Who in their right mind would organize the main event of a surgeons’ convention around the topic of unnecessary procedures? Surely this would almost certainly guarantee an empty auditorium. But Dr. Peter F. Lawrence, President of the Society for Vascular Surgery, had the wisdom and courage to do just that when he organized the Stanley Crawford Symposium at the recent Vascular Annual Meeting. Amazingly, he was rewarded not with approbation but rather with a standing-room turnout and congratulatory remarks. For Dr. Lawrence had the foresight to realize that vascular surgeons acknowledge that it is not only physicians from other specialties who are guilty of performing unnecessary procedures but also some of our own. Further, he had the insight that the attendees would share his desire to discuss what, in prior years, may have been a taboo subject.
When he first approached me to present at that symposium on the ethics of unnecessary procedures I thought I would produce a talk that would point out how the SVS could help its members reach an ethical high ground. But I soon realized that the SVS cannot be responsible for its members’ ethics. Ethics is, after all, an individual matter. Yes, I am certain that the vast majority of our members are indeed ethical and place their patients’ interests ahead of their own.
However, as in any large group, there will be individuals who value “I” in the word “Individual” as being more important than the “i” in the word “Ethics.” “I” becomes “Me” and, unfortunately, “Me” becomes the defining factor in the equation that describes the doctor and patient relationship.
In preparing the talk I was struck that the word Individual provides clues to unethical behavior. The word contains three I’s, and three words that begin with the letter I are primarily responsible for unethical and unnecessary procedures. They are Indifference, Ignorance, and Incompetence. Perhaps the most unethical is the physician who is Indifferent: Indifferent to data, indifferent to results, indifferent to complaints, indifferent to patient suffering. This physician has no moral compass and will do whatever he or she pleases.
However, let’s start with Ignorance. I don’t want to come across as biased against other specialties, but I will not step away from a position I have frequently stated: Some of our colleagues in other specialties are not sufficiently educated in vascular diseases to be able to recognize that they do not have the judgment or skills to offer appropriate treatment. Nor do they recognize when they should refer to a vascular surgeon rather than attempt a procedure they should not be doing. How else can we explain the full metal jacket superficial femoral artery in a patient who was not even complaining of anything but was found to have a stenotic artery on routine testing?
Well, I’ll give the physician the benefit of the doubt. Perhaps the physician is uneducated about the natural history of peripheral arterial disease and believes that he or she was preventing an amputation. However, with some physicians I believe ignorance is not only a choice but an excuse!
Similarly, Incompetence is an individual problem. It seems it is a little-appreciated fact that surgery and endovascular procedures are not generic. Just as not every golfer can play scratch golf and join the professional circuit, not every surgeon or interventionalist is proficient. Rather, some will have bad results and bad results cause more procedures.
By coincidence, there are other factors that begin with the letter I that may promote unnecessary procedures and that are not necessarily related to individual mischief. Perhaps the most important I word is Insensitivity. It is the inability to recognize that one actually is ignorant, incompetent, or lacking in strength of character to the point of being indifferent to the effects of unethical behavior; that one is indifferent to the suffering of others or the moral responsibility of being an ethical physician.
But it’s not only self-driven issues that promote unethical procedures. It’s those other I’s, and first amongst all must be Income, or rather, lack of it. As long as our government does not adequately reimburse us for our work, some physicians will see volume as the only method to rectify the disparity. I believe that there were fewer inappropriate procedures when there were not as many surgeons, cardiologists, and radiologists and when they were all paid more appropriately. Related to Income is the I of Insurance reimbursement, which also drives procedures. We have only to see what happened to atherectomy after it was finally reimbursed. I am not necessarily implying that the tremendous increase in volume is inappropriate but surely it can be explained only by the fact that we are now being paid for a procedure that previously was not being compensated.
I was consulted on a patient who exemplified this point. He had no complaints whatsoever but during a cardiac evaluation was found to have an absent dorsalis pedis pulse. For no apparent reason, he was taken to the privately-owned angiography suite where he had a pedal access procedure to atherectomize an occluded anterior tibial artery. This resulted in an anterior compartment syndrome, yet the interventionalist was still enriched by many thousands of dollars. Of course, Innovations such as atherectomy may be important clinically but they invariably spur increased utilization. There is pressure to be the first to bring a new advance to the community. This may be entirely ethical if one is well trained in the procedure, but is not so if the physician jumps on the bandwagon with minimal instruction. Furthermore, Industry may also be guilty in promoting overuse by advertising benefits beyond what is known about these new procedures and by encouraging adoption with minimal oversight as to credentials. I may be overly cynical but why should Industry care who uses its device as long as it is used?
Inefficient treatments with unacceptable long-term outcomes also pose an ethical dilemma. Perform a highly compensated atherectomy, angioplasty, and stent of a totally occluded tibial artery knowing that one will be back for the next procedure in the not-too-distant future? Alternatively, bypass the blocked artery with a less well paid and time-consuming autogenous vein graft that may last for years?
Further, at first glance you may wonder how I consider Indications as driving unnecessary procedures. But consider a procedure such as renal artery denervation for treatment of hypertension that has, as yet, not proved to be worthwhile.
Couldn’t a physician justify performing it until such time as it is shown to be inappropriate even if that physician may not have much faith in its benefits?
Dr. Lawrence also charged me with evaluating whether there were differences in ethical issues between employed physicians (at universities, for example) and those in community practice who are self-employed. I would suggest that there is such a difference, especially when we evaluate the I of Incentives. And here I refer specifically to relative-value units and academic promotion.
Although I do not have a better method of evaluating work, I believe that institutions that reward employed physicians based on RVUs cause a perverse incentive to do more. Certainly the single physician is not going to be enticed by this manufactured number. Academic promotion may also incentivize a surgeon to do more, especially if it is in the area of research for which the surgeon is renowned. The surgeon who has made a reputation studying surgery for small aneurysms may find the need to operate on ever smaller ones!
Perhaps one of the most important causes of ethical lapses is the absence of oversight in Independent outpatient environments separate from hospitals. This is where most bad things are happening. Here anyone can do anything and the intervention occurs only when a major complication sends the patient to a hospital or a negligent act results in a malpractice suit. As long as the government refuses to credential who can do what in the outpatient setting we may have poorly qualified, immoral doctors let loose on their unsuspecting prey. Physicians from almost every medical specialty are ablating saphenous veins in so-called “vein centers.”
Further, some cardiologists without vascular training – and even some surgeons – with little indication are lasering tibials or inserting stents into every known artery in outpatient cath labs.
Fortunately, although the three I’s in the word Individual may explain unnecessary procedures, there is one I word derived from the single I in Ethics that denotes why almost all of us will do what is right. That word is Integrity – the quality of being honest and having strong moral principles – that will prevent us from doing what we know is wrong.
So this leads to Dr. Lawrence’s final charge to the speakers: to come up with three suggestions to help reduce unethical procedures. Although there must be many more, I would suggest the three most important would be the following:
• Only physicians who are board certified by a recognized specialty and who have been appropriately trained and credentialed should be allowed to perform procedures in hospitals and independent facilities.
• Payment must ultimately be based on outcomes where not only the result but also the indication needs to be taken into consideration.
• Medical schools need to provide courses in ethical behavior, which must be conceived as being equally as important as anatomy and physiology.
In conclusion, I congratulate Dr. Lawrence and the SVS VAM organizing committee under the leadership of Dr. Ronald M. Fairman for putting this potentially contentious subject on the program. For by so doing, vascular surgeons demonstrate that we have the courage and ethics to acknowledge some of our shortcomings. At the same time we prove our leadership as the specialty most suited to treat and protect patients with vascular disease.