In the previous article, the term “siloed physician care” was introduced. Physicians who practice in this manner see their roles as narrow in their patients’ care. Often, they don’t see themselves as obligated to any greater purpose in a patient’s management. For any number of reasons, including historical precedent, location of postgraduate training, personal habits, and many others, these physicians see their obligations to the patient as sparse.
However, for the best possible care the patient, this approach can no longer continue. Additionally, the best possible care is almost always the most cost-effective care. These 2 are not mutually exclusive.
As a change of pace, allow for a few examples which this author personal witnessed to explain behavior that has to cease for best patient care. Please note that this is by no means exhaustive and in fact is only the tip of the iceberg.
My colleagues who are ER physicians show up frequently in these discussions because care from them is often a gateway to very expensive services. In the May 1, 2024 article, “Misaligned Incentives: A Case Study in Unnecessary Hospital Admissions”, this was noted. Another (of many) memorable admission from an ER physician involved a relatively healthy young man who had taken a great deal of pseudoephedrine for cold symptoms. The cold was very vexing to him and he went to the ER for more definitive treatment. His heart rate was high in the low 100’s, i.e. somewhat elevated. Although he was stable, he had an EKG the results of which were misinterpreted. For those keeping score, the rhythm was interpreted as paroxysmal atrial tachycardia but it actually was the more benign sinus tachycardia. This distinction is important because the latter could have been treated by telling the patient to take no more pseudoephedrine, rest, hydrate, go home, and call his PCP in the morning. However, because the rhythm was misinterpreted he was admitted to the telemetry section of the hospital. Once admitted, the admission was not reversible even though I went to the ER physician who had handled the case and pointed out the honest mistake. The gist of his response was he was very busy that night (true) and that the hospital and he were going to be paid anyway. So, what was the harm?
Put another way, even though this error was going to cost the patient’s risk pool a few thousand dollars unnecessarily, there was unlikely to be negative feedback for his action other than my modest attempt to clarify the misinterpretation on the EKG. Without a health system that provides constructive feedback, this behavior will never change.
Another incident which struck me involved a radiologist who was in charge of reading all films for patients in the critical care units. The sickest patients of the hospital are kept in critical care units and many of them undergo radiographs daily (sometimes even more frequently). The radiographs often look for similar things: are the feeding tubes in the patients’ stomach (good) or in the lungs (bad)? Are the endotracheal tubes properly within the trachea? Are the central lines properly placed? Is the excess fluid in the lung better, worse, or unchanged? The critical care team (ICU attending, senior resident, interns, medical students) would go down to the Department of Radiology to review the films (this is years before they could be displayed on computer screens). We would obtain the films and compare them ourselves before the radiologist had a chance to read them. We put out the previous day’s film for each patient and compared it to the current day’s film (a very important process for planning the patient’s care). One day, in a scene that would’ve been comic had it not been so bad for patient care, the radiologist of the day grabbed the jacket in which the films were and the pair which were on display and went off into another room. The critical care team was unable to make any decisions regarding patient care because the radiologist had stolen all the films.
That day, we were unable to make any clinical decisions on patients because the radiologist had a quota to read a certain number of films per day. Never mind that he was not directly involved in patient care and the whole point of the studies were for the patient’s benefit, not his. Again, he was another “siloed physician”.
As a final example, we will revisit the idea of PCPs occasionally needing to “rescue” patients as discussed in the previous article regarding global capitation. In the early part of my career, I had a patient who visited me in my office once. He was a man in his middle 70’s, an inveterate smoker, hypertensive, overweight, sedentary, and a latent type II diabetic. One day, he went to the emergency room because of worsening pain in his legs when he walked. He was admitted to the hospital for claudication (blockage) of the arteries to his lower extremity. His story was not uncommon. Every day, when he awakened, he walked to the entrance level of his hotel where there was a cigarette machine to buy a few packs. Then, he would return to his apartment and smoke them. The ER physician contacted me for the admission as I had known the patient previously. Somehow, a vascular surgeon had been consulted by ER physician also. Without discussing the case with me, the vascular surgeon took him to the operating room (unbeknownst to me) for an elective procedure, an arterial bypass of his lower extremities. No evaluation of the surgical risk was done. No realistic evaluation of postoperative care was done by the surgeon since the patient was unlikely to return for necessary follow-up (making the risk/benefit ratio of surgery even more ridiculous). Finally, why was an aggressive surgery favored over conservative measures, especially since the patient’s goal was to buy cigarettes which would undo the bypass procedure?
In the case of the misread EKG, there was no negative feedback to the ER physician regarding an unnecessary admission (I was a humble resident and he was an attending level physician). Although this 1 act cost the patient either directly or through his insurance a few thousand dollars, there was no “teaching moment” for the physician who made an honest mistake. Absent any incentive like negative feedback from the utilization review committee or indeed negative financial consequences, behavior was not going to change.
The radiologist who stole the films is somewhat more egregious. This is both a case of bad citizenship and misaligned incentives. Taking the x-rays from the team which ordered the films and would actually make decisions based on the results is unbelievable. The radiologist would say that he’s paid to read them, whether they influence patient care or not. Sadly, the medical system has no checks and balances for this type of behavior either.
The final case is uniquely egregious. Although this patient survived the surgery, it was a case of medical Russian roulette. Patients who have symptomatic atherosclerotic blockages of major arteries in the legs have a very high risk of coexisting critical blockages of coronary and/or cerebral arteries. The surgery did not extend the patient’s life. For his symptoms, he could have been instructed to start a low intensity ambulatory regimen to attempt to improve his symptoms conservatively (remember that the patient did not believe in either preventative care or compliance with follow-up). The vascular surgeon had applied the Willie Sutton rule of patient management.
For the medical system to work best on behalf of patients, there must be a system of feedback for suboptimal behavior (but also positive feedback when merited). Checks and balances are critical. “Siloed physicians” are often sequestered without finding need to see the bigger picture, the greater good. Global capitation will incentivize better behavior by forcing the medical system to review all the processes and goals to care for patients. A key part of that is communication and, indeed, respect. Positive feedback for good outcomes and negative feedback for bad outcomes are woefully absent in our system (short of mortality events). Care entities which don’t develop a culture of insight and efficiency in caring for patients will vanish, as they should.