Frank L. Urbano, MD

I want to respond to the negative experience that Al Lewis details in his March 2014 Viewpoint “My Own Trip Into the Treatment Trap … A Cautionary Tale” (http://bit.ly/TreatTrap). While I agree with some of his comments, I feel that he oversimplifies the issues, doesn’t consider the physician’s viewpoint, and makes statements that are offensive in their tone and assumptions.

Lewis details how he developed symptoms, went to an ENT specialist and then was prescribed several courses of action. He then proceeds to dissect them and detail why they were incorrect, and essentially how this physician was completely wrong in how she approached his problem. He says that she “subliminally marketed” a surgical correction to his problem without first considering conservative treatment options, and that this is because she makes more money by doing surgery. Isn’t it equally plausible that in her experience with problems like his (which far outweighs Lewis’s experience, which is why he went to her in the first place), surgery might have been a better option?

Doesn’t this physician deserve the benefit of the doubt in this case, that she might actually be interested in Lewis’s welfare and not her pocketbook?

Next, Lewis criticizes the physician for not describing “the drawbacks or risks of taking a course of antibiotics.” I agree that if she omitted this information, she was not fully informing her patient; however, perhaps the physician didn’t go into the information because so many other patients simply demand antibiotics without reference to their potential toxicities, and when she was seeing Lewis, she thought he might act the same way. Besides, if he was truly concerned about the potential toxicities of three weeks of antibiotics, why didn’t he ask for more information? The physician-patient relationship is a two-way street.

Lewis comments on how “doctors are supposed to follow evidence-based guidelines,” but what about conditions for which there are none? And is there no patient individuality or leeway in this process? Lewis’s statement is an oversimplification of how a physician manages a patient’s problem; if we are only to follow guidelines, then why are we needed at all? Why just not punch your symptoms into a computer and then have it spit out a treatment based upon “evidence-based guidelines”?

Other entities

As to Lewis’s comments about the physician scheduling a CT scan the next week, I admire his self-concern about not being exposed to the ionizing radiation associated with a CT scan; however, how does he know that the reason for the CT scan was only to monitor the progress of his treatment (which he didn’t even want to take)? Isn’t it possible that the physician wanted to look for other entities that might be causing his symptoms, or see areas of his anatomy that were beyond the reach of her “gadget”? And later on in the article when he comments about physician-owned equipment, is he referring to this physician’s ownership of a CT scanner as the reason why she recommended the scan in the first place? That is nowhere to be found in the article.

Now, I do actually agree with some of what Lewis says, particularly that there is a need for payment reform in health care, and we do need to move from volume to value in how we pay physicians and organizations for health care. I also agree that there are some physicians who put personal enrichment ahead of patient well-being, but in my opinion, this is a very small minority. Unfortunately, the tone of Lewis’s article makes one believe that the world is filled with greedy physicians who just want to order more tests and get paid more for things that really aren’t necessary — and I submit that this couldn’t be further from the truth. There are many other factors that drive a physician’s practice to do more “doctor-type stuff,” and Lewis’s article mentions none of them, which leads to his lopsided analysis.

Lewis says, “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.” This is an incredibly offensive oversimplification that makes physicians sound like trained seals and in no way reflects how physicians practice in today’s world. If I were to rewrite this statement to be accurate, I would say that “doctors take care of patients in the best way they know how to do, and when they do more doctor-type stuff, it is either because patients demand it, or because they believe patients truly need it. In both instances, the physicians are doing what they feel is the best thing for the patient at the time they are seeing them.”

I’d like to ask Lewis how he would have felt if the physician he went to see had examined him and then said, “You have nasal polyps and you don’t have to do anything about them.” Would he have been satisfied with that response? Would he have believed that response or would he have sought another opinion? I would submit to Lewis and others that physicians sometimes recommend actions because that’s what’s expected of them, and when they don’t, patients wonder why they went to the physician in the first place; so, because physicians are human, they try to do what they think is best for the patient, and that may be ordering a test or prescribing a treatment. In the future, we will need to change the way we pay for health care. And since physicians drive a lot of those costs, they are easy targets for criticism like that spewed forth by Lewis. But I would submit that before you criticize physicians for driving costs up, you look in the mirror and see what part others have to play in this drama. After all, if Lewis hadn’t visited the physician in the first place, he wouldn’t have had a story to write about.

Physicians aren’t the bumbling, money-hungry charlatans that Lewis makes them appear to be. They are simply one of many players in a dysfunctional system that needs to be fixed.

Frank L. Urbano, MD, is the medical director for care management at Einstein Healthcare Network in Philadelphia.

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