Archive | April 2011

Medical Publication Gaffes Cost Doctors

This week there were two prominent medical gaffes that garnered media attention.  The first involved the renowned Dr. Lazar Greenfield, who in a February article in Surgical News, discussed mating tendencies in fruit flies, rotifers, and humans.  He cited research that noted lower rates of depression in women practicing unprotected sex compared to those practicing protected sex, or abstaining.  But it was one particular line toward the end of his essay that sparked a backlash which led to the entire issue being yanked from the Surgery News web archive.  Since nothing is ever really deleted in cyberspace, the folks at Retraction Watch have made the original writing, and their analysis, available here.

In addition to the retraction, Dr. Greenfield resigned his post as editor of Surgical News, and as president-elect of the American College of Surgeons.  That is a harsh penalty.  Over 200 comments on Retraction Watch, as well as many more on other media outlets, hashed over the events and whether or not this was an overreaction.

It is an unfortunate situation and it should be kept in mind that Dr. Greenfield’s contributions to surgery are very significant.  His list of accomplishments is extensive, the best known being the development of an intracaval filter which can prevent otherwise fatal pulmonary emboli.  This device is used worldwide and has prevented countless deaths.  He’s the surgical equivalent not merely of an All-Star, but a first-ballot Hall-of-Famer.

The second event occurred in Rhode Island, where a physician posted clinical information on Facebook.  Enough detail was posted so that it was possible to identify the patient even though there was no intent to do so.  Dr. Alexandra Thran was reprimanded by the state’s board of medicine and fined $500.  The hospital involved also terminated her privileges.

I don’t have statistics, but it seems that these types of stories more commonly involve non-physician personnel, such as nurses and technicians.  I have heard of patient photographs being posted, as well as comments and other such inappropriate social-media usage of private information.  Social media is a minefield for medical professionals, who can benefit from marketing and positive effects on branding, but take great risks if there are breaches of patient confidentiality or protected health information.  As noted above, nothing is ever deleted in cyberspace.

Medical Black Swans

A wild black swan Cygnus atratus . taken in so...

Image via Wikipedia

Anyone interested in learning more about the financial meltdown should check out Nassim Taleb’s book The Black Swan.  Published in 2007, it’s message makes the events of 2008 more understandable.  Taleb describes how “predicting the past” by using mathematical models to estimate the future can go very wrong.  When unforseen and unpredictable events, so called “Black Swans” appear, they render all such models useless.

What is the medical connection?  Often we think of medical breakthroughs as the result of carefully directed top-down research carried out in elite institutions.  Though such work does result in many advances, they often are building upon other discoveries which were made quite by accident; medical Black Swans.  Three developments immediately came to mind, and there are certainly far more.  Each is recent, occurring within the past several decades, and none the result of top-down research.

The discovery of penicillin
Antibiotics are ubiquitous today, but they have only been in regular use for about the last 60 yrs or so.  Alexander Fleming’s 1928 chance discovery of mold inhibiting bacterial growth was the spark that led to the antibiotic era in medicine.  Others had noted similar effects in prior decades, and Fleming did not bring penicillin into production.   But his discovery set events in motion that saw antibiotics in widespread use by the mid 1940’s.

The role of Helicobacter Pylori in peptic ulcer disease
In the late 19th and early 20th centuries, it was noted that there was a particular type of bacteria found in the stomach linings of patients with peptic ulcers, gastritis and gastric cancer.  A causative relationship between these bacteria and these disorders was not established until Drs. Barry Marshall and Robin Warren demonstrated it in 1982.  Doing so changed the paradigm of this field,  and transformed the management of peptic ulcer disease.  Prior ulcer treatments consisted of dogmatic behaviors (drinking milk and avoiding spicy foods and stress), and various surgical procedures.  Today, antibiotics are used to eliminate the bacteria and the role of surgery has been greatly diminished.

Laparoscopy
There were efforts in the early 20th century towards laparoscopy, mainly involving veterinary applications.   The technology was gradually improved, and gynecologists were the first specialty to perform laparoscopic procedures on a routine basis.  It was a German surgeon (Kurt Semm) who performed the first laparoscopic appendectomy.  Rather than being heralded as achieving a breakthrough, he was nearly disciplined for “unethical behavior” by the medical establishment.  Once this technique was applied to gallbladder removal (and surgeons had proceeded up the learning curve), cholecystectomy was transformed from a surgery with a  substantial recovery into one that can sometimes be done on a same-day basis.

The $50,000 Laceration Repair

Genähte Wunde am Rücken, vier Stiche. (sewed w...

Hopefully $50k buys a better repair than this.

The American Board of Plastic Surgery’s February 2011 newsletter discusses ethical practice, noting that a surgeon reportedly billed $50,000 for a 1 cm laceration, which was paid as an out-of-network charge.  This vignette presents several avenues for discussion.  It seems clear that such a charge is flagrantly excessive.  Consider a surgeon who repaired six similar injuries each day.  Given a five-day week and 4 weeks of vacation per year, total payment would be $72,000,000.  Wound healing physiology being what it is, even a $72 million surgeon has to leave a scar!

But the newsletter does not explore the issues behind the problems illustrated by this example.  Notably, that there is no price transparency in healthcare services, and that leads to market failures that do not serve patients, doctors or insurance companies.  The concept that “in healthcare, nobody pays sticker price” is hardly untrue.  There is no problem with insurers or patients paying sticker price, as long as that price reflects reasonably accurate value for services provided.  It seems odd that the insurer had no safeguard or review procedure for extreme claim amounts.  Health insurance policies could contain out-of-network benefit limits that would limit extreme claim amounts.  Would the surgeon realistically expect a patient to pay $50,000 for a 1 cm laceration?

In defense of the surgeon, there are abuses on the other side as well.  Out-of-network doctors covering emergency patients often are not paid, or see payments disbursed to the patients directly, then are forced to try to collect from them.  Reimbursement of the patient for out-of-network services works well for elective care, but is not feasible for emergency situations.  My guess is that the surgeon was trying to “make back” many past losses.

Insurers have bitten back on out-of-network overcharging, as noted here.  I don’t agree with the charges noted in the article (over $56,000 for a 25 minute consultation?) because they are clearly disjointed from value provided.  These instances are too often portrayed as vast overcharging and price-gouging, but they really should serve as a primer to discuss the return of value-based pricing to the system.  This is best done by allowing market forces to act far more than they can at present.