EXPENSIVE, INVASIVE HEART PROCEDURES: SHOULD YOU HAVE ONE?

 

You could look upon coronary disease and the treatment dilemmas it poses as a game--or actually a game within a game.  The main game is the contest between the patient and the disease.  The other is a game played by the doctors.  Their game is a complicated mix of science, personal opinions and odds-playing complicated by political and individual incentives that are difficult for anyone but them to decipher. 

 

Patients don’t participate much in that part of the game.  Most don’t even know it goes on.  The object of the game is to optimize the patient’s chances of winning.  While the rules require that everyone be on the patient’s side, there’s no penalty for the participants’ scoring points for themselves.  And that’s where the element of physicians’ incentives comes into play.

 

You consult Cardiologist X about your coronary disease.  Unbeknownst to you, the hospital where he performs angioplasties requires him to do 50 per year to maintain his privileges.  It’s the middle of November, and he has only done 40.  He loves the challenge of doing these procedures.  If all goes well, he will spend about an hour and a half of his time on your angioplasty.  His fee will be $2000. 

He says the best treatment for you would be--you guessed it--an angioplasty.

 

You consult Cardiologist Y who doesn’t do angioplasties.  He makes a living seeing patients in his office, giving advice and prescribing medications.  He would receive no financial remuneration if you decided to have an angioplasty.  He says you don’t need one.  He thinks that treatment with medications and lifestyle changes would be better.

 

 Deciding Which Strategy is Best

 

Let’s give physician’s a break.  Let’s assume they are, as the Boy Scout’s oath goes, “morally straight”, that they are ethical and genuinely interested in helping you.  Indeed, whatever personal aspirations doctors have, their contract with society obligates them to put the welfare of their patients first.  Self-serving conduct is strongly discouraged in the medical profession.   Disingenuous behavior for the sake of personal gain is grounds for loss of the right to practice medicine. 

 

Nevertheless, assuming your doctor is honest and genuinely concerned for your wellbeing, it’s possible for his decision-making processes to be influenced by the incentive system in which he works.  Remember Pavlov’s dogs. 

 

A century ago, the Russian psychologist Ivan Pavlov studied how the digestive secretions of dogs responded to various stimuli.  He found that naturally enough the sight and smell of food stimulated the flow of these juices.  Then he arranged for a bell to ring whenever a meal was presented.  Eventually the digestive juices squirted at the sound of the bell, food or not.  Pairing a previously neutral stimulus, the bell, with something that provoked a pleasurable response, the food, changed the dog’s “gut response” to the bell, a phenomenon that came to be known as Pavlovian or operant conditioning.

 

Operant conditioning is a way a person’s basic responses change according to reward or punishment.  If a particular choice is repetitively followed by a gratifying outcome, a bias toward that option will develop.  Positive reinforcement refers to an outcome that encourages a behavior.  Negative reinforcement, to one that discourages it. 

 

The fact that people alter their behavior according to reward and punishment is certainly nothing new.  Self-interest is not the most flattering of human motivations, but it’s undoubtedly the most predictable.  However, the potential for Pavlov’s theories to explain more complicated aspects of human behavior lies in the fact that conditioning need not take place at a conscious level.   Pavlov’s dogs didn’t consciously decide to secrete stomach acid when they heard the bell.  The process took place without their being aware of it, let alone being able to control it. 

 

The subliminal manner in which positive and negative reinforcement can work is illustrated by a story one of my psychology professors told about a group of students who decided to team up and trick their instructor.   During class, when he stood on one side of the podium, they feigned inattention, letting their eyes wander toward the window and dallying with their pencils.  When he stood on the other side, they pretended to pay rapt attention, their pencils poised to take notes. 

 

Not surprisingly, the professor started spending more time on the side of the podium that gained the students’ attention.  Remarkably, however, he had no awareness that the student’s actions affected his behavior.  

 

Operant conditioning takes place subconsciously.  A person can try to maintain a neutral stance toward a particular option, but if he is repetitively rewarded for choosing it, he will inevitably become biased toward that strategy. 

 

Doctors may believe their judgements are impartial, and, indeed, they are trained to be objective in their thinking processes.  Nevertheless, a physician’s basic reactions towards various choices cannot help but be influenced by the positive and negative reinforcement he or she receives.

 

Physicians are charged with making decision about their patients that are often difficult in their complexity and need for experience and judgement.  Those choices involve risk, discomfort, expense and inconvenience to patients.  It’s critical that judgment be objective--that self-serving motives be set aside. But the reality is that the decisions doctors make often have important consequences for themselves.  Some choices enhance income, boost prestige and provide a sense of accomplishment; others are financially unrewarding, unappreciated and provide little satisfaction.  

 

No matter how hard doctors try to maintain objectivity, positive and negative reinforcement is bound to influence their decision-making processes.   Their responses, like Pavlov’s dog’s, can be influenced by rewards and punishments without their realizing it, in fact, with their believing sincerely that their behavior is unaffected by the reinforcement they get.

 

Medical Facts Are Often Subject to Interpretation

 

Surely, you might think, doctors cannot be so susceptible to self-delusion that they would overlook or misinterpret the plain facts of a common medical illness.  If you made your living examining patients, you would know how subjective medical observations can be.  The expressions on patients’ faces; their gestures as they describe their symptoms; the way they have previously dealt with illness, all have profound potential to influence doctors’ conclusions.  For example, it’s a well-known medical maxim that if a patient describes his chest pain by clenching his fist in front of his breastbone, his symptoms should be more taken more seriously than if he points to it with a finger.  And, without a doubt, if a patient has a stoic streak, he will be less likely to end up having aggressive treatment for a problem than if he is a complainer.

 

Recent experience also influences physicians’ decisions.  A doctor who has just  missed a diagnosis is going to take patients’ complaints more seriously for a while a doctor who has repetitively ordered tests without finding anything might be hesitant to order another.  Medical decisions often hinge on such nuances.

 

Despite a reverence for scientific method, it’s acceptable--in fact, obligatory—for doctors to act on instincts and hunches.  That’s why medicine is said to be an art as well as a science.  However, the larger the role of subjectivity, the greater the potential for bias to influence decisions.

 

Incentives in Favor of Doing Procedures

 

The fee a specialist would charge for examining you in his office, rendering an opinion and prescribing treatment is about what a general practitioner would charge for the same service.  In fact, most insurance companies don’t allow specialists to charge more than other doctors for performing the same basic service.   However, things change when you leave the doctor’s office and enter the high-tech arena of hospital--the world of angiograms, angioplasties and cardiac surgery.  Doctors who do these procedures work within a different incentive structure. 

 

Invasive cardiologists and cardiovascular surgeons are among the top moneymakers in medicine, and the reason they earn so much is not that they get higher fees for doing the same things other doctors do.  It’s because their incomes are enhanced by the fees they charge for doing lucrative, technologically complex procedures.   A typical surgeon’s fee for a coronary bypass, which requires approximately two hours of operating room time and three or four post-operative visits, is about $5000.  The cardiologist’s fee for doing an angiogram, which usually takes less than a half-hour, is approximately $800.  If at the same time he does an angioplasty, the charge is about $1600.  It is not unusual for an established invasive cardiologists or cardiac surgeon to earn four or five hundred thousand dollars per year, and most of that income is derived from doing procedures. 

 

It is important to keep in mind that millions of dollars of investment go into setting up a cardiac surgery or angioplasty programs and paying the salaries of technicians that staff these facilities.  The physicians who do these procedures have invested hundreds of thousands of dollars into their education and devoted many years of their life to training for the sole privilege of doing them.  Indeed, actuarial analyses of physicians’ lifetime earnings minus education costs place them at little financial advantage over other college graduates.  Nevertheless, once fixed costs and overhead have been met, profit margins on cardiovascular procedures are generous for both physicians and hospitals.

 

As powerful as the financial incentives are in cardiovascular medicine, it’s often the non-proprietary motivations of physicians that most baffle those who would try to understand their behavior.  Surgeons on fixed salaries who receive nothing extra for doing more procedures are usually still eager to do them.  There is more to their behavior than simple acquisitiveness.  Indeed, their motivations would be easier to decipher if they were purely monetary.

 

Most cardiac surgeons and invasive cardiologists enjoy working with their hands.  They love the physical challenge that these complex procedures pose.  They often describe the same sense of satisfaction from successfully competing an operations as others might experience playing a violin or shooting a good round of golf.   Many surgeons attest to experiencing a sense of heightened awareness and contentment when they are doing procedures. 

 

Undeniably, there is also an element of what might be referred to as “ego.”  Despite their sometimes-gentle demeanors, surgeons and cardiologists are often by nature aggressive and strongly motivated to succeed.  They’re confident in themselves and believe strongly in what they do.  In their minds, the volume and the complexity of the procedures they do is a measure of their prowess and they didn’t train for eight years to sit on the sidelines.

 

The Influence of Hospital Administrators

 

There’s someone else in the game that most patients don’t think of, the people who run hospitals.  Hospitals might call themselves “for-profit,” answerable to investors, or “non-profit,” owned by a city, county or religious organization, but they are all run by managers.  Even if the stated mission of the owners is altruistic, the managers that they hire are usually career-oriented and interested in power and perquisites. 

 

As hospital administrators usually see it, their goals are forwarded by expanding the organizations they run.  As a result, hospitals, whether for-profit or non-profit, are among the most aggressively run businesses in the country.  The fact that they are owned by organizations such as churches or governments doesn’t make them immune to predatory business practices.  In fact, freeing their managers from responsibility to owners and stockholders often encourages adventurous market forays.

 

The aspiration of managers to enlarge their hospitals’ share of the healthcare market breeds a culture of expansion, and, indeed, the Holy Grail for any hospital with ambitions to get bigger is to have a busy cardiovascular surgery and angioplasty program. These are among hospitals’ biggest revenue-producers. Most hospital administrators are delighted to see their doctors do more coronary bypass operations, angioplasties and angiograms.

 

In such an environment, hospital administrators have little to gain by emphasizing preventive cardiology.   They look favorably upon practice patterns that generate more cardiac surgery, cardiac catheterization and angioplasties while strategies that reduce the need for such procedures--although not blatantly discouraged--are rarely actively promoted.  The people who run hospitals might take pains to assure the quality of surgery and angioplasty, but they typically invest little energy into strategies to avoid those procedures. 

 

In recent years, preventive treatment has reduced the need for emergency cardiac care, coronary bypasses and angioplasties.  At the same time, efforts by the insurance industry to control expenses have put pressure on doctors to reduce unnecessary procedures.  While most of us would regard these trends as a cause for rejoicing, they put a pall on the aspirations of many hospitals and clinics.   After years of commitment toward enlarging their cardiovascular capabilities, many hospitals find themselves competing with one another for a shrinking pool of patients.  Consequently, they have become increasingly aggressive about promoting their services. 

 

Reversed Incentives

 

While most incentive structures in medicine favor expensive, high-tech procedures, some systems operate in reverse.  Just as you might wander into a hotbed of enthusiasm for surgery and angioplasty, you can also end up in an environment that discourages tests, medications and procedures.  Such a mind-set is typical of so-called “HMO’s”, or Health Maintenance Organizations. 

 

HMOs pay doctors and hospitals according to a scheme called “capitation”.   For a set amount of money per patient, an alliance of doctors and hospitals forms an arrangement with an insurance company to provide all the medical needs of a group of premium-payers.   In these arrangements, the doctors, clinics and hospitals are paid the same amount whether patients receive treatment or not.  Thus, there is incentive to avoid doing procedures.           

 

Recently I had a disquieting conversation with an administrator who worked for an HMO.  I was telling him about a patient of mine who was overweight, diabetic and desperately sick with a heart attack.  He confessed to me that after years of working in an HMO he had developed a prejudice against “fat patients who don’t take care of themselves.”  He resented the fact that some patients in his organization required so much more care than others.    

 

The cost of taking care of unhealthy patients reduces profits for HMO-type systems.  This incentive structure runs counter to a fundamental assumption most patients make, that their doctors are willing do whatever they can to make them well no matter how frustrating their problems are. 

 

An Erosion of Checks and Balances 

 

Another fundamental change in the political structure of cardiovascular medicine has taken place in the past 30 years that has made the treatment of coronary disease more subject than ever to the whims of individual physicians and hospital administrators.  In the past, doctors who made decisions about treatment were generally not the ones who profited from it.  For example, an internal medicine specialist would diagnosed a tumor but refer to a surgeon to have it removed.  Cardiologists decided if patients needed artery-opening procedures but cardiac surgeons did the operations.  Such a separation of powers provided internal supervision that helped keep decisions objective. 

 

In recent years In the United States, a change has occurred in the system of checks and balances between those who recommend cardiac procedures and those who do them.  Somewhere back in the nineteen sixties, cardiologists started performing the procedures they recommended, a trend that continued to grow.  Cardiology, a branch of internal medicine, now resembles a surgical specialty.  The difference is, however, cardiologists haven’t given up their role in deciding who should have treatment.

 

While being able to have the same doctor who recommends an operation do the procedure is expedient, it eliminates an important means of internal supervision. A cardiologists can now diagnose a condition, decide upon treatment and perform a procedure with little or no consultation with other physicians.  That change in the traditional system of checks and balances has made coronary patients more dependent than ever upon the opinions and philosophies of individual doctors and has contributed greatly to the variability in treatment of heart disease seen throughout the United States . 

 

Two Schools of Thought in Cardiology 

 

Adding to the complexity of decision-making in the Heart Game is a schism between two schools of thought regarding both prevention and treatment of coronary disease.  The development in the past thirty years of ways to unclog arteries with surgery and angioplasty has allowed doctors to treat certain stubborn problems for which in the past they had little to offer, but the massive commitment of human and financial resources required to build surgery and angioplasty centers has created a powerful momentum toward artery-opening operations. That impetus has been slow to change despite advances in knowledge and new treatments that have reduced the need for such treatment. 

 

Because of those movements, tension has been building between proponents of two schools of thought, one that advocates a “mechanical” approach and the other, a “metabolic” approach.  For proponents of the mechanical approach, prying open or surgically bypassing narrow arteries is central to treatment.  For advocates of the metabolic approach, correcting the underlying causes of coronary disease by treating such problems as high blood cholesterol and overactive blood clotting takes precedence. 

 

Certainly, the two mentalities are not exclusive of one another.  Specialists who emphasize reopening blood vessels are aware of the importance of correcting underlying metabolic disturbances.  However, they are often not as aggressive at ferreting out and correcting the underlying disorders as those who view the disease metabolically.  Advocates of the mechanical approach are skeptical of the idea that narrow coronaries can be addressed with pills and life-style changes and are uncomfortable leaving such arteries alone.  They abide by the premise that because narrow arteries are abnormal, it is of primary importance they be reopened. 

 

Those who advocate the metabolic approach acknowledge the importance of mechanically reopening or bypassing narrow coronary arteries when needed.  However, they are concerned that such measures do not address the underlying causes of coronary disease.  They view artery-opening procedures as being necessary only when efforts to relieve symptoms with medications and correct underlying metabolic imbalances have failed.  They advocate reopening narrowed arteries only when there is solid evidence that doing so will improve chances of survival or relieve symptoms. 

 

There are certainly plenty of cardiologists and cardiac surgeons who try to occupy the middle ground, who search for the right mix of the two approaches.  Nevertheless, there remains wide variation of opinions as to what the appropriate blend is.  

 

The difference between the mechanical and the metabolic viewpoints manifests itself most sharply in two areas.  One is the role of coronary by-pass operations and angioplasty in treating coronary artery narrowing.  The other is the potential of cholesterol lowering and other metabolic manipulations for preventing and treating the condition.   Lack of consistency of the mix of these two approaches has contributed greatly to the variation in treatment that is seen throughout the United States .

 

For the doctors, the controversy between the mechanical and metabolic approaches is more than philosophical. Money and professional status is at stake.   Years of education and training are required for physicians to do artery-opening procedures.  Hospitals invest millions of dollars setting up cardiac laboratories and operating rooms.  Shifts of emphasis in the way coronary disease is treated involve major reallocations of resources. 

 

Which School of Thought Does Your Doctor Belong to? 

 

While cardiologists might be aware of approximately where in the spectrum of opinions their colleagues lie, patients usually have no way of knowing.  In fact, they are generally unaware that such divergence of opinions exists.  Whether their doctor favors a metabolic or a mechanical approach is largely a matter of chance.  It is easy for a patient to happen into a pocket of unusual enthusiasm for one approach and receive treatment that would be considered unnecessary and inappropriate by proponents of the other.  

 

The controversy between those who favor mechanical versus metabolic strategies for treating coronary disease has been raging for so long that doctors have come to accept differences in treatment philosophies among their colleagues as a matter of course.  What is often overlooked is the plain fact that for each patient there can ultimately be only one optimal approach.  Ideally, a patient’s treatment should be the same no matter which board-certified cardiovascular specialist he or she consults.  But the reality for most coronary patients is that whether or not they receive cardiac surgery, angioplasty or aggressive cholesterol lowering therapy depends as much upon which cardiologist or clinic they happen to attend as upon any kind of consensus among physicians as to the best treatment. 

 

How to Get an Unbiased Opinion

 

How can you as a patient assure that the forces of physician incentives or clinic politics do not influence the critical decisions affecting your care?  Managed care organizations, whose business it is to efficiently allocate medical resources, have recognized that problems can arise when the same physicians who recommend treatment also benefit from them.  Their response has been to establish “gate-keeper” systems, to insist that referrals for major diagnostic or therapeutic procedures be approved by physicians other than the ones who actually perform them. 

 

In fact, there has always been an informal gate-keeping system in place in medicine.  Primary care physicians--including internists, family practitioners and general practitioners--were the first doctors patients encountered and were the ones who decided if patients needed specialized treatment.  What managed care organizations did was formally incorporated this procedure into their financial reimbursement systems.   

 

Gatekeepers can, in fact, significantly influence the use of medical resources.  In organizations where such systems have been established, the number of visits to specialists as well as the volume of expensive procedures has been reduced without compromising patient care.   

 

The Importance of Involving Your Personal Physician

 

The involvement of a personal physician, even if he or she is not formally designated as a gatekeeper, can significantly influence the decision-making processes of specialists.  Cardiologists tend to be more circumspect about recommending procedures if there is a personal physician looking over their shoulder.  In my own hospital, Providence Medical Center in Seattle , I studied the hospital courses of 231 patients admitted for heart attacks all of whom had a cardiologist involved in their care.   Among patients cared for by cardiologists alone, 65% were treated with angioplasty compared to 38% of those who had a personal physician participating in their care.  The presence of the personal physician exerted a “watchdog” effect, cutting down precipitously the number of procedures. 

 

Aside from their roles as overseers, patients’ personal doctors can provide important information to specialists.  Good decisions sometime depend on their participation.  The decision to do heart surgery, for example, often hinges on a patient’s general health and prognosis.  A referring physician familiar with the patient’s medical background is often the one best able to assess that.

 

Get a Second, even a Third, Opinion.

 

As beneficial as it is to have your personal doctor refer you to a specialist, there are shortcomings to that time-honored procedure.  It doesn’t guarantee a consistent level of supervision.  Sometimes primary care physicians are uncomfortable shouldering decisions about coronary disease and defer entirely to the judgement of specialists, in effect, relinquishing their role as gatekeeper. 

 

There is also potential for referrals to be affected by personal incentives and clinic politics.  The gatekeeper system works best when there is no positive or negative reinforcement for the referring physician to recommend a specialist.  However, when a doctor refers to members of his own clinic, he is in essence putting money into his own pocket.  The more fees the specialist generates from referrals, the lower the clinic’s overhead and the higher each member’s net income.  

 

Prestige within a clinic depends to some extent upon referrals.  The more business a doctor generates, the more valuable he is to the organization and the more power he wields.  As in most organizations, prizes such as department chairs and administrative positions are awarded to influential members. 

 

In the era of managed care, there are incentive structures in some systems that operate in reverse of the usual forces; there are incentives not to refer.  Under such programs clinics lose money when they send patients to specialists or recommend expensive treatments. 

 

So having a referring physician does not guarantee a consistent level of supervision of specialists’ activities, and there are often hidden incentives to refer or not refer.  If the decision-making does not make sense to you, or if you are dissatisfied with the incentive structures under which your physicians work, it is a good idea to seek an objective second or even third opinion.

 

You should rid yourself of any concern that your doctor is going to be offended if you seek a second opinion.  Most physicians accept this as part of the game.  You shouldn’t have to worry about protocol when your health is at stake.  In fact, many insurers require a second opinion for major procedures.  If your doctor has difficulty with the idea of your seeking another opinion, perhaps he is overly sensitive or not sure of himself, even more reason to seek another viewpoint.  

 

Most doctors are happy to share responsibility for their decisions.  Whether the second opinion supports his recommendations or not, it relieves him of some of the burden of responsibility. 

 

What is the best source for an objective second opinion about your condition?   You need a specialist, but, ideally, one who wouldn’t benefit from whatever treatment you chose.  To remove economic incentives from the decision-making process, you should consult a specialist who is independent from the ones who would provide the treatment. 

 

As beneficial as an independent second opinion can be, it is still no guarantee against bias.  The second specialist will have his own incentive structures.  If he has been repetitively rewarded for choosing a particular type of treatment, he is undoubtedly going to favor that approach whether or not it benefits him in your case.   So ideally, the second opinion should come from a specialist who receives no remuneration from the type of treatment under consideration.   For example, if you were considering having an angioplasty, the most objective opinion should come from a cardiologist who does not do angioplasties for a living.   

 

Typically, the most difficult decision is whether to have a major procedure such as coronary bypass surgery or angioplasty.  How do you find a specialist who is knowledgeable about those treatments but does not actually benefit from doing them?   In fact, this is quite simple.  Many cardiologists choose not to do invasive procedures, concentrating instead on diagnosing heart disease and making treatment decisions.  Those specialists are called “non-invasive” cardiologists as as opposed to “invasive” or “interventional” cardiologists. 

 

You are unlikely to see the designation “non-invasive” listed in the Yellow Pages under cardiology.  However, you call a cardiologist’s office and ask his receptionist if the doctor does angiograms and angioplasties.  In addition, your personal physician should know which cardiologists are invasive and which are not. 

 

There are two especially important decision-making junctures.  One is whether to have an angiogram.   The other is how to treat whatever is found on the angiogram.  The decision to have an angiogram represents a degree of commitment toward angioplasty or cardiac surgery.  Indeed, angioplasties are often done during angiograms eliminating the opportunity for second opinions.  It is best, then, to get a second opinion before rather than after an angiogram.  

 

You may wonder if you can afford a second opinion.  In fact, a visit to a second or even a third specialist is inexpensive compared to the rest of your treatment.  It usually involves no diagnostic or therapeutic procedures, only the rendering of an opinion based upon information already available.  An angiogram costs several thousand dollars.  A consultation with a second specialist shouldn’t cost more than a routine physical examination from your own doctor.  Most insurance companies are willing to reimburse patients for such services.   

 

Using Guidelines as a Framework for Second Opinions

 

As valuable as a second opinion can be, you can never really be sure that the viewpoint of the second cardiologist is unaffected by personal biases.  Just as invasive cardiologists tend to favor angioplasty and surgery, non-invasive cardiologists are sometimes overly enthusiastic about the idea of treating coronary disease with medications alone. 

 

Practice guidelines provide a framework within which the opinions of multiple consultants can be placed into perspective.  Unless a specialist plainly disagrees with the guidelines, a variance of opinion can only reflect differences in perception of critical details.  For example, the guidelines might recommend an artery-opening procedure only if treadmill testing indicated “high risk.”  Your doctors might agree with the recommendations, but disagree as to whether the treadmill results fulfilled criteria for being high risk.  While you might still be unsure of what treatment you needed, at least you would know that your physicians were paying attention to the critical details of your case.   In this example, the best course of action would be to perform additional tests, such as a nuclear scan, to clarify the issue. 

 

One of the most important functions guidelines can serve is to provide support for an objective opinion.  When doctors’ disagree with one another, the one who often gets his way is the one who advances the “worst-case scenario.”  For example, if one doctor says it is dangerous to postpone surgery, others become hesitant to disagree because in case of a bad outcome they might be criticized for not taking the situation seriously enough.  In fact, treatment should be guided by established principles rather than the “cover-your-tail” mentality.  Guidelines can provide support for those who would venture an unbiased opinion.