Cookie-cutter cardiology

A cardiologist for the poor battles his nihilism.

A doctor's stethoscope on top of a pile of money.
I love these goofy stock images and will use them whenever I can. See, it’s a STETHOSCOPE (cardiology) on MONEY!!! (Photo by Wodicka/ullstein bild via Getty Images)

Happy Friday! This week I’m running an extra interview today, and the news roundup will go out tomorrow. But I feel like maybe Saturdays are better for the news roundup anyway? Let me know if you have a strong preference either way. I’m still figuring it all out over here.

Today’s conversation is with a cardiologist in a large Southern city. His clinic mostly serves a poorer population. I’m protecting his identity to allow him to speak freely about his situation and the kinds of pressures he faces in his work.

A few of those pressures: First, the sheer number of patients doctors are expected to see, and how that affects their ability to care for each one—and incentivizes them to order probably unnecessary tests, driving up the cost of healthcare overall. This is true for a number of specialties, as well as primary care (look out for a future interview on this topic in the coming weeks). If you only have 15 minutes to see a patient, you don’t have time to ask about the full range of symptoms, or the “exact circumstances and qualities and characters of their chest pain,” as our cardiologist says here. You don’t have time to be sure they don’t need the imaging study or the stress test, so you order it to be safe, adding to their bill and the cost of healthcare overall. On the other hand, this cardiologist says he doesn’t face this as much—caring for the poor is already so unprofitable, he says, that he can spend more time with his patients. Still, his ability to do this is “constantly under threat.”

You’ll see we also discussed the darker side of this equation—the pressures placed on doctors to order more tests for financial gain. Large hospital systems, like the one that owns the practice where this cardiologist works, do very well financially from elective procedures. During the pandemic, those procedures have dropped off, increasing the pressure on doctors to order more. We also talked about RVUs—the “relative value units,” which is a measure of a doctor’s ‘productivity’ used in medical billing; Medicare has used them to calculate how much it pays for procedures since 1992. Many large hospital systems tie doctors’ reimbursement to their RVUs, according to Elisabeth Rosenthal’s essential book An American Sickness, and some “even deduct money from a doctor’s salary if his or her RVUs are too low.” This system incentives doctors not just to “do more shit,” as the cardiologist put it, but to do more complicated, expensive shit that is billed at a higher level. (And those levels can be really, really high: Cardiac stents cost up to six times as much as in European countries, according to a 2018 study in Health Affairs.)

Check out this forum post on the Student Doctor Network, for example, on how this effects emergency room medicine (“dispo” means determining the result of the ER visit, like admitting to hospital or discharging patients, and therefore getting them out of the ER):

Another consequence of 100% RVU is the general concept of people doing less doctoring and more tests just to see more patients. There is no incentive to do anything in these ER's besides pick up patients. So if you are carrying 10-15 patients at a time, you just end up ordering a bunch of tests rather than actually being a doctor. Remember there is little-to-no incentive to dispo people as you only make money picking them up. If a doctor is given the choice of 1) dispoing a patient or 2) picking up a patient, they will always do #2. That's one reason why people with ankle sprains and ingrown toenails stay around in the ER much longer than they should.

[…]

Remember if you can either one of the following things NEXT
1) dispo a patient
or
2) pick up a new patient, spent 5-10 minutes with them, put in orders, then do #1

doctors in an RVU environment specifically have an incentive to do #2 and not #1. I want the money from the new patient.

Grim shit.

But, as the cardiologist says, it’s not just pure financial pressures: It’s also inertia, a “cookie-cutter” approach to medicine that emphasizes just doing what is always done.

It just so happens that approach tends to lead to a lot of profit at the top.

As always, our interview has been edited and condensed.

Anonymous cardiologist: I’m a cardiologist by training, and I guess I would just start by saying there’s probably not many cardiologists from the get-go work in a low-income or more underserved setting, and I don’t say that to inflate my own reputation or anything like that, it’s just kind of a fact. I think that’s due to a number of reasons, not least of which is the fact that cardiology is among the more highly remunerated specialties [...] There’s a lot of selective pressures there, but I think the people who tend to go into cardiology are not necessarily the same ones that are interested in providing care in an underserved population, for lack of a better term.

Sick Note: What are some of the incentives, other than the salary, that lead people to choose specialties that pay them a lot?

Anonymous cardiologist: I guess doctors are paid based on pay for performance, so what you do and how much you do directly translates to how much you get paid. So there are these really perverse incentives to churn through patients—I have partners who see patients every 15 minutes, which is crazy to me. Just the fact that you could in a day see like 30 patients, at a 15 minute per patient clip, and think that you are at all providing halfway decent care, is crazy to me. And I think at some level most doctors and most specialists know that to an extent, and they either just don’t care, or they’ve gotten used to it and this is the way things are. Or, and I think this is a very real thing, is when you work for a large health system, you are expected to hit certain targets. It’s very much as if you’re working in a factory, and you have to turn out a certain number of widgets per hour or something.

Anonymous cardiologist: Tell me a little bit more about these targets.

Sick Note: The basic fundamental unit of productivity or production in the US medical system is this thing called the “RVU,” the relative value unit. It’s a way of quantifying the work that doctors do for the purpose of reimbursement. It’s this exceedingly stupid and arbitrary system […] it was never meant to be a permanent solution to this issue of physician reimbursement. It somehow became codified and sclerotic and now here we are. So it’s this thing that’s clearly slanted or biased towards specialists to begin with, and then within that procedural specialists, so there’s this perverse incentive to just do more shit. 

And nowhere is that clearer than in a field like cardiology, where because of these financial incentives that are involved, the number of frankly unnecessary procedures that are done every year in the United States is kind of appalling. This is my first “real” job, quote unquote—doctors as you know, we train for a long time and I also have in addition to my clinical training, I’ve done research and stuff, so I have this academic understanding that this is the case. But now, having been in practice for a year or two, and just really seeing it—it’s pretty crazy, just the amount of shit, the number of procedures, the sheer volume of procedures that get done on a day-to-day basis, the majority of which I would say are—they range from being not necessary and in no way advancing the care of the patient, to in some instances actively harmful. 

Again, I don’t think it’s a question of individual malintent or bad actors, although that exists I’m sure, you hear about these cases of very egregious Medicare fraud where these doctors are doing some insane number of procedures in Florida or something.

Sick Note: It’s always Florida.

Anonymous cardiologist: That shit happens, but I also think there’s this institutional, there’s a lot of inertia in medicine. There’s a lot of like, this is the way I guess we do it, so we’re just going to do it. I see it in myself too. We all went into medicine for the right reasons, ostensibly, we want to help people in their time of need. I do believe that is the case for most physicians that are in practice. But once you realize that the system is what it is […] you very quickly realize, you can’t change it, you might as well go along. 

Sick Note: I want to hear more about the clinic where you work—is that a full-time thing?

Anonymous cardiologist: I think the folks that hired me with this health system knew I had this interest from the get-go, they knew I had a research and scholarly background in it. I think to their credit, they wanted to make it a full-time gig, like—this will be great, we’ll have a cardiologist in this historically underserved, underinvested part of town, where patients are largely Spanish-speaking, undocumented, uninsured or underinsured, receiving charity care, this will be great. 

I think they didn’t think it through, if I’m being honest. It’s remarkable to me that they didn’t connect the dots, like—oh wait, if we actually do this, we’ll hemorrhage money because this cardiologist who’s gone through all this training, it makes no financial sense for him to be seeing patients here when we could easily have him at the clinic on the other side of town, seeing patients and doing procedures that would generate revenue for this department. And I think they quickly realized that, and I think once they realized that it has been an ongoing struggle to try and maintain my presence out in this part of town, where I initially wanted to work all along. 

I think the pandemic certainly didn’t help that, because the way hospitals make money in the United States is through elective cases and procedures. Once all of those stopped or slowed to a trickle, when the pandemic first started to really get back, they were scrambling—they were losing money, and had to figure out how to make some of that back. And I think any time that happens, the first services to get cut are always going to be those that weren’t large revenue generators to begin with. I will say, taking care of poor people, not a huge revenue generator at all.

Sick Note: When people hear elective, they think of stuff that’s sort of for fun, even a nose job or something. I think this idea of driving up revenue with elective procedures is something they don’t even realize is happening, if the doctor is trying to up-sell them on procedures they might not need. 

Anonymous cardiologist: I think you’re right, people hear that and think, plastic surgery, having a mole removed or something. This term “elective,” what it really just refers to is not emergent, where someone is actively sick or dying and needs to have a procedure done to change the trajectory of their illness or possibly save their life. That actually accounts for the minority of things that we do, even in cardiology. 

The most classic or clear example would be something like stents. It’s basically like a little metal tube that’s inserted through a catheter into a blood vessel, and it’s supposed to open up a blocked or narrowed artery that feeds the heart muscle. The idea is that it restores blood flow to the heart muscle, and all is well. That procedure is done millions of times over in the United States, we do it day in, day out. And it’s a huge money-maker, and has in large part contributed to the financial stature and prestige of cardiology as a field, because it is hegemonic, this foundational thing of American medicine. This procedure’s done worldwide, but when it first came out three decades ago, it was this novel thing, it revolutionized the treatment of heart attacks. But now, what has happened is the indications for putting the stent in have sort of expanded over the years to no longer simply include patients who are having a heart attack, they’re actively dying and a stent will save their life. In cases like that, a stent being put in is by and large, nine times out of ten the right thing to do, and it is completely warranted and will save the patient’s life, or prevent serious morbidity. 

But the problem is the majority of stents that get put in in the United States are elective. They get put in not under situations of emergency where the patient is actively dying, they’re done because the patient maybe had some complaint of chest pain, they got a stress test, the stress test was abnormal, and lo and behold, they get a stent. It’s almost this cookie cutter thing that just happens. What we’re now understanding as more research is done into this is that’s actually not the right way to go about things at all. Beyond that initial indication of stents in something like a heart attack, where it truly does benefit the patient—not a lot of evidence that outside of that stents do anything. And yet, God, we put so many of them in, and there can be complications, and you’re committing patients to medication for the rest of their lives. There’s this whole industrial, device manufacturers have a vested interest in this whole apparatus. It’s crazy, and that’s just one example. I think as cardiology and other fields become more and more dependent on technology and devices, this sort of thing will only continue to get worse. 

[...]

I think the majority of cases of vague chest pain are not related to something serious going on with your heart. But if you are only seeing patients for 15 minutes at a time, how would you ever be able to discern what’s truly going on? It sounds so cliche, this is something they tell us in medical school and something I admittedly used to blow off, but now I’ve actually been practicing medicine it makes sense, which is—the thing we have to go on, as doctors, the best thing, the most reliable source of information—really the thing you should be basing most of your clinical decision-making on—is what the patient is telling you. Which sounds like, on the one hand, yeah of course, what the hell else would you base it on? But if that were true, you wouldn’t see nearly as many CT scans ordered. 

The reason, I have to think—and this I think now is also well documented, this epidemic of over-testing and over-diagnosis—at least part of the reason for that, far from being simply a consequence of greedy, solely profit-motivated providers, is the time constraints. If you are expected to hit certain targets, you can’t spend 45 minutes with a patient talking about the exact circumstances and qualities and characters of their chest pain. Which I would love to do! I really try to do that, actually, and that’s one of the things that drew me to caring for the underserved in the first place, is actually I felt like, ok, this particular area of medicine, because it doesn’t really pay to begin with, is kind of freed from some of these financial constraints, so I might actually have the time to chat with patients and hear their stories. That is constantly under threat, but I do find it to be true. Almost paradoxically, I do a lot less in terms of ordering unnecessary tests and procedures when I have more time with patients. 

Sick Note: Can you talk a little bit about the kinds of health problems in the population you serve?

Anonymous cardiologist: I think it’s the stuff you would expect—a lot of chronic conditions, coronary artery disease, congestive heart failure, diabetes, high blood pressure, obesity. All of these things go hand-in-hand, and I think this term “social determinants of health” gets thrown around a lot, often by people who don’t know or care what they’re talking about, but they are often disease of poverty in a lot of ways. Not always, by any means, but chronic diseases in the United States are often diseases of poverty, for a number of reasons. So I think that constitutes the bulk of what I see. 

Sick Note: It must be really frustrating when you can’t prescribe things like, “don’t live in an area where it’s only Wendy’s that you can go to.” How do you deal with that?

Anonymous cardiologist: It’s really hard. There’s two levels to that question—how do I deal with it personally, which is, I think, I’m almost ashamed to say that, I think had always erred on the side of therapeutic minimalism, but now I find myself encroaching into the territory of therapeutic nihilism. Which is to say like, what does it really matter what I do, what medications I prescribe, when as soon as the patient leaves my office, just like you said, they have to take three buses back to the segregated part of town where they are effectively living in a food desert, and they have to piece together a meager salary from three different jobs as a home healthcare aide? All these things, when you think about it that way, it probably doesn’t matter so much that I am treating them exactly in accordance with the most up-to-date contemporary cardiology guidelines. 

So then, I try to modify my practice so that like—this is what I say to my patients, my job is to make it as easy as possible to take your medications. I want to make this so easy for you. Many of these medications are prescribed, two times a day, three times a day—no one can do that, let alone somebody who is mired in the circumstances I was just talking about. So I find myself thinking a lot, about, okay let’s think through this—you get up at this time because your first shift starts then, ok, maybe you could take this medication on this first break… It’s interesting, I have come to almost like that intellectual aspect of it, but it’s very different from the type of medicine that I guess any of us thought we’d be practicing. When you’re taking care of patients that are subject to such constraints, you alter the way you think about treating their disease. Always nagging and lingering in the back of my mind is, I’m probably not doing as good of a job as I could be in treating this patient’s heart failure or blood pressure, or anything. And it kinda sucks. I think there’s a real sense of nihilism or fatalism that I always have to keep at bay.