An odd fight to pick

Recently I took some time to criticize Dr. Andrew Weil, about whom I continue to know very little. My beef was with his recommendation that direct-to-consumer pharmaceutical marketing be banned. However, as far as famous-doctors-who-probably-are-incredibly-rich-and-blog-at-HuffPo are concerned, he seemed relatively benign.

Well, it seems that Dr. Tuteur over at Skeptical OB begs to differ. She's taken after Dr. Weil a couple of times. I will let you check out her post on Dr. Weil's thoughts about preventive medicine yourself. However, I'm a bit perplexed by her more recent gripe.

In his post Fear, Greed and X-rays, Dr. Weil wrote:

Along with over-scanning, over-biopsying, over-blood-working and other diagnostic excesses, fear propels over-treatment. Anytime a physician diverges from standard U.S. treatment protocols, nearly all of which skew toward expensive drugs and surgery, lawsuit-fear looms. "Defensive treatment" strips physicians of clinical judgment, costs billions and leaves patients less healthy, but it's hard to blame physicians who practice it. As one wearily told me, "You never forget your first lawsuit."

Physicians like to discuss the fear side, because it shifts the blame to lawyers. The greed side, however, deserves just as much scrutiny and reform. Consider "The Cost Conundrum: What a Texas town can teach us about health care," a must-read New Yorker article by Atul Gawande, M.D. Gawande visited McAllen, Texas, to discover why per-capita health care expenditures there are the highest in the nation. He found that many physicians in high-medical-cost cities such as McAllen have a diversified "revenue stream," the result of what one hospital administrator termed "entrepreneurial spirit." This "spirit" often manifested in physicians owning their own medical testing equipment, which meant the more tests they ordered, the more money they made. A 2002 University of North Carolina study showed doctors who own imaging equipment sent patients for roughly two to eight times more imaging tests than those who don't own.

[snip]

To quell the fear that drives physicians to over-test and over-treat, we need vigorous legal reform to cap malpractice payouts. Staunching the greed motive requires a more dramatic change. Since a single CT scanner can bring in $400,000 a year in profit, it's vital to sever the link between ordering tests and making money. Restricting ownership of testing equipment to nonprofit, government, or independent private entities is crucial.

As for popularizing less lucrative -- but often better -- low-tech treatments, putting physicians on salary can also help. Whether the paycheck comes from a nonprofit organization such as the Mayo Clinic or some variety of single-payer national health care, stabilized incomes would let physicians more readily focus on the health of their patients rather than on their own finances.

Dr. T responds:

Does greed play a role in healthcare? Unfortunately, in the case of unethical practitioners it does play a role. Should greed play a role? Of course not. So please tell us, Dr. Weil, why we should pay the least bit of attention to your faux outrage? None of the products that you hawk are essential and most do not even provide the health benefits that you claim for them. The only thing they do is line your own pocket.

You're right, Dr. Weil. Patients shouldn't trust doctors who recommend treatments that provide financial benefit for the doctor and little if any health benefit for the patient. In other words, Dr. Weil, by your own logic, patients shouldn't trust you.

Hmmmm. I'm giving this one to Dr. Weil.

First of all, over-testing because you fear a potential lawsuit is a real phenomenon. Ordering tests "just in case" motivates a lot of unnecessary blood tests and CT scans. I fully support capping malpractice claims, and creating a means of tort reform that alleviates the culture of fear that pervades contemporary medical practice.

But I think it is 100% appropriate to call for an end to the unethical, egregious practice of physicians owning the same testing equipment they refer patients to use. It defies any sense to pretend that such double-dipping does not create an incentive to order tests that aren't necessary to bulk up the "revenue stream." Further, I can attest that linking patient care to revenue creates an unhealthy dynamic in which patient care becomes a commodity. I fully support making physician pay salaried, and decoupling it from revenue generation.

Finally, there is a difference between buying some specialty tea or other product because you choose to spend your money that way, and getting a test or procedure because you trust your doctor that it is necessary. People view famous alternative medicine practitioners (who, for the record, I think are in the business of hooey) differently than they view their primary care physicians. If people with the cash to spend want to buy some kind of crack-pot olive oil, who am I to stop them? But it undermines the trust we as physicians rely upon if our colleagues are using that trust to order tests people don't need in order to line their pockets.