Monday, March 18, 2013

If Treatment Is Expensive, Is It Therefore Effective?

           Our hospital CEO mentioned at an administrative meeting the other day that an anesthesiologist who owns a pain clinic on the mainland is aggressively pursuing an appointment with her.  He wants to talk, she thinks, about providing some service on our island.  She says that he has an impressive website and 20 employees.  We Googled the website at the meeting.  It is impressive.
            She’s been resisting the meeting on the grounds that he wouldn’t find enough work here, but he’s insistent.  She’ll meet with him soon, I imagine.
            What can he offer?  Treatment for pain, certainly.  How?  Simple things are already available here, so he will probably want to offer complex and expensive options – injections (the website lists more than 15 general types), implanted drug delivery systems, and implanted spinal cord stimulators.
            Though he’ll probably want to do procedures, he will probably not propose a complete coordinated multidisciplinary service.  Still, wouldn’t that be great?  Somebody could come help us stamp out pain through technology and drugs.
            But there’s a question.  Do interventional pain procedures really stamp out pain? I had dinner last week with an old friend from the University of Washington, an anesthesiologist who has been involved in chronic pain work for more than 40 years.  In his view, there’s very little objective evidence that any of the expensive, high-tech new therapies work well in treating or eliminating chronic pain.  In particular, few double-blind studies justify the procedural approach to pain relief, despite its popularity and despite the fact that pain docs bill bushels of money for performing these procedures.
            Our CEO is one of the smartest and most dedicated administrative people I’ve ever known.  But she’s in no position to say, “Yeah, well prove that all this expensive stuff works, Bub.”  Instead, she may feel obliged to make space for a doc who wants to do procedures that produce substantial revenue for the hospital.  She’s obliged to serve the hospital’s financial viability, not make judgments about the efficacy of expensive treatments.
            So she may need to support procedure-based medicine that sounds good and is reimbursed without question by all insurance companies, whether or not it’s really of lasting value to patients.  She can’t question the value of pain procedures, any more than she can question the value of invasive cardiac procedures or cancer therapies.
            But there’s certainly room to question.  Who should be doing that?
            Jeffrey Parks questions.  Dr. Parks is a general surgeon who blogs courageously as Buckeyesurgeon.  His most recent entry refers to a review of Broken Hearts: The Tangled History of Cardiac Care, a new book by Harvard medical historian David S. Jones.  Jones’ book, he observes, “explores the rise of interventional cardiology and cardiac surgery since the 60's and how much of the rationale for such a procedure-dominated treatment strategy is undergirded by some surprisingly shoddy data.”
            Parks says that Jones’ book cites the troubling lack of evidence from controlled trials that either coronary artery bypass grafting or less-invasive coronary stenting has any demonstrable effect on survival when compared to medical management of coronary artery disease.  Parks recalls no time during his surgical training when he heard cardiac surgeons question whether CABG procedures were effective, though they lamented the decline in such procedures, as it restricted new jobs available for fellows.  Cardiologists, too, he says, have persisted in inserting coronary stents in spite of lack of evidence clearly showing improved long-term survival.
“We may be too far gone to change anything,” Parks says.  “The coronary intervention/surgery sector is a $100 billion industrial complex.” The idea that the medical/pharmaceutical/industrial complex might be as troubling as the military/industrial complex against which Dwight Eisenhower warned us is increasingly part of conversation now.  See Steven Brill’s lengthy Time Magazine piece entitled “Bitter Pill: Why Medical Bills are Killing Us” . Brill covers a lot of ground, but he’s pretty clear that medical billing is out of control.  Hospitals charge whatever they want, according to seldom shared price lists that he calls “chargemasters.” People pay whatever their insurance companies have negotiated – except for the uninsured, who are expected to pay the hugely inflated prices of the chargemaster.  It’s been that way all the time I’ve been in medicine, but the gap between what’s charged and what’s paid is much greater now.
When I was diagnosed with prostate cancer in 2000, I didn’t care how much it cost to cure it, if somebody else was paying.  And I definitely didn’t want to wait for double-blind studies to validate the treatments that sounded best to me. I found it difficult at that time to compare one treatment with another, and very difficult to get an idea of the side effect and survival profile of any particular treatment.  At some point I realized that it was virtually impossible to get any information on the difference between being treated and not being treated.  I had some idea what might happen with different treatments, but almost no information on what would happen if I took no treatment at all.  I could clearly see that some people were dying of prostate cancer, but I couldn’t see clearly that any of the treatments I was looking at would have “saved” those people.  Controlled trials were completely unknown.
I asked the physician who ultimately became my treating physician in Georgia why it was so hard to get good comparative data, and why people seemed so reluctant to be objective about the treatment they offered.  “It’s big money,” he said.  Each of the docs offered only a single treatment modality – external beam radiation, seeds, prostatectomy, cryotherapy, and so on. And everybody was so desperate to hang onto the big money in cancer treatment that docs simply could not afford to have their business fall off substantially if patients moved to a more appealing treatment, one which would be provided by somebody else.  Objectivity was an expensive luxury for docs maintaining a state-of-the-art treatment center.
Treatment was expensive even then, thirteen years ago -- $25,000 to $50,000 – and it was paid for because the treating docs believed in it and convinced insurers of their beliefs, not because they’d clearly shown effectiveness.  They knew that they could make prostates disappear, but they didn’t know whether that would make a long-term difference in who survived the disease.  And not one of us wanted to wait ten or fifteen years for results, imagining all the time that the disease was crawling through our innards and destroying our precious generative organs.  We patients were never, ever, going to argue for restraint in medical spending, especially if somebody else was going to pony up the money for us.
On another note, I’ve been interested in end-of-life care for a number of years.  I’ll practice palliative medicine when I leave the OR, and I’m training in the meantime to be a hospice volunteer.  In addition, Jan and I have just been through the process of filling out extensive end-of-life directives with each other.
I’m reminded especially, now, that medicine at the end of life is more of the same.  We fear death, and we do whatever we can to avoid it – we commit ourselves to operations, to chemotherapy, to intensive care, to CPR, to intubation and artificial ventilation, to tube-feeding. When we lose the ability to choose, those who love us may commit us to these same options.
As a society, we support that. Medicare will pay for any care a doctor orders, including all futile efforts at preserving fleeting life at the end. On the other hand, Medicare pays a severely limited amount of money for six months for a patient who elects hospice care.  How much of this limited care do people on Kauai actually use?  We learned that on Kauai people who come to hospice get an average of three weeks of care.  We’re that afraid of giving up.
Here’s where palliative care has a role, the search for what Ira Byock calls “the best care possible,” not simply the most interventions.  Right now if we simply insist on the next possible treatment, Medicare will pay for it all, no matter how futile.  On the other hand, if we actively make a selection in favor of pain relief, comfort, support, and gentle death we swim against the tide of technology, and we find that money available for our care is limited and carefully doled out.
            We have plenty of money to provide good medical care. Powerful forces distort the distribution of this money.  Our medical/industrial/pharmaceutical complex has effective ways of attracting money preferentially to the new and glamorous – not necessarily the effective.  Not all that money improves patient health.
            On a final note, a group of Canadian docs who were teaching in the Difficult Airway Course pointed out an interesting difference between their practice and mine.  In Canada, they said, the money is all on the table at the start of the game.  Surgeons and proceduralists do procedures that use up the money, and are regarded as cost centers.  In the US, on the other hand, hospital income comes from reimbursement for medical procedures.  Surgeons and proceduralists do procedures that generate revenue for themselves and for hospitals.  They’re revenue generators.  Cost center versus revenue center.  Which has the most power?  How can we expect hospital systems to resist the temptation to support procedures that increase revenue, no matter how poorly-studied they may be?  Whose job is it to put a flag on the play when a medical procedure is unstudied?  Or worse, studied and shown of little value?  If we stop paying for unproven procedures, will we have anything left we can offer?

Thursday, January 31, 2013


        Today was the day for my cataract removal – technically, a phacoemulsification and insertion of intraocular lens in my left eye.  That’s my only working eye, about which more later.  If you haven’t thought about how that’s done, here’s a nice short video:
         Basically, the surgeon puts the eye to sleep, exposes the lens, inserts a device that emulsifies the lens (sort of like putting a portable blender into a pot of boiled potatoes and moving it around until you have a pot of mashed potatoes), then sucking it out.  The intraocular lens is a piece of optical plastic slipped into the cavity created by the absent natural lens, held in place by springy arms that extend out to the sides.
         It’s highly skilled bit of surgery that has become very common.  I’ve watched more than a hundred, and thought it looked as though patients had a pretty easy time.  However, I now know that their experience is more complicated than I thought. 
For several days now I’ve been dousing my eyes with eye drops to kill bacteria and reduce inflammation in preparation, as well as washing with antibacterial soap and scrubbing eyebrows and lashes vigorously to exfoliate bacteria-containing debris.  I now have a really clean eye.
         Though patients usually don’t get more than topical anesthesia and an oral valium pill, they’re treated as though more anesthesia might be necessary.  An anesthesiologist is at hand, an IV is started, and the patient refrains from eating or drinking after midnight to ensure an empty stomach.
         I was to report at 0645 this morning, to be the second case.  I arose at 0430 and made Jan’s breakfast while she cleaned up.  Thinking that I might absent-mindedly take a bite of food or a drink, I plastered a piece of packing tape over my mouth, good for a laugh when I brought Jan her tea.  As it turned out, the tape was a good idea.  I made a mess out of peeling a hard-boiled egg, and only the tape prevented activation of the reflex that causes me to dispose of food mistakes by eating them.  I would have stuffed the whole mess into my mouth to keep Jan from seeing it.
         At the hospital, I thought I knew the drill for the procedure, so I thought I’d be pretty relaxed. Check-in was easy, and soon I was perched on the gurney that I would ride into the eye room.  My anesthesiologist chatted affably as he waited for his first case to be ready, and in short order my nurse began my check-in procedure -- name, birthdate, name of procedure, scan of name tag, scan of all medications, administration of eye drops for numbing and dilation of the pupil. After the eye drops, the nurse placed a tiny sponge in my lower lid and taped the operative eye closed. Finally, it was time for the IV.  My nurse recruited a colleague with a reputation as the best IV starter, and even though she had been up all night she inserted a truly painless IV.
         And then I waited.  Blood pressure had been about 130 over 80, so I knew I was more uptight than I’d admitted.  The valium helped, and simply closing my eyes and relaxing helped.  It was hard to open my eyes without dislodging the tape holding the operative eye closed. Jan held my hand and we talked as we waited.  I thought I was being careful not to start mumbling so Jan would believe she was witnessing my superior self-control, not merely the effect of a potent drug.
         And then it was time.  Down the hall, into the room, monitors on, head down, pillow down to my knees, head wedged into position, oxygen under my nose, Velcro snuggie wrap around my torso, drapes ready to pull up over my face.  Betadine eye scrub, more local anesthetic drops, sticky drapes over the eye after sheets are pulled up over my face.  I had a moment of wondering whether I was going to turn out claustrophobic.  It passed.
         I heard the surgeon’s voice, and in a minute the microscope swung into place over me as he asked the anesthesiologist to lower the bed slightly.  The springy eyelid retainer clicked into place in my eye, and a blinding light gave me an overwhelming urge to close a now wide-open eye.  “Some cool drops…” said the surgeon, an opening line I’ve heard over and over again as he starts a case.
         And he was at work. I could feel pressure and movement, but not at first any discomfort.  As we progressed I realized several times that I was responding to minor discomfort in the same way I do in the dentist’s office – by tensing up in anticipation of the big pain that never comes.  So I relaxed, consciously, several times.  Blood pressure stayed up a bit, and I could hear the occasional skipped heart beat, testimony that the patient hadn’t quite gotten over being a little uptight.
         The surgeon was calm and directive – “look at the black bar between the lights, look down an inch, look down again, thank you, you’re doing very well.” I heard the phacoemulsification process begin, and had an impression of the light image in my eye being fractured into a bunch of sparkly pieces.  Maybe I made that up.  In no time, the old lens was out and the artificial lens had been inserted and I was done, aware of blurry vision in the operated eye as drapes were untaped from my face (really the only uncomfortable part of the procedure).  I sat up, and the gurney was conveyed royally back to my starting point.
         Another vital sign check proved I was still alive, so Jan was invited in and a delicious cup of coffee appeared, along with the ophthalmologist’s special healthy cookie and two kinds of less-healthy hospital crackers.  As soon as the coffee was gone, I was allowed to put on my shirt and retire briskly to the bathroom.  Where does all that water come from when you haven’t had a drink since the night before?
         I was ready to leave.  I could see tolerably, partly through the perforated aluminum eye patch over the operated eye, and partly through my other “bad” eye.  My right eye is amblyopic, ostensibly because the brain turned it off when I was a kid to resolve double vision.  So forward vision in my right eye is very limited.  It looks like your vision looks when you push your eye for a minute and then let go, sort of all blackish (I was explaining this to a nurse the other day and she gave me an odd look, saying “Who ever pushes in on their eye like that?”). Whatever I look at directly is blacked out, and the blackness spreads the more I stare and try to resolve the picture.  The only solution is to keep moving the eye around, so I look pretty shifty when I’m trying to see with the bad eye.  It’s useless for advanced life tasks – reading, driving, cutting up food, repairing machinery, practicing medicine.  But it works fine for avoiding walls and noticing when somebody else is in the room.
         So right now I’m using the vision through my perforated eye patch as I type this, while my “bad” eye continues to supply the right-side peripheral vision that it’s supplied so dependably all these years. My experience with the eye patch makes it clear why perforated aluminum is so seldom used in the lenses of spectacles, despite its obvious advantages in durability on the playground.
         I see the ophthalmologist tomorrow morning.  I hope he’s right when he says that vision will get better and better.  I’m ready.
         When I was leaving the hospital to walk out to the car, I was laughing very readily, finding humor in nearly everything.  Jan asked if I was always this way at work.  I said I thought so.  I thought I was good-humored and easy to work with.
         Now it’s afternoon, and I have better perspective.  I’m afraid that was the valium talking this morning.  I’m not actually jolly at work, and perhaps often not even pleasant.  I can see that it might be fun to be that way, though…
         Amazingly, my ophthalmologist called me personally this evening to see how I was doing.  I was moved by the gesture, and my already high opinion of my ophthalmologist has moved even higher.

Sunday, January 27, 2013

The Eye Man Cometh

“Better than a poke in the eye with a sharp stick…”

         This week I’ll pay a man to stick a sharp knife in my only functional eye.  He’ll destroy the lens through which I’ve watched my life for 68 years and leave an oddly-shaped bit of clear plastic in its place.  He’ll do all this under topical anesthesia while I’m wide awake.  He’ll make only a tiny incision, much smaller than the lens that he’ll insert, which will start out as a tightly-rolled cylinder and unroll once it’s in the eye.
         This lens, I expect, will restore my once-dependable distance vision.  I could once see so farsightedly, even without glasses, that I was the go-to guy for visual ID questions.  When we travelled, I could usually read the road signs before anybody else in the car.          
         Now, especially in the past year, my ability to resolve detail at a distance has deteriorated alarmingly.  I can’t see small boats on the horizon, I can’t see the whale spouts when Jan points them out, and I can’t read many street signs until I’m abreast of them.
         When we visited Sacramento in October, I drove downtown by myself early in the morning to meet with my men’s group.  Looking for “P” street, I found that I suddenly could not read any of the single-letter signs against the sunrise-bright sky.  I groped my way to the meeting, guessing at familiar sights, feeling for the first time in my life visually impaired.
         In Las Vegas in November, I had the same experience of being unable to read freeway signs against a bright sky unless I already knew what they said.  I found I was leaning heavily on Jan as a sign-reader.
         Driving at night has become incrementally more difficult, and I have difficulty seeing the road in the glare of some oncoming headlights.  When we go to dance lessons, even the brilliant green of the multiple traffic lights at our turnoff from Kuhio Highway seems blinding, forcing me to shade my eyes so I can see where to turn.
         Roadside objects emerge surprisingly from the scenery.  Walkers and cyclists appear on bright days where there was only a shady berm seconds before.  Dark cars with their lights off suddenly appear on empty pavement at dusk and dawn.  People who think they can be seen just have no idea how invisible they are to somebody with even a little visual difficulty.
         My appointment with my ophthalmologist in December revealed that things were actually as bad as they seemed.  It was not likely, his optometrist told me, that I’d be able to pass eye exam for a Hawaii Driver’s License now.  Lord, how the mighty have fallen…
         So it’s time to have the cararact extracted.  I’m on the edge of being significantly impaired, of being unable to read well, of being unable to drive, and of being unable to practice medicine. (“I’ll be putting a breathing tube in your windpipe, ma’am.  I can’t actually see it that well any more, but I’ve done it lots of times and could pretty much do it in my sleep.  Pretty much…”)
         I’ve taken care of lots of patients having this operation, and have watched this surgeon do dozens of these without a hitch.  In fact, I’ve admired his technique from the first time I sat in his room, everybody silent, all the details just so…  And now it’ll be my details that will be just so.
         For a long time I feared having this procedure, back in the days when retrobulbar block with a needle behind the eyeball was the standard method of regional anesthesia for the procedure.  I knew the block usually went well, but with only one eye that works, I wasn’t eager to risk any complication at all from such an injection.
         And now, most surgeons do this operation with topical anesthesia.  Even though we still make a big deal out of it, which it is, surgically, the patient’s experience is more pleasant by far than the average visit to the dentist. Jan reminds me that people don’t even know about eye pain unless they’ve had lids and eyebrows tattooed, a procedure that seems increasingly common here.
         So I’m not nervous.  I’m eager.  Tomorrow I’ll undertake my three-day regimen of eyelash cleaning and cleansing eyedrops, and Thursday I’ll have more to tell.