A classic from a cardiologist

The NY Times has a long piece on the fast spread of 64 slice CT scans and their using in cardiac imaging. This is all pretty much taken straight from Shannon Brownlee’s fabulous book Overtreated which has a whole chapter on the topic. But it’s good to get the debate out there.

It appears that essentially there’s no real reason to use these scanners for the vast majority of patients. And in fact they’re use probably leads to more unnecessary angioplasties and stenting (which in itself doesn’t seem to reduce the number of heart attacks). But of course once a practice buys a 64 slice CT it’s an ATM machine sitting in the corner—not much good if you don’t use it, but very profitable if you do. Of course, the more conservative approach gets short shrift and those waiting for evidence to justify all this spending get ignored in the rush by both doctors, hospitals and manufacturers to get at the taxpayer’s coffers.

I was though vastly amused by this quote from an Manhattan cardiologist which will bring joy to the ears of those fuddy-duddies in the pay for performance movement:

Cardiologists like Dr. Brindis hurt their patients by being overly conservative and setting unrealistic standards for the use of new technology, Dr. Hecht said. “It’s incumbent on the community to dispense with the need for evidence-based medicine,” he said. “Thousands of people are dying unnecessarily.”

Of course he just knows that thousands are dying due to lack of these scans, so why do we need any evidence!

5 replies »

  1. There is a deeper story to the entir article.
    Anybody feel the NYT article was a bit suspicious? No new studies and 5 asymptomatic patients anecdotal stories to highlight the abuse of one new imaging modality?
    If you look into who critics Rita Redberg and Sean Tunis are, you’ll see they actually represent the private payers via a psuedo-non profit called CMTP.
    They are looking to take down all new medical technology (i.e. save payers $).
    Dig deeper and you’ll find that Tunis influenced his former subordinates at CMS to try to cut funding and require clinical trials. Tunis and Redbergactually asked the CT manufacturers to pay them millions of dollars to fund their private CTA study. The ROI on this lucrative study is very high.
    More info needed? Did the authors reference one scientific study in the article? Nope. They quoted 2 executives from private payers. Hmmmm… would it help you to know that the patient Dr. Hecht scanned actually had cest pain and the authors decided to leave that out of the story, despite being informed of it by Dr. Hecht…
    Despite what you think of CTA, this is a sad day for medical science when private payers are getting emotional front page marketing peices in the highly respected NYT.

  2. tcoyote–of course “it’s the payment system, stupid.” But no reason not to keep banging on about the reverse ludditism of the current system, while it’s still here and still in control.

  3. Brownlee blundered into the next huge turf fight- between cardiologists and their gold standard invasive technology, angiography (threading a catheter into one of heart’s arteries, squirting in some contrast medium and taking an X-ray of the flow pattern) and radiologists/cardiologists using a medium which produces a better picture of the actual organ (with no catheter or squirting dye) than what you can see if you’re holding the damned thing in your hands.
    The legacy technology was seriously overused as well (some places routinely had very high, eg 25% or better, “normal” caths, meaning that people did not do the appropriate screening with less invasive techniques (like stress tests). And hospitals have been doing skanky deals w/ cardiologists that rewarded them for cathing excessively.
    Blaming the new technology, which is less invasive, for a problem which is generic to fee for service medicine, is a classic Luddite response. The correct answer: fix the payment system for all such tests to minimize or eliminate the reward for excessive testing. Simply convicting the new technology leaves the power (and the millions) in the hands of the incumbents, and a technology which young physicians will giggle at (“they weren’t really doing THAT, were they?) when they learn about it in thirty years.

  4. Completely agree…best quote of the entire article.
    This guy is a complete idiot, a shill, a reckless danger to patients, and an embarrassment the medical profession. I mean, why doesn’t he just finish the thought: let’s bring back patent medicines, cupping, and leeching. Insulin overdoses for schizophrenia? You go, dog! Let’s un-invent modern standards of measuring efficacy and effectiveness…not to mention the ethical principle of beneficence. His ability to continue practicing medicine demonstrates physicians’ inability, as a professional group, to regulate ourselves.
    The horrifying thing this article brings to light isn’t the proof–yet again–that physicians, like anybody else, will tend to do what they’re paid to do. That should surprise nobody.
    The truly sickening part is Medicare’s unconscionable cave-in to these greedy, crass special interests: cardiologist-imagers and CT manufacturers. What do my taxes buy? Cancer-causing, waste-inducing, idiot-enriching needless harmful tests and their incredibly expensive, harmful, further-idiot-enriching sequelae. We keep seeing this pattern, and as much as I like the idea of universal insurance, it really undermines the case for an American single payer system: Medicare can’t stand up to special interests, whether they come in the form of the RUC, medical equipment manufacturers, or misguided pet-disease patient groups.
    I’ve said this before, but this is why the medical loss ratio is such meaningless drivel. Sure, you get very little overhead when you just act as a frictionless tube shunting my tax dollars into this cardiologist’s pockets. If CMS could spend a bit more on actual management, stop acting like a complete limp noodle, and actually do some serious rational payment policy review, we’d see better health outcomes and lower costs as a consequence of having appropriately higher administrative costs.
    On second thought, maybe I should just take a valium and buy me one of these money-mills.