Tuesday, July 21, 2009

Risky Business (Marin IJ)

In the midst of the national discussion about health care reform, much has been made of dynamics that encourage “over utilization” of medical resources. If the phrase “over utilization” doesn’t outrage you, think of it as medicalese for unnecessary care – such as the excess use of diagnostic tests and overly aggressive treatments. Some of the commonly cited instigators of over utilization are: the litigious nature of our society, the millions of uninsured patients who defer primary care and seek (more expensive and usually last minute) treatment in the Emergency Department (ED) and fee-for-service re-imbursement structures that reward doctors who provide more care (whether it’s needed or not) rather than less. If you haven’t read it, Atul Gawande’s recent piece “The Cost Conundrum” in the New Yorker is an excellent examination of this topic. But, there is one variable Gawande fails to discuss and it is an important one: personality. Specifically, I am talking about the risk-tolerance of individual doctors. Risk-tolerance? This phrase is commonly associated with the diversification of 401K portfolios and jumping out of airplanes, but it actually plays a bigger role in medical decision-making than you might realize.
Consider a study from the University of Pennsylvania (UPenn) published last month in the American Journal of Emergency Medicine. Dr. Jesse Pines and his colleagues examined the use of abdominal cat scans (CTs) in the ED and correlated the ordering trends of individual physicians with their responses to a standard risk-taking survey. The UPenn study catalogued 838 adult patients with new-onset belly pain (excluding those who were pregnant or had suffered an injury) and reviewed their records to see if they received an abdominal CT or other imaging studies. The abdominal CT was by far the most commonly used imaging test and in this respect the UPenn study captured a microcosm of the national debate on over utilization. The abdominal CT is an expensive test (costs vary, but a typical bill is at least several thousand dollars) and involves some risk to the patient (in the form of radiation exposure and potential harm to the kidneys). Belly pain can, however, be caused by a lot of different things and CTs are a very reliable way to rule-out most of the concerning diagnoses (such as appendicitis or metastatic cancer). Thus, the UPenn team hypothesized that “risk-tolerant” physicians (i.e. those more willing to take risks) would order fewer abdominal CTs (foregoing them in low risk situations) than risk-averse ones. To distinguish between the two types of doctors, the researchers used a subscale of a standardized personality test (the Jackson Personality Index) that asks respondents to indicate how much they agree with statements such as “I try to avoid situations that have uncertain outcomes,” and “Taking risks doesn’t bother me if the gains involved are high.” When they crunched the numbers and adjusted for other variables (such as gender, age, and the specific location of the patient’s belly pain), they found that their hunch was correct; the most risk-tolerant physicians were 15% less likely to order an abdominal CT. Interestingly, when they searched for two other predictors of increased use of CT – fear of malpractice and stress scores in uncertain situations – there were no associations. So, based on this study, the risk-taking nature of physicians, rather than their fear of being sued or their reaction to stressful situations, is a key determinant of how they practice medicine. Other studies, involving chest pain patients and those with strep throat symptoms also demonstrate that risk-taking doctors have different practice patterns than risk-averse ones.
Now, before we start testing all prospective medical students for risk-taking preferences (if you want to see where you fall on the spectrum, check out http://testyourself.psychtests.com), let’s take a step back and ask what these findings mean.
Do doctors who order fewer abdominal CTs provide less-than-optimal patient care? The UPenn study didn’t address this question, but I’d venture to say that more CTs do not necessarily mean better care. In fact, physicians who order more CTs may expose their patients to unnecessary risks. As Johann von Goethe once wrote "the dangers of life are infinite, and among them is safety." And do the results of this study mean that physicians who agitate about the high costs of runaway medical malpractice claims are blowing smoke – because it may be that their personalities are more to blame than the lawyers? Once again, not necessarily – there are a number of other studies that have found an association between fear of being sued and over treatment and it may be that this connection only applies in certain clinical situations. I know plenty of physicians (and would include myself in this group) who sometimes make decisions in the treatment room that are aimed at avoiding a date in the courtroom.
Finally, this is a single study, involving a relatively small group of physicians and performed in a setting (a university medical center) that functions differently than most “normal” community EDs. Nonetheless, this study is further proof that from one physician to the next, there can be significant differences in how medicine is practiced. At the risk of being called a socialist, I contend that individual variations in care, while inevitable and necessary, should be constrained within reasonable limits. For example, risk-taking physicians should be encouraged to consider the worst-case scenario when they decide to minimize care, and risk-averse physicians should remember that over-testing not only costs money, but can lead to further unnecessary testing and procedures. Many physicians have grumbled that practice guidelines and comparative effectiveness research unduly limit their autonomy, but I see these things as tools to help modulate the inherent human attributes that contribute to doctoring, whether they be experience, empathy, or tolerance of risk.
Consumers of medical care may want to consider not only the risk-tolerance of their physicians (perhaps risk-averse patients are well served by having a risk-tolerant physician) but also the risks associated with their own lifestyle habits. But, this is a topic for another day. Now, I am off for an afternoon of bungee jumping and drag car racing.

Monday, July 13, 2009

Pain Kills (Marin IJ)

Michael Jackson had pain, unbearable pain. Not just the chronic physical ailments of a middle-aged performer, but also the unique pain of being Michael Jackson; the pain of stardom too early, of being uncomfortable in his own skin, of multiple failed marriages, of a damaging lawsuit, and of a never-ending parade of rumors and innuendo.

As we found out last week, Michael Jackson was treating his pain aggressively with prescription drugs. Reportedly, one of these drugs was Demerol, a painkiller so addictive and dangerous that it has been banned from many Emergency Departments. Another was Oxycontin, a drug that if chewed or crushed rather than swallowed whole causes a heroin-like high. A third may have been Diprivan; a powerful anesthetic that should only be used in carefully monitored settings because it suppresses the drive to breathe. Regardless of whether some or all of these drugs played a role in his death (and my guess is that they did), it is pretty clear that Michael Jackson was an abuser of prescription drugs. And in this, he was certainly not alone.

Prescription drug abuse is a big problem in this country, and one that is getting bigger by the day. A 2006 national survey estimated that 5.2 million Americans take prescription painkillers for non-medical reasons each month – that’s more people abusing prescription drugs than cocaine, hallucinogens and methamphetamine combined. And this number does not include those people who have been diagnosed with chronic pain, a group who are known to suffer from a high incidence of untreated depression and other psychiatric problems. Among the tens of millions of prescription painkiller users, thousands die each year from unintentional overdoses – in 2004 alone 7,500 deaths were attributed to narcotic painkillers (synthetic opiates such as Oxycontin). This, from a numerical standpoint, makes prescription narcotics far more lethal than either cocaine or heroin.

So, as Michael Jackson’s sad demise illustrates, we have a prescription painkiller problem, and I, for one, wonder if we are over-treating pain. Have we, in the process of attempting to ensure the comfort of the gravely and terminally ill, created a morass of prescription drug addicts? Of codeine collectors, Percocet poppers, VicoHeads and Dilaudid darlings? I see these people every day; because while Michael Jackson had his own Dr. Feelgood, many prescription drug abusers rely on their local emergency physician to get them a fix. Some of these “patients” are in their twenties and have no clear medical reason to be hooked on 360 pain pills per month. Of course, I’ll admit that pain is a difficult thing to measure, and I am sure that the majority of my patients have real pain. But some of them are just plain junkies. And junkies will say or do just about anything to get high. They will give fake names (which is a criminal offense) and construct elaborate stories. One patient recently told me that his house had burned down, taking with it a six-month supply of Vicodin and Xanax, and demanded that I refill the medications immediately, as he was due to catch a flight to Costa Rica in a few hours. Upon further investigation, the fire department had no record of such a fire and his flight to Costa Rica was merely theoretical. Prescription drug addicts will even cause themselves physical harm in order to get a prescription – a colleague of mine once caught a patient trying to fake a painful kidney stone attack by scratching at his urethra with a paper clip.

In an Oregon study tracking 30 drug-seeking patients over the course of a year, these patients had more than 12 pain-related ED visits annually, visited an average of 4 different hospitals and used 2.2 aliases. Sadly, if healthcare providers at one facility refused to give unnecessary narcotics, the patients were usually able to obtain them elsewhere (over 90% of the time). Two of the 30 Oregon patients died of drug overdose. They weren’t named Michael Jackson, so their deaths didn’t garner much attention. But they should have, because they were preventable.

It’s time to recognize that not all pain is equal and that we need a structured means to cut off the supply lines to abusers and funnel them into treatment programs. Some addicts may be beyond help, but we must stop facilitating the habits of those who can be rehabilitated. And, friends, family and physicians need to confront people who appear to be entering a cycle of narcotic dependence lest they themselves become ‘the man in the morgue.’