Shared Decision Making and Mike Wallace

Mike Wallace, the well-known veteran journalist of CBS' 60 Minutes, passed away on Saturday.

Working in journalism for more than 60 years, he died at age 93. He had lived for many years with heart problems. He had had a pacemaker installed more than 20 years ago, and had had triple bypass surgery in early 2008.

Experts are becoming more skeptical about many forms of surgery and screenings, particularly heart surgery. The National Priorities Partnership, for example, has identified coronary artery bypass grafts (CABGs) and percutaneous transluminal coronary angioplasty (PTCA), among others, as often unwarranted, and has recommended that healthcare organizations concentrate on reducing them. Yet Wallace was able to live to a ripe old age with the benefit of several heart operations. It's very complex to ascertain whether an operation is right for a certain person. That's why shared decision-making, perhaps with a patient advocate, is so important.

Shared decision-making will be the subject of a forum in Waltham, Massachusetts on April 10, organized by the Massachusetts Health Data Consortium. Dr. Henriette Coetzer and David Veroff of Health Dialog will make presentations for the session, entitled "For Good Measure: Identifying Opportunities and Outcomes for Patient Decision Quality."

For considerations in the surgery decision, see Chapter 3 of my book, Getting Your Best Health Care: Real-World Stories for Patient Empowerment.

The Big Short and Inappropriate Eye Surgery

In The Big Short: Inside the Doomsday Machine, Michael Lewis insightfully dissected the reasons for our financial meltdown. He pinpointed the role of perverse incentives, illustrating his point with a healthcare story:

"Warren Buffett had an acerbic partner, Charlie Munger....If you wanted to predict how people would behave, Munger said, you only had to look at their incentives....Dr. Mike Burry agreed. [He believed] even in life or death situations, doctors, nurses, and patients all responded to bad incentives. In hospitals in which the reimbursement rates for appendectomies ran higher, for instance, the surgeons removed more appendixes. The evolution of eye surgery was another great example. In the 1990s, the ophthalmologists were building careers on performing cataract procedures. They take half an hour or less, and yet Medicare would reimburse them $1,700 a pop. In the late 1990s, Medicare slashed reimbursement levels to around $450 per procedure, and the incomes of the surgically minded ophthalmologists fell. Across America, ophthalmologists rediscovered an obscure and risky procedure called radial keratotomy, and there was a boom in surgery to correct small impairments of vision. The inadequately studied procedure was marketed as a cure for the suffering of contact lens wearers. 'In reality,' says Burry, 'the incentive was to maintain their high, often one-to-two-million-dollar incomes, and the justification followed. The industry rushed to come up with something less dangerous than radial keratotomy, and Lasik was eventually born.'"

Read a story in Chapter 7 in my book, about my own decision on elective surgery.

When you buy a car: Inappropriate surgery

Here's an idea that should both empower consumers and nudge costs down.

When you buy a car, critical information for this major purchase decision is immediately available, and clearly and prominently displayed on key features of the product, e.g., the miles per gallon. The decision of whether to have surgery is just as important, but information as clear and objective as that is usually absent.

The National Priorities Partnership is a broad group of experts, convened by the National Quality Forum, who have agreed that certain operations are often unwarranted.

Patients who are considering a coronary artery bypass graft (CABG), hysterectomy, knee/hip replacement, prostatectomy, percutaneous transluminal coronary angioplasty (PTCA), or spinal surgery should carefully consider beforehand whether the surgery is appropriate for them. To enable them to do so, patient advocates should find out and tell them the:

Survival rate;

Identification and frequency of the most common adverse effect;

Fraction of patients who need the operation to be performed again;

Best alternative to surgery; and

Cost to be billed by the surgeon and hospital.


I wish I had this information when I considered surgery. A friend's father also would probably have wanted to know it, as it might have saved him from an ineffective operation that left him incontinent. When consumers learn this information, many will probably consider alternatives to surgery, which may well be less expensive.

Half the rate in the U.S.: Mammograms and physicians' learning curve

The recent change in recommended mammography screening stems from a concern that the huge number of false positive readings led too many women to get unnecessary surgery, and to feel great needless anxiety.

Doctors who read a lot of mammograms are far more accurate than those who don't. To be a mammographer, the United Kingdom requires their radiologists to read ten times more mammograms than the U.S. does. That explains why the rate of false positives (when they say there IS cancer, when there really isn’t) in the U.K. is only half the rate in the U.S. A study in the Journal of the National Cancer Institute by Dr. Rebecca Smith-Bindman and others of mammograms in the U.S. confirms a similar pattern. In the largest study of its kind, they found that radiologists who read 2,500 or more mammograms each year have a false positive rate half that of radiologists who read 480 - 750 per year. And the radiologists who read the most mammograms are just as likely to detect breast cancer when it exists (in other words, their false negative rates are just as good as those of their less experienced colleagues).

Read another story about a mammogram.

Advice to women: Before your next mammogram, find a doctor who does more than 2,500 a year.

Too little and too much: Inappropriate treatment

On Tuesday, I had the great pleasure of participating in the kickoff of a group of 60 health care leaders who are coming together in the Aligning Forces for Quality (AF4Q) project in Eastern Massachusetts. The group is setting a bold goal to provide healthcare more appropriately. Barbra Rabson and Prof. Stuart Altman are the primary investigators on the planning grant awarded by the Robert Wood Johnson Foundation.

There are two kinds of inappropriate care: too little, and too much. In my own family we've had both, with great harm to my aunt and uncle. My Aunt Anne lived for many years in Denver, by herself, and enjoyed traveling widely and taking part actively in the city's cultural events. I never heard her complain about poor health, and we assumed she was fine. I only learned, after her death, that she had had adult onset diabetes. She herself had learned that only late in life, when she had a blood test before having cataract surgery. She hadn't trusted doctors, and had seen them too rarely. One day she complained to a close nurse friend of pain in her foot, and showed her the foot. Already black and gangrenous from the poor circulation caused by diabetes, much of it had to be amputated – which greatly reduced her mobility and crushed her spirit. Within a year or so, she had a fatal heart attack. When we cleaned out her possessions in her apartment, we found many pill bottles, each almost full. She would comply with a new prescription only for a couple of days, and if the medicine didn't work immediately, she apparently would stop taking it.

She got too little treatment, and too little education, for her diabetes. She didn't partner with her doctors, or any other health professionals, costing this vibrant woman years of life.

My Uncle Leon lived in the Washington DC area for most of his adult life. He trusted his doctor fully – to the extent of having him perform multiple angioplasties. Even so, he had several heart attacks. It's hard to believe that all of the angioplasties were appropriate. It seems he had too much inappropriate surgery, and too little effective education about self-care and prevention.

Neither Anne nor Leon received appropriate care. The partnerships they had with their medical teams were ineffective at keeping them healthy. The AF4Q brings together clinicians in hospitals with insurers, government agencies, and consumers. Hopefully this collaboration will strengthen the partnerships between doctors and patients, to make treatment more appropriate.

Read a story on unnecessary surgery.

With significant potential financial gain: Unnecessary cardiac surgery

Father John Corapi went to Dr. M. for a diagnosis, and the doctor recommended surgery. Father Corapi then got second, third, fourth and fifth opinions, all of which disagreed with Dr. M.'s diagnosis and recommendation for cardiac surgery. He was so struck by these additional opinions that he went to the FBI.

The FBI performed a three-month investigation, interviewing medical staff at the local medical center in California, other patients of Dr. M., some of his colleagues, Dr. Gerald Rogan, and outside cardiologists as far away as the Cleveland Clinic. The FBI produced a 67-page affidavit that led to a search warrant authorizing an FBI raid on Dr. M.'s office. The affidavit contained a description of Dr. M.'s interaction with patients: the doctor bullied patients, and scared them. He would consistently tell patients, many of whom had ambiguous symptoms and no history of coronary disease, that he needed to perform an angiogram to determine whether the patient required invasive treatment. (An angiogram is a diagnostic test that takes X-ray pictures of the heart arteries, highlighted by an injected dye, via a soft catheter tube that the surgeon threads into the heart from an incision in the patient's groin. )

If the angiogram failed to document treatable disease, or as was frequently the case with Dr. M., was unreadable, he would perform an intravascular ultrasound, which at the time was new, and unfamiliar to many cardiologists. By improperly setting the gain on the ultrasound too high, Dr. M. guaranteed the appearance but not the reality of significant arterial blockages. Dr. M. would then lean over the supine patient and tell him in dire tones that without immediate bypass surgery, he would die. In such a stressful situation, few patients were sufficiently confident, rational, or sophisticated to ask for a second opinion. For the few who did, Dr. M. typically referred the patient to another doctor in his practice, who would confirm the diagnosis, relying on Dr. M.'s recommendation, and perform the surgery.

The California Medical Board sought a restraining order against the two doctors, finding that:

"Both have fraudulently misrepresented the findings of tests to induce and/or scare patients into having unnecessary surgeries or interventions. At best, this can be viewed as incompetent and/or grossly negligent as well as dishonest and corrupt. [They] misled, lied to or attempted to frighten patients into consenting to invasive coronary surgical procedures, at significant risk to the patient and with significant potential financial gain."

Advice: Work to reform the payment system that rewards unscrupulous doctors for unnecessary and dangerous surgery.

Read another story about unnecessary bypass surgery.

Thanks to Drs. Gerald Rogan, Frank Sebat and Ian Grady for the source, Disaster Analysis Redding Medical Center Congressional Report, June 1, 2008, and to Helen Haskell.

An armed guard told him his kidney had been removed: Theft ring for kidney transplants

As the anesthetic wore off, 25-year-old Naseem Mohammed said, he felt an acute pain in the lower left side of his abdomen. Fighting drowsiness, Naseem, a day laborer, fumbled beneath the unfamiliar green medical gown and traced his fingers over a bandage attached with surgical tape. An armed guard by the door told him that his kidney had been removed.

He was the last of about 500 Indians whose kidneys were removed by a team of doctors running an illegal transplant operation, supplying kidneys to rich Indians and foreigners, police officials said. A few hours after his operation last Thursday, the police raided the clinic and moved him to a government hospital. He has been recuperating in a Gurgaon hospital.

He had had no idea that it was possible to sell a kidney. He had been picking up odd jobs in Delhi for the past two years and had been sending money to his family in Gujarat.

Two weeks ago, he was approached by a bearded man as he waited at the early-morning labor market by the train station. The man offered him a generous deal: six weeks of painting work, with free food and lodging. He was driven four or five hours, to a remote bungalow, where he was placed in a room with four other young men, under the watch of two armed guards.

"When I asked why I had been locked inside, the guards slapped me and said they would shot me if I asked any more questions," he said. The men were given food to cook and periodically nurses would take blood samples. One by one, they were taken away for operations.

"They told us not to speak to each other or we would pay with our lives," he said. "I was the last one to be taken."

Advice to people needing a kidney: Explore kidney sharing, as described here recently.

Browse for related stories in the index at the very bottom of this page, or read a kidney swap story.

Thanks to Amelia Gentleman for the source article in the Jan. 30 issue of the New York Times.