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countries like the United States, one idea sounds simple: Just get
doctors to quit ordering unnecessary procedures and tests. An
article published on the US business news web site, NPR, says
evidence suggests that some doctors dole out more treatment, and yet
their patients don't fare better. If you talk to doctors, though,
the idea of cutting back starts to sound more complicated. Take, for
example, Drs. Paul Teirstein and Eric Topol. Both are interventional
cardiologists practicing at Scripps Health in San Diego. Yet the two
physicians see their field, and health care in general, from opposite
poles. Teirstein calls Topol a good friend, but says, 'We disagree a
lot. I find him challenging.' Dr. Eric Topol, also a cardiologist,
says doctors have an incentive to use stents more often than
necessary. One of their biggest disagreements concerns stents,
tiny metal tubes that cardiologists use to open clogged arteries and
relieve chest pain. Studies show that cardiologists sometimes use
stents in scenarios where research would indicate they are
unnecessary. Topol says he believes as many as 20 per cent of all
stents aren't really needed. He notes that annually, 1.2 million
patients undergo a stent procedure. 'Undoubtedly, that's more than we
need to do,' he says. Sitting in the same California hospital,
Teirstein says he's not convinced by the research Topol leans on.
Teirstein is an ardent believer in the technology and puts in an
average of seven stents a day. 'I definitely have a bias towards
stents,' he says. 'I have a lot of experience with stents. I've seen
patients do so much better.' It's clear that many patients with
serious blockages in their arteries have benefited greatly from
stents. But a lot depends on the exact type of treatment involved. A
trial called COURAGE — short for Clinical Outcomes Utilizing
Revascularization and Aggressive Drug Evaluation — found that for
patients with ' stable angina,' stents are no better than drugs at
preventing heart attacks or death. Drugs take a while to work,
Teirstein argues, while stents offer an 'instant fix.' After surgery
to receive a stent, patients tend to go home quickly and feel better
almost immediately. Topol counters that cardiologists, like most
doctors, get paid on a fee-for-service basis. The more stent
procedures they do, the more money they make. Topol says that dynamic
has to drive up the number of stent procedures. 'Some of it is
financially motivated, but at a subconscious level,' he says.
Teirstein says income is not the driving factor. 'The physicians I
know do what I do, which is say, 'If this was my mother or father,
what would I do?' Financial incentive is the last thing you think
about,' he says. 'What is inspiring is trying to help a patient.'
If policymakers are to uncover health care savings in curbing
unnecessary procedures, they' ll need doctors to believe that at least
some of what they do is wasteful. As the ongoing conversation
between Teirstein and Topol shows, individual doctors make sense of
the available research differently, as each makes choices for
individual patients. The one thing Topol and Teirstein agree on is
that they want to be able to make those choices. They're fine with
telling each other what to do, even when they don't agree. They just
don't want the government or insurers telling them what to do.
