiologists at Jamaica Hospital, a competing facility, were already poaching patients in their emergency room who were slated for transfer to LIJ. He'd decry the clinic that LIJ had proposed to build in Queens because it was within a block of a busy internist, who might feel threatened and start referring his patients elsewhere. “As much as we hate to admit it, patients are a commodity,” he once unashamedly declared when we were brainstorming about how to increase procedural volume (which would help determine his and his interventional colleagues' salaries).

For my part, I couldn't help wondering how the hospital was going to handle more patients. Where were we going to put them? The ER was already overflowing, and patients on the wards were sometimes stowed in the corridors.
Did we really need to keep putting stents into everyone?
But I kept my mouth shut. If I ever had any doubts that medicine is distinct from business, these gatherings absolved me of that notion.

The meetings multiplied, and soon I was attending hospital conferences on quality improvement and resource utilization. Published studies show wide variation in death rates between best and worst hospitals. For example, thirty-day mortality ranges from 11 to 25 percent for patients with myocardial infarction and from 7 to 20 percent for patients with congestive heart failure. The mantra at these meetings was “evidence-based medicine,” which meant looking for reliable metrics, not clinical judgment or experience, to quantify performance and identify best practices. There was a kind of staleness at these meetings, a saccharine, artificial quality that permeated everything from the agenda to the muffins. People would say stuff like “We need a holistic approach that addresses the issues of variability and interdependencies” and “Let's review our program across the entire spectrum of processes,” or they'd use phrases like “continuum of care” or “integrate and transform.” It was corporate gobbledygook, and it never made much sense.

I discovered a tension between my dual roles as a faculty physician and a hospital employee. As a faculty physician in the Division of Cardiology, I was trying to generate more revenue for my particular section. As a hospital employee, I was trying to keep down overall hospital costs. Nowhere was this conflict more evident than in my charge to reduce the length of stay of patients hospitalized with heart failure. Like all acute care facilities, LIJ received a set payment for each admission based on the patient's diagnosis. (Such a prospective payment system for hospitals had been in operation since the early 1980s.) The longer a patient stayed in the hospital, using up a greater amount of resources, the more money the hospital stood to lose. Of course, the longer a patient stayed, the greater the likelihood of hospital-acquired infections or harm from tests and procedures, which meant that timely discharge, in most cases, was good for the hospital and patients alike.

But individual doctors, paid separately by insurers for patient visits, had little motivation to discharge patients quickly. As long as their patients were in the hospital, they could bill and be paid for each visit they made. The incentives were misaligned. The hospital was paid a fixed payment. Physicians were paid à la carte. (The incentives might have gotten aligned if hospitals had been allowed to share savings with doctors, but the law at the time prohibited any practice that might influence doctors to provide less care.) Reviewing heart failure cases, both mine and other physicians', on rounds, I frequently encountered patients getting diagnostic workups or trivial medication adjustments that could have been performed on an outpatient basis. What was keeping these patients in the hospital?

The administration did not think it was because private doctors with admitting privileges were eager to bill more. “I am not jaded enough to think that doctors are going to keep patients in an unsafe environment for an extra seventy or eighty bucks a day,” Bill Remsen, a senior hospital executive, told me when we discussed it at a utilization meeting. “I really don't believe that is happening.” Instead, he attributed the problem to a fragmented delivery system. “Most hospitals don't have the number of physician's assistants and nurse practitioners we do,” he said. “It's a unique model: more handoffs, more confusion. Who's taking responsibility for the patient?”

However, some private doctors had a different take. One afternoon, while nursing a cup of coffee at the doctors' station on ward 7-South, I found myself discussing my administrative responsibilities with Samuel Oni, an affable Nigerian internist in private practice whose patients had some of the longest lengths of stay. When I brought up the issue of hospital stays for heart failure, he confirmed what I suspected. “I understand why hospitals want to cut down length of stay,” he told me matter-of-factly. “As the length of stay goes up, they keep less money. But if I discharge a patient early, I don't get paid at all. It's okay if you have enough patients in the hospital, but if you don't, you sometimes have to drag out the stay. I don't like to do it, but sometimes you have to.”

Overutilization was the gorilla in the room. Everyone could see it, but few seemed to acknowledge it was there. A fifty-year-old patient of Oni's was admitted to the hospital with shortness of breath. During his monthlong stay, which probably cost upward of $200,000, he was seen by a hematologist; an endocrinologist; a kidney specialist; a podiatrist; two cardiologists (me and another doctor, named Chaudhry, who joked, “I am just going to write, ‘Agree with Jauhar'”); a cardiac electrophysiologist; an infectious-diseases specialist; a pulmonologist; an ear, nose, and throat specialist; a urologist; a gastroenterologist; a neurologist; a nutritionist; a general surgeon; a thoracic surgeon; and a pain specialist. The man underwent twelve procedures, including cardiac catheterization, a pacemaker implant, and a bone marrow biopsy (to work up mild chronic anemia). Every day he was in the hospital, his insurance company probably got billed nearly a thousand dollars for doctor visits alone. Despite this wearying schedule, he maintained an upbeat manner, walking the corridors daily with assistance to chat with nurses and physician's assistants. When he was discharged (with only minimal improvement in his shortness of breath), follow-up visits were scheduled for him with seven specialists.

This case, in which expert consultations sprouted with little rhyme, reason, or coordination, reinforced a lesson I learned many times in my first year as an attending: In our health care system, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur.

There are many downsides to having too many doctors on a case. Specialists' recommendations are often at cross-purposes. The kidney doctor advises “careful hydration”; the cardiologist, discontinuation of intravenous fluid. Because specialists aren't paid to confer with one another or coordinate care—at least as of this writing; Obamacare is looking to put into place payment systems that will do just this—they often leave primary attendings without a clear direction as to what to do. More important, patients don't always require specialists. Patients often have “overlap syndromes” (we used to call it aging), which cannot be compartmentalized into individual problems and are probably best managed by a good general physician. When specialists are called in, they are apt to view each problem through the lens of their specific organ expertise. (Perhaps the hardest thing in medicine is to do nothing, especially when you're called for help.) Patients generally end up worse-off. I have seen it over and over again.

Oni was hardly the worst offender. He once called me about a patient who had a right lung “consolidation”—probably pneumonia, though a tumor could not be excluded—that a lung specialist had decided to biopsy. Oni wanted me to provide “cardiac clearance” for the procedure.

“Sure, I'll see him,” I said, sitting in my office, checking e-mails. “How old is he?”

“Ninety-two.”

I stopped what I was doing. “Ninety-two? And they want to do a biopsy?”