Wednesday, April 30, 2008

The Inappropriate Appropriateness Argument

Dr. Ron in the last post has done away with the convenience argument, as far as I'm concerned. But don't worry, our friends the self-referrers have more justifications up their sleeves. Even Tim Trysla, head of AMIC, voiced the "Appropriateness" argument when discussing an article by Dr. Jean Mitchell:

We have reviewed the article in Health Affairs on equipment leasing and are hopeful that the author will release the underlying study data so that her peers can replicate her analysis. Since its inception, the Access to Medical Imaging Coalition (AMIC) has worked with policymakers with the goal of ensuring appropriate utilization of medical imaging services. Unfortunately, the Health Affairs article does not offer any data on the appropriateness of the imaging procedures it analyzes -- which is the key to crafting responsible and sustainable policies on access to medical imaging services.

Without having access to the author's data, it is impossible to know if the conclusions she has drawn are reflective of the facts. However, if the arrangements described in the Health Affairs article are in violation of federal or state law, those violations of the law should be prosecuted.

AMIC looks forward to continuing to work with the Congress to enact a reasonable Medicare imaging policy that preserves and strengthens beneficiary access to the right imaging procedure at the right time.

This opens up an ethical minefield, which is mostly controlled by the self-referring clinicians themselves. They are the ones who determine which patients deserve a scan and which do not. These are "their patients" after all, and who are we to second-guess their judgement? If a patient walks in with a headache, should they not be scanned to rule out a subdural? Well??? Bottom line here is that the clinicians win the appropriateness argument, since in a real sense, they set the rules for it.

But wait. This logic can be turned on its head and thrown right back at them.

We know without any real doubt that those with imaging equipment in their offices order more scans than those who don't self-refer. This is pretty much a given. Let's say that they order twice as many studies, which is really underestimating the problem, but that's OK for the moment. AND, let's assume that all of those scans are appropriate. We wouldn't want to question the judgement of our friends, now would we? With me so far? Now, we turn back to the behavior of those who DON'T have scanners in their offices. They are ordering at One-HALF the rate of their colleagues. Therefore, if the self-referrers are ordering appropriately, the non-self-referrers are jilting their patients, not utilizing the life-saving services available right down the street at their local hospital.

The truth cannot fall both ways, can it? Either the self-referrers are ordering inapproriately, most likely due to the fact that they will make a profit doing so, or the non-self-referrers are restricting their ordering inappropriately. One group is harming their patients, and I'll leave it to you to figure out which one that is.


Ron A. Dawson, MD. said...

Dr. Harold, I think I have figured it out... What you say makes perfect sence.

Today, doctors must practice evidence based medicine. A doctor is someone that has earned the MD or DO behind their names through years of hard work and qualification.

So what is evidence based medicine? What drives doctors to rebuke evidence in their practice of medicine? What would cause a doctor to set aside everything they have learned and make decisions that are not based on clinical and scientific evidence?

“Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” ( You can also refer to for an overview and more information on the subject.

I have a theory on what drives doctors to set aside science and clinical evidence and evidence-based medicine in making decisions in regards to radiology examinations:

1. Medical legal and the ability to spread responsibility of a bad outcome and have it shared by another.
2. Ignorance and or arrogance.
3. Setting aside science in favor of old wives tales.
4. Failure to meet their responsibility to oversee their PA’s and Nurse Practitioners ignorance and arrogance.
5. Falling prey to patient directed medicine.
6. Laziness.
7. Imaging, the “antibiotic” of the 21st century.
8. Financial gain.

Imaging is not a benign procedure. Using imaging for any of the above reasons is not just unethical, but, mark my word, criminal.

“AMIC looks forward to continuing to work with the Congress to enact a reasonable Medicare imaging policy that preserves and strengthens beneficiary access to the right imaging procedure at the right time.”

Who determines, the right imaging procedure at the right time? Is it evidence based medicine? Is it the self referring physician whose credibility is worthless when they stand to make financial gains by choosing imaging? Or, is it the expert, the gold standard, the person who is trained and certified to make those decisions, the Radiologist? Oh, and I just did a search of our constitution and for the life of me could not find “the right to imaging procedures” anywhere. No life, liberty and the pursuit of the imaging dollar anywhere.

Dr. Harold states, “Bottom line here is that the clinicians win the appropriateness argument, since in a real sense, they set the rules for it.”

With all due respect (to those making the rules), hitting the lottery once does not make one an expert in winning the lottery. Getting hit by lightning once does not mean you can predict that you will be hit again.

Yes, these folks may create a rule, but based on what? Serendipity? What is the chance a person with a brain cancer will present with a headache? If you use this as a basis to make a rule to image all people with headaches for cancer, then you either did not go to medical school or you went and just did not pay attention very well. It also means you failed the test for basic common sense. Making a rule based on serendipity or lottery based thinking is not the same as making a rule based on science or seated in evidence-based medicine. Dr. Harold, it sounds like you find yourself in a situation of being the only sane person in a group of insane or idiots, looking for someone to agree you are sane. Your peers in medicine should know better than to put you in such a predicament.

By the way, before I forget, is there a database that shows the statistics for doctors that order CT’s? Wouldn’t a patient want to know that a certain doctor prescribes 400 CT scans of the brain a year with a yield of only two significant findings and 60 incidental insignificant findings? As a physician and scientist, shouldn’t they desire this information themselves? Radiologists are mandated to keep this information for mammograms, a low dose, low cost exam seated in evidence based medicine, with proven criteria, risks and benefits.

Dr. Harold states, “These are ‘their patients" after all…’”

This is a very interesting statement. It totally disregards the will of the patient that brought the patient to this doctor. Does a referral to a specialist confer title of the patient to the specialist or does the patient still “belong” to the referring doctor? Who does the patient belong to? Does the patient initially belong to the phone book, their friend, the insurance company, the ER charge nurse or doctor, or the family practitioner? Is title transferred or shared and how? Is patient will left in a bucket at the entrance door of the specialist’s office? Why when a patient is referred to you Dr. Harold, is ownership not transferred to you?

When does a patient become a tool of control? Does a doctor who is the position to take control of a patient have a higher ethical responsibility to not take advantage of the patient? Do patients realize their doctors may not have their best interests in mind? Do they realize that physicians believe they control patients as a means for the physician’s own gain? How would a patient feel if they knew their imaging study was being performed for any of the eight reasons listed above?

Dr. Harold then states, “and who are we to second-guess their [the referring physician] judgment?”

I understand this rhetorical question, but I will still respond.

Radiologists are in a unique position in medicine, similar to other fields such as pathology. Although there is still a doctor patient relationship with the patients you see, there is a unique separation from the patient, not seen in clinical practice. In fact I offer you see more of the patient than other doctors evaluating them. This unique situation for your specialty affords a level of protection to the patient as well as a new set of eyes to evaluate the situation in a different light. It was and has until now been an imperative separation of the clinical evaluation of the patient from the imaging evaluation. In this role, the Radiologist doctor has served as an important gatekeeper for potential abuses of either self referral or rather protection from any of the eight abuses listed above. It has also served as a built in peer review. Removing this peer review by self referring, removes any peer review of their work and I offer that this poses a significant risk.

For gods sake, when did the Radiologist hand in their MD and gonads and take a back seat as a lesser in the overall practice of medicine? By doing this, the Radologist has relinquished his role as gatekeeper and protector of last resort to the patient. The bottom line is Radiology is reserved for those in the top percent of medicine. You did not earn your position only to give up the title of pysician the day you left residency. I say, a Radiologist is a doctor and probably the most important doctor in medicine today particularly if you equate costs to importance. Medicine should understand your political weakness based on your unique position and low numbers and make special provisions to protect your autonomy and scope of practice.

There are laws in society and ethical laws that prevent a doctor from having a relationship (usually sexual) with his patients, because of his unique position of control. However, nothing protects patients from being screwed by their doctors in other ways. Pitty…

Harold said...

Very insightful, Dr. Ron. If you don't want to start your own blog, I would love to work with you on this one!

In brief, your comment decries the radiologists' abdication of their responsibility to filter the exams for appropriateness. But if we actually try to do so, we are called "lazy" jerks who are just trying to get out of a scan, or "obstructionists" or worse. And, of course, if the patient is that one in a million who does have a significant finding when we all know they shouldn't, the "lazy" radiologist will find himself at the wrong end of a subpoena.

The real reason no one rocks the boat is money, and we all know that. The self-referrers would lose billions overall if their game was brought to a close. The appropriate exams would still be done, but we all agree there would be far fewer of those than of the inappropriate kind, so the radiologists participitaing in this abomination would lose money as well, and that is what drives them too.

There are high-sounding ethical statements coming out of the AMA about the sanctity of the doctor-patient relationship, and how one must not make decisions based on profit. This should be self-evident to anyone with a normal set of morals in the first place. The eventual laws against this, and they are coming, are directed toward those that only understand punishment as a deterrent to doing what they know they shouldn't.

Ron A. Dawson, MD said...

Dr. Harold,
First, I'm a bit too lazy and frustrated to start my own blog and certainly did not mean to hijack yours. I'm always willing to post commentary. You have no contact on this site?

I did a search on appropriateness and did a bunch of internet research. Like many, I am affected by the problems in imaging and I too must pay $10,000 a year for insurance for which I am fortunate not have have needed. Neither I nor my family get unnecessary exams to pay for someones house or car.

Please take a look at what is happening in Australia. My feeling is that in order to request an appropriate exam, it takes a certain level of sophistication. In our country, it takes an unethical person trying to make a buck. In Australia, those at the level of general practitioner are deemed as a group not have have that level of knowledge. They are not allowed to request MRI's. This has led to an inappropriate over use of CT, but that is a whole different discussion.

In our country, based on my limited personal experience, not too many of our physicians, lets say family practitioners, would compare favorably to those in Australia. Yet, they have the ability to request, no better yet "order" at will. In addition we have also allowed them to oversee PA's and NP's who also order at will. This is ethically and morally inappropriate and defies common sense.

For our specialists here, I just don't know what to say. It disturbs me that medical schools selected these types of individuals to train. Certainly it is inappropriate for them to be fleecing the system with inappropriate studies.

There is alot of things that need to be fixed, all of them inappropriate. I think Australia is working on these problems in a better way then here in the US.

Harold said...

You can find me at harold.hoover(AT)

Thanks for reading and sharing your thoughts!