Wednesday, May 27, 2009

All You Want To Know You Already Knew

Sometimes I wonder if I'm the only person in the world who occasionally reads findings and conclusions by experts in the health care field and say to myself, "Well, duh!"

Two such studies appeared on the Internet today. One debunked the practice many cardiologists prescribe for wearing tight stockings to prevent blood clots in heart attack patients. The other torched the myth that exercise will turn you into a fat-burning machine.

But a third report, an essay written by a Long Island medical specialist, answered a lot of questions I had about the buddy system practiced in doctor referrals.

Okay, taking one at a time. The tight stockings study of 2,500 stroke patients by a London research team concluded the stockings did nothing to reduce the chances of a clot. Not only that, but they caused problems like skin ulcers and blisters.

I have personal experience with those damn stockings although in my case they were said to improve my Venus blood circulation on the return trip from feet to heart. They didn't. Besides, I came close to cardiac arrest just trying to put them on. Even the nurses in a physical therapy hospital labored furiously albeit with more success.

The study on exercise conducted at the University of Colorado trashes a misperception that diet doesn't matter as much as physical workouts.

“People think they have a license to eat whatever they want, and our research shows that is definitely not the case,” says Edward Melanson, an exercisiologist and associate professor of medicine at the University of Colorado in Denver.

In the new report, published in the journal Exercise and Sport Sciences Reviews, Melanson and colleagues discuss research to date on the issue of burning fat during and after exercise. The authors conclude that while people do burn more fat when they are exercising than when they are not, they have no greater ability to burn fat over the next 24 hours than on days when they are couch potatoes.

Do you get the feeling such as me -- "I knew that"?

Of much graver importance is the custom how and why primary care physicians refer patients to specialists. In practice, its a case of networking and the buddy system in which ethics are at issue but not as severe as it would be of pharmaceutical salesmen offering kickbacks to doctors for pushing their products.

Sandeep Jauhar is a cardiologist on Long Island and the author of the recent memoir “Intern: A Doctor’s Initiation.” Here are excerpts from his essay published in The New York Times.

Physician-to-physician referrals are the currency of day-to-day transactions in medicine, but as with any currency, they can be manipulated.

Logic says that a referral should depend only on a patient’s needs and the reputation and skill of the physician to which the patient is referred. But medicine is a business too, so that isn’t how it always works in practice.

The talk springs up in every doctors’ lounge: “Dr. X is opening shop — let’s give him some business.” When my wife told me she wanted to start an endocrinology practice, I reassured her that I would send patients to her, and that so would my brother, also a doctor, and his friends. As far as I can tell, there are no restrictions on such a practice.

Studies suggest that physicians receive up to 45 percent of new patients by referral, usually from other physicians. Referral rates to specialists in the United States are estimated to be at least twice as high as in Great Britain.

The rates reflect several aspects of American medicine: increasing specialization, the lack of time for any doctor to give to complex cases, and fear of lawsuits over not consulting an expert. At the same time, referrals are a way for cash-strapped doctors to generate business.

When I was in training, simple referrals from internists, like patients with only mild hypertension, bothered me as a waste of time. Now that I am in practice, I welcome them. I haven’t changed my mind that these referrals are probably unnecessary, and there is plenty of evidence that wasteful expert consultation is adding to health costs and creating redundant care. But as a full-fledged doctor, I appreciate the business. It is hard not to view a referral as an overture from another physician, and it is equally hard not to return the favor.

A sort of paradox is at work. Specialists are better paid than primary care physicians, but they are also less autonomous because, unlike primary care physicians, they depend on other doctors for referrals. There is pressure on specialists to keep referral sources happy, especially in doctor-saturated metropolitan areas like New York City.

There are limits, of course, on the autonomy of referring physicians, too. For instance, by federal law a doctor cannot refer patients to himself or to a business in which he has a significant financial stake, like a laboratory or imaging center, and he cannot be paid for a referral. The reasoning is that such behavior can interfere with clinical judgment, decrease quality and increase costs.


But there are gray areas in practice. The Office of the Inspector General in the Department of Health and Human Services has investigated office space rentals, for example. Across the country, mobile medical imaging companies have made arrangements with internists to perform, in their offices, cardiac ultrasounds, which the companies send to cardiologists for interpretation. Insurance companies that cover the imaging pay the companies, and the companies pay rent to the internists. By law, these rent payments must reflect fair market value and be unrelated to the volume of patients referred by the internists for imaging. But according to doctors familiar with these agreements, that isn’t always the case.

“Obviously you get more rent if you provide 50 patients than if you provide 5,” an internist on Long Island, who did not want his name used, told me.

When I asked whether it wasn’t just a form of a kickback, he shrugged.

“When the companies take more time, they have to pay more rent,” he said. “You don’t say it is per patient; you say per hour. But patients equal time.”

Though he no longer participates in these contracts, he was open about the payments — about $100 per patient — and he saw nothing wrong with them. “As internists, we don’t bill for procedures, so we have to figure out another way to make money,” he said. “Every little bit helps.”

Whether the rent payments amount to indirect kickbacks is an open question still being investigated by the inspector general. The real issue, I think, is not the rentals but a referral system that is too easily corrupted. There is so much pressure to generate referrals that lines become crossed.

Our health care system needs a different approach, one in which patients are not treated as commodities.

Well stated, Dr. Jauhar. Not always, but a few times, I as a patient felt like I was treated as a commodity. Another piece of meat inspected on a conveyor belt.

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