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My Own Trip Into the Treatment Trap .... A Cautionary Tale

MANAGED CARE March 2014. © MediMedia USA
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My Own Trip Into the Treatment Trap .... A Cautionary Tale

The author reviewed and rejected all four options offered by his ENT and lived to tell about it

Al Lewis

After the first taping of my radio show (The Big Fix, in case anyone wants to check — http://wamu.org/programs/bigfix — on the off-chance that it’s still on the air), the producer asked if I had a cold, which I didn’t. Not wanting to be fired my first day on the job, and recalling that someone once told me I had a deviated septum, I immediately called my primary care physician (PCP) for advice.

Appointment made

Now, most PCPs like to satisfy patient requests (among other things, their compensation increasingly depends on satisfying patients by giving them what they want — whether they need it or not) and mine is no exception. She immediately set up an appointment for me to see an ear, nose, and throat (ENT) specialist.

The ENT used a gadget to look in my nose, and then announced that my deviated septum was the least of my problems, and that I had: polyps. She suggested surgery, steroid nasal spray, or the nasal spray combined with a three-week course of antibiotics. She also recommended scheduling a CT scan of my sinuses for the following week. “So,” she asked after quite literally seven minutes explaining the surgery and other treatment options, “which do you want to do?”

Seven minutes … and already the treatment trap beckons. Amazingly, in just this short period of time, the ENT is in the process of making five treatment trap errors. Let’s start with order of therapy, which was my initial question.

“Um, shouldn’t we start with the most conservative therapy?” I inquired.

“Well, you could,” she replied, using a tone of voice that, to me at least, implied that while I could, only an imbecile actually would. Of course, conservative treatment is supposed to go first, but like butchers, hairstylists, and corporations, doctors are people, too. The more they do to you (in most cases), the more they make. Conservative therapy is therefore the least profitable course of treatment. Hence, the subliminal marketing of the surgical option.

Second, the surgeon didn’t mention any drawbacks or risks of taking a course of antibiotics for three full weeks. How many people would think to challenge a doctor recommending antibiotics? After all, when we were kids we practically lived on those things, which for our own kids now come in delicious flavors, cherry being my kids’ favorite. However, antibiotics are far from harmless, especially when taken for a long time, which is why they still require prescriptions almost a century after the discovery of penicillin.

Third, speaking of antibiotics, the surgeon didn’t even hypothesize that the cause of my problem was bacterial, the only instance in which an antibiotic would be indicated. She asserted instead that “some people report getting relief by using the antibiotics.” More than coincidentally, “some people report relief getting by…” is also the classic “before” comment in an evidence-based medicine continuing education session.

Doctors are supposed to follow evidence-based guidelines, but recommendations that start out with that phrase are not found in any guidelines.

Nothing to learn from the scan

Fourth, recall she also wanted to schedule a CT scan the following week. But such a short follow-up interval after I filled the prescription would not have given the nasal spray a chance to work. And, I already had a diagnosis, so there was nothing else she could learn from the scan.

Had I bothered to ask the key recommended questions, (see “Four Questions To Ask Before Any Non-Routine Test,” below) this proposed test would have flunked three of them.

Four questions to ask before any non-routine test

  1. What do you hope to learn that you don’t already know?
  2. Is there a potential danger if you don’t order this test?
  3. Does the test itself pose any risk of complications?
  4. What is the probability, and consequence of a false positive result?

Although her staff conveniently made the CT scan appointment for me (I didn’t even have to ask), I had enough sense to cancel it. Among other excellent reasons for avoiding them, sinus scans introduce 100 x-rays’ worth of radiation into one’s skull plus a color of dye into one’s veins that is not found in nature nor should be. Yet, people tend to acquiesce in or even request “scans” because, like phrases in the wellness industry such as “health fair,” the word “scan” sounds much more innocuous than it is, conjuring up images of using binoculars to view the horizon, an action which leaves the horizon none the worse for wear. When recommending a scan, doctors rarely mention this dye and radiation, let alone the IV and the potential discomfort and side effects.

So, I had enough sense on my own to pass on the surgery, pass on the CT scan, and pass on the antibiotics, but I went ahead with the nasal spray. What the heck, I thought — how bad could that be? It’s just nasal spray.

Pretty bad, it turns out, which brings me to the fourth treatment trap mistake. After I bought the drug (or more accurately, after the other members of my health plan treated me to the drug) and used it a few times, I read the medication package insert, which revealed that one of the nasal spray’s potential side effects was: hoarseness.

Recall from the beginning of this story that hoarseness was precisely what I was trying to alleviate. So, the surgeon was 4 for 4 on bad ideas, which is exactly why you never want to get near a surgeon except as a last resort.

I was done with that doctor. I solved my immediate problem by simply talking louder and letting the studio engineer calibrate his volume instead. If, by the time you read this, The Big Fix (“Policy without Politics”) did not get renewed, it won’t be because my voice sounds like that guy on Boardwalk Empire whose vocal cords were blown up in World War I. It will be because I’m not a very good radio host.

Indeed, a few people did complain, not without justification, about other aspects of my hosting skills, but no one wrote in to say: “This guy sounds like he needs his polyps removed.”

And, then the fifth and final insult: Obviously I stopped taking the medication, and never scheduled a follow-up visit. A month later, I received a bad “report card” from MedImpact, my health plan’s pharmacy benefit manager (PBM), due to my failure to renew the nasal spray, a failure that they said “may need immediate attention,” without mentioning that they gross about $10 every time someone fills a prescription, making report cards the PBM industry’s air filters.

PBMs, like the rest of the health care system feeding on your benefit dollars at your employer’s trough, apparently are people, too. Seems like the whole health care industry is comprised of people.

Postscript

Many people have observed that this will all change when payment mechanisms change, and physician practices stop getting paid more for doing scans using their own equipment and especially for doing more surgeries.

Such a payment mechanism is called “capitation,” where the practice’s revenues are based solely or largely on their number of patients, not the number of things they do.

This scenario makes some sense in theory — but this particular practice already is capitated, and doesn’t own a scanner. My take-away from this experience was that doctors do doctor-type stuff because they’re doctors, and unless you literally take away any payment involved in doing more, they will continue to do what they are trained to do.

Al Lewis is the founder of the Disease Management Purchasing Consortium.

This is an excerpt from Surviving Workplace Wellness by Al Lewis and Vik Khanna. It is used here by permission of its publisher, The Health Care Blog.