How to Out-Argue Your Doctor with Data

Your doctor believes he’s “patient-centered” because he wants to provide the the treatment he thinks you need as quickly as possible. Or as the fictional Dr. Heart tells his chest pain patient right after recommending a stent, “As it happens, I can do the procedure for you next week. Does that work for you?”

Before giving in to the gurney, what questions should patients ask? One data-driven script was presented in skit form at the recent Health Datapalooza 2015 meeting in Washington, D.C. The drama was light-hearted; the clinical and financial issues underlying it are not.

Dr. Heart was played by Glyn Elwyn, a theater student-turned-family practitioner recognized as one of the world’s leading researchers in patient preferences and values. Casey Quinlan, a writer and activist widely known for her unfiltered expression of those preferences and values, played the patient.

In the skit, a persistent Quinlan keeps pestering the doctor with questions about what a stent will accomplish that changing her medications won’t. At first glance, a stent sounds appealing because it props open the blood vessel. What could be better? However, when Quinlan asks directly about the effect of meds versus stenting on preventing a heart attack, the doctor admits that data show medication lowers the odds but stenting does not.

In addition, while medication gives Quinlan a 52 percent chance of conquering the stable angina (chest pain) that brought her to the doctor in the first place, stenting performs barely better at 59 percent. More worrisome is that medication has “some side effects,” but stenting brings with it a 1-in-100 risk of death, heart attack or stroke.

At this point I suspect the real-life Quinlan would “rip her doctor a new one” (a non-surgical procedure) for being so cavalier about her possibly becoming a corpse. In the skit, “The Mighty Mouth” (her self-selected nickname) politely settles for saying, “I think I need to think about this.”

The skit wasn’t meant to skewer cardiologists but to promote a new series of decision guides arranged as FAQs (frequently asked questions) from The Preference Lab at Dartmouth, where Elwyn is based. The guides are intended to provide a high-quality data synthesis an ordinary patient can use.

The procedure Elwyn picked is one in desperate need of pro-patient reinforcement. Researchers who analyzed conversations between cardiologists and patients with angina discovered that just two out of 59 covered everything a patient needed to know to make an informed decision. Doctors discussed alternative treatments to angioplasty and stenting just one quarter of the time, according to the research, published online in May in JAMA Internal Medicine. Not surprisingly, most patients believed stenting would prevent a heart attack or even death. (In Elwyn’s skit, Dr. Heart never plays his trump card by gazing directly at the patient and saying, “To be honest, if it were me, I’d get a stent.”)

The dramatic findings in a paper presented in March at the annual meeting of the American College of Cardiology demonstrate the extent of overuse. Implementing “appropriate use criteria” for coronary interventions at one community hospital caused volume to plummet 17 percent in the first year, researchers found, and another 17 percent the year after. Total reimbursement dropped by millions of dollars. Nationally, more than $10 billion is spent every year on what are called percutaneous coronary interventions.

Expenditures would decline by more than $2.3 billion if similar trends were extrapolated nationally, the authors estimated. “As physicians are more informed when making decisions, costs come down,” lead author Pranav Puri said in a statement.

Of course, a less optimistic way of framing that conclusion would be: “If physicians utilize these criteria, their income and the revenue of the hospital that supports them may drop sharply.”

The medical evidence, reimbursement policy and even factors such as local surgeons’ enthusiasm for surgery all influence the volume of procedures. Better informed patients may out-argue overeager proceduralists and help curb their enthusiasm. However, until financial incentives finally switch from volume to value, patient empowerment remains only one treatment option for the medical waste causing the health care system such acute financial pain.

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5 replies »

  1. The specific reason for the immune system issue is obscure. One hypothesis is that a few microorganisms (for example, microscopic organisms or infections) or medications may trigger changes that confound the resistant framework.

  2. As cardiac disease is the most prevalent disease in America, scenarios like this one play out everyday in real life. But what this scenario failed to draw attention to is the fact that the doctor didn’t even mention the intervention with zero side effects. Yes, it exists. And it’s not new technology. It’s a plant-based diet. Although the evidence is overwhelming that diet can reverse heart disease, few cardiologists mention it as a powerful intervention. Dr. Robert Ostfeld is director of the Cardiac Wellness Program at Montefiore in New York City. Dr. Ostfeld reverses heart disease in patients and I’m guessing he hasn’t lost a single patient “on the table” or because of adverse side effects to medications. Some patients will need interventional cardiologists for unstable heart blocks but most need a cardiologist like Dr. Ostfeld who will provide the best intervention, not the one with the highest reimbursement. As a cardiac nurse, I agree with Millenson: financial incentives need to switch from volume to value (and evidence) so there can be more Dr. Ostfelds.

  3. It’s our fault. As Docs we have oversold certainty in medicine. I tell my patients to NEVER go to a doctor who never says “I just don’t know”- (because we don’t know everything and never will)- More humility is long overdue

    Rick Lippin
    Southampton, Pa

  4. I agree with your mood and assessment. Maybe docs should be on salary? Patient agency should be cleaned up and conflicts removed. How you do this if the agent is neing paid by an employer is a dilemma. Non-profit hospitals are as greedy as for-profits because managers want to be important and famous. FDA and US Patent office should not approve new drugs and interventions until “usefullness” is actually proved. Recall that this is a criterion for a patent. This effort is truncated too often so that we are using stuff that is iffy and then clinical trials have to prove whether it is valuable years later, at patient’s expense. I don’t know how you get a doc who is trained to use a tool not to try to use that tool too often (eg cardiologists and their stents). I hate to see regulatory glue poured over everything. Informed consent has to be of biblical importance. And patients must be informed of costs and prices in real time, as the intervention unfolds. Fix all these and you still have a very imperfect system that ultimately relies on trust.

  5. This is how a patient, who has signed a consent to treatment form, gets sucked into the cardio-vascular industrial complex’s diagnostic vortex. Every time she/he asks if death is imminent there is no clear answer by (international) cardiologist. Not that patient is conscious and alert and is ED for traffic accident not cardiac event. They do NOT hear NO, I DON”T THINK SO or can’t this wait until I’ve consulted my primary care physician. You have signed consent to treat.
    The result is they suck you in do the test and then refuse to show you the result but just say your results are within normal range. Oh yes don’t forget prescription for most expensive cholesterol drug on market.
    PS. When doing follow up visit within 10 days with PCP, PCP can’t locate the tests or results on the EHR. This is NOT PATIENT CENTERED CARE.