Wednesday, June 17, 2009


The Atul Gawande article from the New Yorker went viral not only in the esoteric world of the medical blogosphere, but it also grabbed the attention of our health care policy makers in Washington DC. Almost universally, Dr. Gawande's piece is being hailed as "hitting the nail on the head". President Obama has referenced it in several speeches. I actually invested a lot of time in the article. I pored over it like I was studying for an embryo exam in med school, underlying key passages like a tool. My impression is perhaps less flattering.

In the piece, he visits McAllen, Texas, notorious for being one of the most expensive places (per capita) for the delivery of health care in America. McAllen spends twice as much per patient as the national average. Gawande sought to understand why.

Now I've been reading Gawande's stuff in the New Yorker for ten years and I've always enjoyed his writing. He writes with a lucid effortlessness that makes me extremely jealous. You always get the sense that he pumps these pieces out between cases, writing on the back of his patient census. (As a side note: I've always enjoyed writing but for years I'd been painfully paralyzed by self-doubt and over-analysis. I was the kind of guy who would write paragraphs over and over, tinkering, changing a word or syntactical construction here and there to get it "just right". Incapacitating writer's block. I couldn't finish anything. I hated everything I wrote. Especially after writing the same sentences 6 or 8 times. It was blogging that gave me the release. In the blog format, you have to just "let it fly". It's almost like an on-line writing workshop. Straight from mind to paper to critical evaluation. There's no time for timorous apprehension. Anyway.) In addition to his adroit style, he has a way of focusing attention on the heretofore unnoticed details that actually play a larger role in how events play out. He's a lot like Malcolm Gladwell in that respect. In this article, instead of focusing on insurance companies or defensive medicine or the pharmaceutical industry, Gawande alights on the idea that the driving force behind escalating health care costs are doctors. After all, that useless MRI never gets done unless a physician orders it. The suspect heart cath doesn't get performed unless a cardiologist (the one who stands to profit) deems it necessary.

Ultimately, he concocts a theory of physician mindset. Doctors at the Mayo Clinic deliver premium health care at a much lower cost than the national average. Gawande's proposal is that we need to change the way we structure ourselves as physicians. At Mayo, collaboration is strongly encouraged. Everyone gets paid the same. There are no financial incentives to perform unnecessary medicine. This is his ideal. How such a collectivist commune translates to the rest of the country where the overwhelming majority of medicine is private practice is unclear. In any event, he comes to focus on what he denotes the "culture of money" that is driving the extravagance seen in McAllen. To elucidate this, he goes on to note that many doctors in McAllen have alternative sources of income, such as partial ownership of strip malls and apartment complexes. (Another side note: What does it matter what a doctor does with his/her spare time? If a doc is making money off real estate deals on the side, how in god's name would that effect his clinical decision making as a physician? If anything, I would think it would tend to make him/her less apt to order/perform unnecessary procedures. As a matter of fact, maybe I ought to stop wasting so much time blogging and look to capitalize on the depressed Cleveland real estate market in my spare time. Then I could kick back and do "casual" general surgery.)

But it is this phrase---culture of money---- which has seized the attention of our DC policy wonks. And it's not surprising. Solutions to compex social problems tend to get oversimplified, in the "Aha! I never realized that!", Gladwellian fashion. It's much more reassuring to attribute something like exponentially rising health care costs to a single factor like doctors succumbing to the "culture of money" than to acknowledge that the real etiology is extraordinarily nuanced and multifactorial. Targeting physician motivations as the primary culprit makes it much easier to construct a feasible reform strategy. Eliminate incentives that drive physicians to overutilize and voila', health care crisis solved! Then you can package a reform bill that includes features like bundling of payments with extended global periods, disallowing physician ownership of surgicenters/hospitals, restructuring reimbursement such that graduating doctors are less inclined to subspecialize, and encouraging the creation of collaborative physician groupings a la the Mayo Clinic. Assuming that your underlying premise (greedy doctors) is correct, then the legislation makes perfect sense; it's a no brainer.

I obviously think Dr Gawande has gone off the tracks just a bit with his analysis. In the beginning of the article, he chats with a family practice physician who says "...young doctors don't think anymore". But that line of thought is truncated. Instead, we wander off down the pathway of physician greed and intransigence and we never return. I'd like to revisit the idea of physician thinking.

Let's first address the idea that monetary considerations are driving physician decision making. In the article, Gawande admits that the physician-owned hospital in McAllen barely gets a sixth of the patients in the region. So that means that the overwhelming majority of physicians in McAllen do not derive any economic benefit from self-referral to a physician owned facility. So what about procedure-based incentives? Certainly, we need to do a better job of clarifying the indications for specific interventions. The cardiologists and orthopedists who are overutilizing healthcare resources are doing so to line their own pockets. This is undeniable. But I truly believe that this sort of unprincipled practice represents the exception rather than the rule. (Remember, McAllen itself is an outlier; most hospital systems hover around the mean in terms of health care expenditures.) Also, these proceduralists don't materialize out of thin air. Someone has to consult them. And this gets me to my point.

I think the family practice guy in McAllen who talks about young doctors who "don't think anymore" gets at the crux of the problem. A lot of physicians have stopped thinking about patient care, for a multitude of reasons. Reimbursements suck. You have to see a gazillion patients in the office keep your head above water. Internists cover several ER's and accumulate large censuses at hospitals all across town. There are only so many hours in the day. You can't possibly provide the amount of thought and time that each patient on your list requires. So you subcontract out a lot of the work of medicine to specialists. You don't make any less money either way. So you might as well "cover yourself" and get the specialists involved. And of course specialists will tend to recommended expensive radiographic tests and interventional procedures. That's what they do. And they don't necessarily benefit financially from all the orders they write. Think about the typical 44 yo female admitted with abdominal pain. GI gets consulted. The patient recently had a colonoscopy and an EGD which were normal. The CT is normal from the ER. How often will the GI consultant simply write: no further recommendations? How about never. He's a specialist for god's sake. There's this tendency to DO. To order something. So you get an ultrasound and a HIDA scan and maybe a CT angiogram of the mesenteric vessels and finally a small bowel follow through. It all comes back normal of course, but now you've covered all your bases. You've done something. And this happens all the time. Meanwhile, the internist cursorily swings by once a day, sees all the work being done by his consultants and rushes off to his next patient. Is it laziness? Or is it just a natural reaction to an increasingly difficult economic reality?

A slightly different scenario. I know an excellent internist at one of my hospitals who has a proclivity for shotgun consulting half the hospital on a lot of his admits. As a clinician, I think he's fantastic; detail-oriented, takes his time, cares about his patients. But he gets a lot of consults. Any fever gets an ID consult. Abdominal pain warrants consults from GI and general surgery. He tends to order a lot of needless X-ray studies. If a CT scan mentions a small incidental adrenal adenoma, he'll order an MRI and get an endocrine consult when all you need to do is get a follow up CT in 6 months or so. He isn't lazy. He works his ass off. He knows everything that goes on with his impatients. But in his mind he is providing a higher standard of care by involving multiple specialists and getting the maximum amount of work up done. He doesn't have any nefarious kickback schemes. He just truly believes that his patients are better served by having multiple sets of eyes looking after them. The issue of cost never crosses his mind.

So we have two paradigms: The primary care doc who has stretched himself out too thin and the one who thinks he is providing superior care by overconsulting. Neither of these two paradigms has anything to do with greed. One covers his benign neglect by getting specialists to do the dirty work. The other succumbs to the idea that more is better, that it isn't enough to just tell a patient to take a couple of Tums and call him in the morning.

These two models are what need to be addressed because they're much more prevalent than doctors self referring unnecessary cases to facilities that they have a financial stake in. The gatekeepers of medicine (internal medicine, family practice) control the flow of patients to specialists. Specialists will never change; they will always be procedurally oriented. On the other hand, changing the thinking of the gatekeepers (altering the way they practice medicine, how and when they order consults, incentivizing them financially to do more of the work on their patients themselves) will do a lot more to reduce health care spending in the long run than trying to attack this supposed "culture of money" afflicting American physicians in places like McAllen. We aren't in the position we are because of McAllen. McAllen is an outlier, it's atypical; but it certainly represents a faster way to fall further into the red. But places like McAllen are rare. We've tripled the amount of health care spending in America since 1985 even without the McAllen model being common. There's obviously more to it than strip mall owning, fast car driving, overly-prolific orthopedists in south Texas.

So let's ease up on the Gawande/McAllen fawning for just a bit. It's an interesting, well written article but the conclusions in it are highly suspect and certainly don't represent a panacea solution to the extremely complex healthcare dilemma....


Josh said...

I actually don't think the type of medicine he describes in McAllen is all that rare, as you are arguing. Maybe you have been more fortunate in some of the places you have practiced. All I know is that so much of what he described was far too similar to what I observe every day. From the automatic 'ever colonoscopy gets an EGD too for whatever reason' to 'well, I'm squirting the heart so I might as well squirt the legs and throw some stents in those too, even though I didn't do an H&P ahead of time to even find out whether there was even the hint of an issue'. I wish I could share our optimism about the physician populace, but I think its far more prevalent mindset/practice environment than you are suggesting.

Jeffrey Parks MD FACS said...

If McAllen is the most expensive healthcare region in America, then by definition (think of bell curves, means and modes), it isn't all that common. Certainly practice habits as described in McAllen are prevalent in most other places. But obviously it doesn't happen to the extent it does in south Texas.

james gaulte said...

Excellent analysis.There is both much more( the more nuanced aspects you describe) and much less (you are right, by definition south Texas is an outlier and not the norm) that is implied(claimed)in the viral McAllen "expose".With 40 years logged in the practice book my experience is more like yours as regards greed or the lack of it as the major driver in doctor's behavior. Often it is not what you say but where you get it printed.

HudsonMD said...

i sense that you are a bit jaded by the PCP's in your area. I tend to disagree with you though that this is how it is everywhere. I guess my practice style and that of my partners is very different. We really only consult when we need a procedure done that we do not perform. I see the other side:
when i consult a cardiologist it goes something like...stress,echo, etc
A pulmonologist=PFT's, HRCT, etc
A surgeon for RUQ pain c/w cholecystitis= CT/US/and the damn HIDA!
I try very hard to get patients in and out in a very timely fashion and my LOS is well below the average. People get sicker the longer they stay in the hospital and more deconditioned. Any test that can be done as an outpatient should be done that way.
The other side of this is ED doctors. Every patient seen seems to need to be admitted. The patient with known CHF that has a little worse edema and sob without hypoxia or ischemia can be diuresed and discharged with changes to their regimen. This is exactly what i would do in the office if that patient walked in that way. I try to make decisions for hospital and ED patients based on what i would do if that patient walked in my office. Every damn patient with CP or SOB gets a BNP drawn and a ct scan of the chest. Noone wants to make the CLINICAL decision and that is frustration and costs our medical system billions. I went into Internal Medicine because if the critical decision making that i thought it took to be good at it. That's what many people have to get back to doing instead of being scared and pan-consulting. I babble on. Thanks for the time to rant

Anonymous said...

ABC News is refusing paid ads for its health care program at the White House. Conservatives for Patients Rights (CPR) inquired about purchasing ad time and was willing to do so. As of now, ABC is not accepting paid advertising, thus they're refusing even a paid-for alternative viewpoint. Here is statement from Rick Scott, chairman of Conservatives for Patients Rights. We remain hopeful ABC News will reconsider.

"It is unfortunate - and unusual - that ABC is refusing to accept paid advertising that would present an alternative viewpoint for the White House health care program. Health care is an issue that touches every American and all potential pieces of legislation have carried a price tag in excess of $1 trillion of taxpayers' money. The American people deserve a healthy, robust debate on this issue and ABC's decision - as of now - to exclude even paid advertisements that present an alternative view does a disservice to the public. Our organization is more than willing to purchase ad time on ABC to present an alternative viewpoint and our hope is that ABC will reconsider having such viewpoints be part of this crucial debate for the American people. We were surprised to hear that paid advertisements would not be accepted when we inquired and we would certainly be open to purchasing time if ABC would reconsider."

The media controls the minds of Americans. The fascist government state we live in is bed with big business including the corporate media. So America is going to believe that Obamacare is the answer. Just like giving the Federal Reserve the power to control the financial system is the right answer.

Problem, big business is in bed with government. Reaction, the people know we are being misled and want to choke slam their leaders. Solution, more government from the clowns in Washington and the Federal Reserve. I don't have the answers but more government and more taxes is not the answer.

These quotes are a little extreme but I see some trends that I don't like.

Fascism should more appropriately be called Corporatism because it is a merger of state and corporate power.
Benito Mussolini

The goal of socialism is communism.
Vladimir Lenin

A lie told often enough becomes the truth.
Vladimir Lenin

This country is not going in the right direction.

Anonymous said...

Good point, buckeye.

Gawande would flunk out of an elementary statistical inference class.

Proving cause and effect is a lot more complicated
than a simple quantitative analysis of one sample from a distribution. The fact that the sample is the biggest
outlier almost demonstrates incompetence.

He needs to show that his hypothesis holds true by comparing two groups. Groups of one mean versus groups of another mean.

Anonymous said...

Ron Paul on healthcare

Dr. Rob Oliver Jr. said...

Nice post.

What was missing from the McAllen piece was any kind of followup on an individual patient whom Gawande was suggesting they were inappropriately treated, and then go back to the patient and the doctor with the particulars of the case. Otherwise we get a useless lump of data with mean expenditures.

I would assume it's clearly cardiology, GI, arthrodcopic knee/shoulder surgery, and imaging studies which drive the excess on the clinical side. It was interesting to note in McAllen that home health expenditures were more then 50% of the excess cost per Medicare benificiary. Clearly too much of that service is being ordered

Robie said...


I agree with you through most of your post but like the disconnect you noted between the mention of PCP mindset and the final solutions offered in Gawande's piece, in your post you do something similar.

Your give two sources of the problem: overworked PCPs and those being trained to run every lab to ensure patient care/cover their ass.

At the end of your post you state possible solutions, "altering the way they practice medicine, how and when they order consults, incentivizing them financially to do more of the work on their patients themselves". So how do we incentivize them to do more work? How about reducing workload through increasing PCP numbers, or reducing incentive to race through patients, by keeping physicians salaried like at Mayo.

You make a great point that McAllen is an outlier and one to be used as an example of a flawed system. But how about focusing on Mayo, another outlier, as a system to be modeled after?

The culture of fear in our country all to often focusing efforts on avoiding those worst case scenario outliers such as McAllen instead of aiming for the Mayo's.

Victor Lazaron said...

Your analysis is right on the money. The over-testing and over-treating is a failure of primary care, and especially of the doctor-patient relationship. We have allowed and encouraged patients to believe that more tests and more procedures is better medicine.

I shudder to think how much WORSE it is going to get when more and more of the primary care is provided by nurse practitioners and PAs.

I mean they send me patients with lipomas or even big sebaceous cysts to excise - and most of the patients have had ultrasounds done. Some have even had CTs!! They could just call me and save a bunch of money for the system, but no. Or they send me patients with obvious IBS by Rome criteria for a workup " including possible upper and lower endoscopy ", or the ladies with slight dyspepsia and a negative GB ultrasound but a GB ejection fraction of 27% on the equally unnecessary HIDA.

I remember a lady sent to me for a hernia repair. She wanted to be sure her cardiologist got to go over all her pre-op workup. She was 52 years old with absolutely no medical problems and no medications. Before I told her that I thought she did not need ANY pre-operative workup at all I had to ask her, "Why do you have a cardiologist? You have no heart disease. " "Well, I had some palpitations once and there was something on my EKG so my doctor sent me to a cardiologist. They did a lot of tests and finally said I was completely fine." "So, you have nothing wrong with your heart, right? So why do you have a cardiologist?" And you know what? - If you tell one of these people that they don't need any more tests, or they don't need that operation THEY THINK YOU ARE A BAD DOCTOR.

Oy vey.

Jeffrey Parks MD FACS said...

I feel your pain...Funny stuff/

Alice said...

We should also mention how over-testing can lead to worse patient outcomes. A glaring example would be the patients I see as a resident at an academic hospital, who finally get referred to our pancreatic surgeon for a Whipple - after spending three to four months having one EGD/ERCP after another, a CT, an MRCP, one or two ultrasounds, then an EUS - when it was perfectly clear from the initial presentation (60yo, weight loss, painless jaundice, strictured CBD with no history to suggest a benign cause) that the patient likely had cancer. They should have been sent to the surgeon within weeks of presentation, after just one ERCP and EUS. (ie, don't do repeat ERCPs trying to get pathology to prove the diagnosis, if your first brushing was indeterminate. The presentation and a few imaging abnormalities are enough to warrant surgical evaluation.) It's impossible to prove with data, but it makes me sick to think how many of these patients have their cancer metastasize during the months of needlessly repetitive workup.

Anonymous said...

Buckeye - Nice post and I agree with much of your analysis. However, one of your statements was particularly interesting:

"The issue of cost never crosses his mind."

I agree that this is the norm but is this really acceptable? How can we ever expect costs to be contained when this is the culture. I don't know of any other industry where this is the accepted norm (or if it is, those companies aren't in business for too long). We, as physicians, must be more conscious of cost. If we aren't, the government will eventually do it for us (e.g fee for service medicine of 1980s).