Doctored (15 page)

Oni started laughing. “What can I tell you? In my country we would leave him alone, but this is America, my friend.”

Though accurate data are lacking, the overuse of health care services in this country probably costs hundreds of billions of dollars each year, out of the more than $2.5 trillion that Americans spend on health. Are we getting our money's worth? Not according to the usual measures of public health. The United States ranks forty-fifth in life expectancy, behind Bosnia and Jordan; near last in infant mortality, compared with other developed countries; and in last place in health care quality, access, and efficiency among major industrialized countries, according to the Commonwealth Fund, a health care research group.

And in the United States, regions that spend the most on health care appear to have higher mortality rates than regions that spend the least, perhaps because of increased hospitalization rates that result in more life-threatening errors and infections. It has been estimated that if the entire country spent the same as the lowest-spending regions, the Medicare program alone could save about $40 billion a year. In some cities Medicare pays more than twice per person what it pays in others. For example, Medicare spends $8,414 per person per year in Miami but only $3,341 in Minneapolis. Even within states there are huge variances. People who live in St. Cloud, Minnesota, are half as likely to undergo cardiac bypass surgery as those in Detroit Lakes, and more than twice as likely to undergo back surgery as those in Rochester. If you have gallstones and live in Wadena, you are three times more likely to have gallbladder surgery than someone who lives in Minneapolis. Among the sixty largest communities in Minnesota, there is a fourfold variation in the frequency of coronary angioplasty and a more than threefold variation in carotid surgery. The greatest variation is in a type of prostate operation, for which rates vary an astonishing sevenfold, ranging from 1.6 per 1,000 Medicare beneficiaries in Rochester to 11.6 per 1,000 in Bemidji.

We don't know exactly why these variations exist, but we do know that in regions where there are more doctors, there is more per capita utilization of doctors' services and testing, including consultations, hospitalizations, and stays in intensive care. (I am reminded of a particle collider: the more energy present, the more mass that's created.)
The Dartmouth Atlas of Health Care,
a publication of the Dartmouth Institute for Health Policy and Clinical Practice, has shown that at my hospital—hardly an outlier—Medicare beneficiaries will see on average seventeen physicians and receive more than fifty physician visits during the last six months of their lives. John Wennberg, a researcher at Dartmouth, has dubbed this supply-sensitive care—the volume of care provided is influenced by the local supply of doctors and health services—and as is by now well-known, health care expenditures don't translate into better outcomes. In fact, health outcomes in the highest-spending regions of the country may be worse. “The hospital is a great place to be when you are sick,” Remsen, the senior hospital executive, told me. “But I don't want my mother in here five minutes longer than she needs to be.”

Overutilization in health care is driven by many forces: “defensive” medicine by doctors trying to avoid lawsuits (unnecessary tests add an estimated $150 billion each year to the health care budget); a reluctance on the part of doctors and patients to accept diagnostic uncertainty (thus leading to more tests); lack of consensus about which treatments are effective; and the pervading belief that newer, more expensive drugs and technology are better. The most important factor, however, may be the perverse financial incentives of our current fee-for-service system. Doctors are usually reimbursed for whatever they bill. As reimbursement rates have declined to control runaway health costs, most doctors have adapted—even if subconsciously—by increasing the quantity of services. If you cut the amount of air you take in per breath, the only way to maintain ventilation is to breathe faster.

Overtesting and overconsultation have become facts of the medical profession. The culture today is to grab patients and generate volume. Internists aren't gatekeepers (as managed care advocates once envisioned) as much as ushers, escorting favored specialists onto a case with “friendly” consults, or calls for help. The probability that a visit to a physician results in a referral to another physician has nearly doubled in the past ten years, from 5 percent to more than 9 percent. Referral rates to specialists in the United States are estimated to be at least twice as high as in Great Britain. The rates reflect several aspects of American medicine: increasing specialization, the lack of time for any doctor to give to complex cases, and fear of lawsuits over not consulting an expert. At the same time, referrals are also a way for cash-strapped doctors to generate business.

Bob and Joe and Dave have an unwritten agreement to call one another when patient issues arise outside their scope of expertise. If Bob, the nephrologist, sees a patient, he finds a cardiac and a gastrointestinal issue and consults the other two specialists, and vice versa. It's not kickbacks per se, which are illegal, but there is a mutual scratching of backs. Physician-to-physician referrals are doctors loudly declaring their independence from insurers and the federal government. Insurance companies can restrict medications, tests, and payments. But they still cannot tell us whom or when we can ask for help.

When I was in training, simple referrals from internists, like patients with only mild hypertension, bothered me as a waste of time. Now that I am in practice, I have learned to welcome them. I haven't changed my mind that these referrals are probably unnecessary, and there is plenty of evidence that wasteful expert consultation is adding to health costs and creating redundant care. But as a full-fledged doctor I appreciate the business. It is hard not to view a referral as an overture from another physician, and it is equally hard not to return the favor. However, referrals can put you into a moral bind. Should you refer patients back to certain doctors—not necessarily the best doctors; sometimes even assholes who aren't particularly good with their patients—just to sustain your business?

It is a paradox of specialized medicine. Specialists are better paid than primary care physicians, but they are also less autonomous because unlike primary care physicians, they depend on other doctors for referrals. So there is tremendous pressure on specialists to keep referral sources happy, especially in doctor-saturated areas like Long Island.

In the spring of my first year at LIJ, a cardiologist named Richard Adelman sent a seventy-four-year-old woman with a leaky heart valve to the hospital for valve surgery. Adelman no longer did rounds at LIJ, so his patient, Mildred Harris, was assigned to me. Ms. Harris had few teeth and hollow cheeks and kind of gummed her words when she spoke. Besides having emphysema and diabetes, she was frail and virtually bedbound, making postoperative rehabilitation difficult. After talking to her, I decided that surgery would be too risky, so I canceled the operation, increased the dosages of her medications, and, after several days, told her I was going to send her home.

The evening before she was to be discharged, I received a call at home from a colleague asking me if I knew that my patient was scheduled to go to the operating room the following morning. Stunned, I immediately phoned the surgeon, who explained that he was being pushed to operate by Dr. Adelman, who was “pissed we got heart failure involved … It's a very political situation,” he said apologetically. “Adelman is a big referrer.”

After getting off the phone, I called Rajiv to ask him what to do. “Tell him it's unacceptable,” my brother cried. “She's your patient!”

So I phoned the surgeon back. “I am the only cardiologist leaving notes,” I told him politely. “I've been recommending no surgery for days.”

The surgeon said he was sorry and explained that Dr. Adelman had called him directly. “My whole career I have always acted with the feeling that it's not worth it to go to town over one case,” he said. “Adelman sends me a lot of business. I don't want to lose it—or your business either.” He wondered if we should get a third opinion. He mentioned asking a private cardiologist he knew to rubber-stamp the decision to send Ms. Harris to surgery.

While the surgeon and I were conferring, Rajiv called me back. Inexplicably, he had changed his mind. “Just let it go,” he now said. “Tell him you're a junior guy and you'll defer to whatever he says.”

“Are you joking?” I said, perplexed by his change of heart.

“Look, you can't always insist on having your way,” Rajiv snapped. “Sometimes you have to let people make their own mistakes.”

A group of us had an urgent meeting in Rajiv's office the following morning before the operation. “Just let them do it,” a colleague told me. “Medically, it may or may not be the right thing, but politically—well, if she goes back to Adelman with shortness of breath, he's going to say, ‘What the fuck, we sent her over there for an operation, and those guys didn't do anything.'”

Rajiv agreed. “You did what you thought was right,” he said. He reminded me that there were differences of opinion over whether mitral valve surgery was warranted in elderly patients like Mildred Harris. How could I be so sure that my judgment was correct? I told him that at the very least there should be another opinion in the chart. How could I agree to send my patient for surgery now when I had dismissed the idea in all my previous notes?

“No one is going to blame you,” Rajiv said coolly. “If they take the patient to surgery without your permission, the burden is on them.” He smiled slyly. “If anything, you may be subpoenaed to testify, but that's all.”

When I went upstairs to talk to my patient, transporters were already there with a stretcher to take her to the OR. I asked Ms. Harris how she was feeling. “I couldn't sleep all night,” she said, as the orderlies transferred her to the narrow transport gurney. “I thought you told me I could go home.” I told her the decision had been changed.

Fortunately, the surgery went well, and she was discharged from the hospital after a few days. I phoned Santo Russo at Columbia to tell him about what had transpired. “This sort of thing happens all the time,” he told me. “Just last week I said no to mitral valve surgery on a ninety-three-year-old. When the surgeon asked me about it, I said it was just my opinion. If they don't listen, I sign off the case. I do it in a nice way, a politically correct way. I try not to ruffle too many feathers.”

“But she was high risk,” I said, hoping for some reassurance. “Her symptoms were controlled with medications. Plus, she didn't want the surgery.” I remembered James Irey, the patient Santo and I had forced into repeating a catheterization—with a fatal result.

“I agree with you,” Santo replied. “I would have done exactly the same thing.” He acknowledged the frustrations of working in a hospital where referring physicians were pushing your hand. “If you mess up relations with a referrer, you can get fired,” he warned.

I told him that I had good relations with most physicians, except for maybe one or two.

“Well, if everyone likes you, then you're probably not doing a good job,” he said.

*   *   *

In my first year as an attending I also sat in on meetings on how to improve the hospital's compliance with certain quality indicators. These “core measures” sprung from a general quality-improvement program called pay for performance (P4P). Employers and insurers, including Medicare, had started about a hundred such initiatives across the country. The general intent was to reward doctors for providing better care. For example, doctors received bonuses if they prescribed ACE inhibitor drugs, which reduce blood pressure, to patients with congestive heart failure. (Only about two-thirds of heart failure patients nationwide were receiving life-prolonging ACE inhibitors, a deadly oversight by busy physicians.) Hospitals got bonuses if they administered antibiotics to pneumonia patients in a timely manner. On the surface, this seemed like a good idea: reward doctors and hospitals for quality, not just quantity. It seemed like the perfect solution to the fee-for-service problem. But pay for performance, I quickly learned, could have untoward consequences.

A colleague once asked me for help in treating a patient with congestive heart failure who had just been transferred from another hospital. The patient was a charming black man in his early sixties who applied mild exasperation to virtually every remark. (“I didn't like the food, Doc. But I ate it anyways!”) When I looked over his medical chart, I noticed that he was receiving an intravenous antibiotic every day. No one seemed to know why. Apparently it had been started in the emergency room at the other hospital because doctors there thought he might have pneumonia.

But he did not appear to have pneumonia or any other infection. He had no fever. His white blood cell count was normal, and he wasn't coughing up sputum. His chest X-ray did show a vague marking that could be interpreted as a pneumonic infiltrate, but given the clinical picture, that was probably just fluid in the lungs from heart failure.

I ordered the antibiotic stopped—but not in time to prevent the patient from developing a severe diarrheal infection called C. difficile colitis, often caused by antibiotics. He became dehydrated. His temperature spiked to alarming levels. His white blood cell count almost tripled. In the end, with different antibiotics, the infection was brought under control, but not before the patient had spent almost two weeks in the hospital.

The complication stemmed from the requirement from Medicare that antibiotics be administered to a pneumonia patient within six hours of arriving at the hospital. The trouble is that doctors often cannot diagnose pneumonia that quickly. You have to talk to and examine a patient, wait for blood tests and chest X-rays, and then often observe the patient over time to determine the true mechanism of disease. Under P4P, there is pressure to treat even when the diagnosis isn't firm, as was the case with this gentleman. So more and more antibiotics are being used in emergency rooms today, despite all-too-evident dangers like antibiotic-resistant bacteria and antibiotic-associated infections.