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Join Don Gaede, an internal medicine and vascular medicine physician, to discuss the “existential threat of greed in U.S. health care” highlighted in a JAMA editorial. Don shares his firsthand encounters with unethical practices within his specialty of vascular medicine, where patients are urged to undergo unnecessary procedures. We delve into the impact on vulnerable populations and the challenges of addressing these issues. Explore the role of initiatives like Choosing Wisely in promoting appropriate care and advocating for patients. Don emphasizes the importance of physicians taking a stand against greed in all health care sectors to protect the medical profession’s noble status.

Don Gaede is an internal medicine and vascular medicine physician.

He discusses his KevinMD article, “The dark side of medicine: an urgent call to action against greed.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Don Gaede. He’s an internal medicine and vascular medicine physician. His KevinMD article is titled “The dark side of medicine: an urgent call to action against greed.” Don, welcome to the show.

Don Gaede: Yeah, thank you very much, Kevin. Nice to be here.

Kevin Pho: We’ll get to the article in a little bit. First off, briefly share your story and journey to where you are today.

Don Gaede: Yeah, so I went to medical school at Loma Linda University, did my residency in internal medicine, and practiced in primary care internal medicine for about 10 years. I honestly got a little bit bored, not really burned out, but bored, and decided after that period of time to do a fellowship in vascular medicine at Cleveland Clinic. I completed that in about a year and then went back to my town in California to practice both vascular medicine and internal medicine. It wasn’t busy enough for me to practice just vascular medicine, so I did both, except for the last few years of my practice, in which I was doing pure vascular medicine.

Kevin Pho: Tell us some common things that you see, common cases that you’ll see in the exam room in your vascular medicine practice.

Don Gaede: Yeah, so probably the majority of my practice was venous disease: superficial venous disease, varicose veins. I have it myself, and my family has it, so it’s a real personal thing for me. Ablating even large varicose veins in the office, as opposed to the previous stripping, is now possible, and it was quite exciting. You could see a patient come in the door with really bad varicose veins, and they could leave a couple of hours later without them. So it was fantastic. I also saw peripheral disease. I saw lymphedema, leg pain, and leg swelling of various causes. But those were the main issues that I was dealing with in vascular medicine.

Kevin Pho: All right, so let’s talk about your KevinMD article, titled “The dark side of medicine: an urgent call to action against greed.” Now, tell us, how did your article come together?

Don Gaede: Yeah, I saw this editorial in JAMA, I think it was in February, in which Dr. Berwick talks about the problem of greed in medicine, in the entire health care system, including us physicians, and how it’s just pricing many people out of affordable health care, even though our health care outcomes are very poor compared to many other countries. And so it made me think of instances of greed that I’ve seen in my own personal practice, and I wanted to comment on them.

Kevin Pho: All right, so tell us, what are some of the things that you’ve seen that make clinicians seem greedy?

Don Gaede: Yeah, you know, in my specialty of vascular medicine, the first thing that brought this to mind was when the head of my HMO wanted me to review a number of case records from a physician who seemed to be an outlier in terms of the number of procedures, venous ablations, that he was performing. So I reviewed these cases. It must have been 30-35 cases, and the vast majority, say 80 percent, were bilateral venous ablations. I said, “This is very unusual.” It’s quite rare, in fact, to see bilateral great saphenous vein reflux, and so it seemed very suspicious. I couldn’t prove it, because I didn’t see these patients, but I told the director that it seemed very suspicious, as if this physician was performing unnecessary procedures.

Then I started seeing some patients who had seen another physician. This is a different physician, and they were not comfortable with what he recommended. He was often recommending a bilateral vein ablation. They’d come in for leg pain, maybe a little bit of leg swelling, not really much in the way of varicose veins. So I examined them carefully, including with ultrasound, and in several of these cases I found absolutely no evidence of reflux. No evidence of reflux. And yet I got the records from this physician, and he had reported that there was significant reflux. It just astounded me, and I saw repeated cases of this.

I called up a vascular surgeon colleague of mine, and he said, “Oh, yeah, I know about this guy.” He related a case in which a person had peripheral arterial disease, and despite this, he’d already undergone a venous ablation by this physician. As we know, that’s an absolute contraindication to performing superficial venous ablation, when somebody has peripheral arterial disease. And I said I’d like to report this guy to the agencies, and he said, “I’d be happy to back you up on that.”

And I’ll just go on a little bit from there. Since I practiced primary care internal medicine as well, I saw a number of my patients who were seeing cardiologists. They had had a cardiac nuclear examination one year, let’s say 10 years ago, but they were having repeat annual cardiac nuclear studies, in which the patient was asymptomatic and had had one study which was borderline. I looked up the recommendations on this, and they really were not following recommendations. I also looked up the Choosing Wisely website, in which cardiologists or radiologists have indicated what’s appropriate, and this is clearly inappropriate. So I would actually give the patient a copy of this to take to their next appointment with the cardiologist.

It was a little bit uncomfortable for me, honestly, but I felt it was my obligation to my patients not to subject them to unnecessary radiation procedures that might lead to other unnecessary procedures. And I felt a little bit alone in my mission. But I think it’s my obligation, and our obligation as physicians, to advocate for our patients, even in opposition to other physicians who may have other recommendations. I think especially as a primary care physician, I felt that it was my obligation to do so.

Kevin Pho: So let’s talk about the case with the unnecessary venous ablation. From the patient standpoint, what are the risks of undergoing that treatment?

Don Gaede: Well, you know, it’s a very safe procedure. But if you have healthy superficial veins, God forbid, you might need, let’s say, cardiac bypass surgery or peripheral arterial bypass, in which case those veins might be very, very useful down the road. There are occasional cases of DVT resulting from venous ablations. There are those cases of skin burns and infections, but they’re pretty unusual, so it’s pretty safe in terms of the patient. But in terms of cost to the patient and cost to the health care system, and even though it’s a minimally invasive procedure, it’s just ethically wrong. We’re going down the wrong road if we’re doing things on patients who do not need them.

Kevin Pho: Now, if these venous ablations were in fact unnecessary, is this a particularly lucrative way for that particular physician to make money?

Don Gaede: It is. It’s quite lucrative in terms of the time involved in doing the procedure, and this physician probably could line them up, you know, several patients in a short period of time. This physician also advertised frequently on television to attract more patients. Many of these patients, a number of the ones that I saw, were not well educated. And even educated patients, when the doctor recommends something, are pretty vulnerable to whatever he was going to recommend to them. So I imagine most of the patients went along with his recommendation, even though a few of them came to me because they felt uncomfortable.

Kevin Pho: So tell me, what did you do next? Did you end up reporting these physicians for potentially unnecessary tests and procedures? What happened next?

Don Gaede: Yeah, so it was a little bit tricky to find a way to report them. I did call up the local medical board. They had an office in my town, and I told them about this physician. I don’t know if there was any follow-up in that case.

I also looked for a way to report this physician for Medicare fraud. I had a hard time doing that initially, because I wasn’t sure if it met the criteria of doing services that were not done. He did a service, but it was an unnecessary service, so I wasn’t sure if this met that criteria. But eventually I did report this physician. This was actually about six months or so ago, and I have not heard anything back. There’s a hotline, a hotline you can report to at the Office of Inspector General, but I have heard no feedback whatsoever. They said there may be no feedback, but it was a little frustrating to me that I felt unable to do a good job of reporting this physician, who I thought, and still think, should be investigated for unnecessary procedures.

Kevin Pho: Now, in your field, specifically vascular medicine, is this a local phenomenon, where physicians are ordering tests unnecessarily, or, to your knowledge, is this happening across the country?

Don Gaede: Yes, that was surprising to me as well. There’s a phlebology magazine that put out an article about four or five years ago saying that this phenomenon of doing unnecessary ablations is a widespread phenomenon, and it’s very disconcerting to me that so many physicians are involved with this. I think it’s because it’s a fairly lucrative procedure, and physicians are simply tempted into engaging in it.

And I have to say, personally, I think there are often gray areas. For example, should I order an EKG on a patient who has hypertension? When you have a fee-for-service system, all of us are tempted to do procedures or certain tests that may or may not be necessary. But sometimes it crosses the threshold, crosses the line, and it can become a habitual problem for some of these physicians. And it’s embarrassing to me as a physician to know that this is so.

Kevin Pho: Now, from the patient perspective, let’s say they see these billboards and advertisements for venous ablation. What kind of questions should they ask that physician in order to make sure that the test is truly necessary?

Don Gaede: Yeah, you know, that’s a very good question. I’m not sure that the average patient has the medical knowledge to be able to ask the right questions to determine whether this physician is telling the truth or not. I suppose the more questions the patient asks, the better. And obviously, the patient should ask, “So, Doctor, why do I really need this procedure? How is this going to help me? Should I get a second opinion?” Most patients aren’t courageous enough to ask that kind of question, but really, patients are in a pretty vulnerable situation. I would say ask other patients, and ask your personal physician, to make sure that the physician you’re seeing is reputable and has been certified in, let’s say, vascular medicine or vascular surgery.

Kevin Pho: Now, from a more macro standpoint, what kind of policy suggestions would you make in order to curb this temptation of greed? You mentioned that the fee-for-service system provides these temptations. How would you change that reimbursement system to discourage unnecessary tests?

Don Gaede: Well, yeah, I think I would get rid of the fee-for-service system. I spoke about the unnecessary repeated cardiac nuclear tests, and I spoke to a Kaiser physician in my hospital. He said that often patients will come to him saying, “Well, I’m ready for my annual nuclear scan,” and he had to spend a lot of time telling them why they didn’t need that annual nuclear scan, that they were going to be fine without it.

And I have to say, I practiced my entire career under that system, except that when I got into the HMO, my primary care was capitated. But I think we’re incentivized as physicians to do more procedures, and, no big surprise, when you incentivize people to do more procedures, when you pay them more to do more procedures, they’re going to do more procedures. Not everybody; some have a better resistance to that temptation.

But I really think we need to reimburse physicians for quality: taking good care of patients, following appropriate guidelines. Pay them well to do that. And I think, in fact, physicians could be paid even better, maybe, than we are now, if we figured out how to do good medical care without doing all these unnecessary procedures. All those procedures are costing the entire medical system a lot more money, and we could really make medical care much more efficient by, in my mind, getting rid of fee-for-service. That’s the main objective.

But also teaching better medical ethics. I don’t know how much that is taught in medical school. And I think our medical societies, and I was a president of our medical society and was also very much involved with our state medical organization, I saw very little evidence of resolutions coming forward on this. Most of them had to do with increasing physician reimbursement. Very few had to do with curbing unnecessary testing and unnecessary procedures. I think that’s a problem that needs to be addressed by our state and national medical organizations, because our reputation as physicians relies on patients, the general public, thinking of us as honest brokers. When they start hearing about blatant disregard and dishonesty, it doesn’t help our cause whatsoever. We are thought of as a noble profession, but our nobility, I think, is in serious decline when we have this sort of thing going on.

Kevin Pho: We’re talking to Don Gaede. He’s an internal medicine and vascular medicine physician. His KevinMD article is titled “The dark side of medicine: an urgent call to action against greed.” Don, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Don Gaede: Yeah, I think that whenever we see greed in health care, whether it’s the pharmaceutical industry or the insurance industry, we need to speak up. We are a trusted source for the general public, for my patients. And so we need to push back against greed, both outside of our profession and within our profession. We need to clean up our own act, because most of us, I think, are upstanding, upright physicians who want to do the best for our patients and want to make a decent living. But we need to get rid of bad apples and make sure those bad apples are brought back into the fold in terms of doing honest, upright procedures that patients really require.

And I think we need to work with our medical associations, our state medical associations, to introduce resolutions to advocate for medical care that doesn’t take advantage of vulnerable patients, and that ensures that all the procedures that are done are necessary procedures.

Kevin Pho: Don, thank you so much for sharing your time and insight. Thanks again for being on the show.

Don Gaede: It’s my pleasure.