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Breast biopsy

March 2011

Many have suggested that errors in medicine could be reduced if we modeled our behavior after the airline industry.

Perhaps, but I remain a bit skeptical. That’s why I was very interested in comments made by a gentleman who’s both a pilot and a physician. He believes that the discipline of flying an airplane may have little to do with best practices in health care, despite our current infatuation with this belief. Still, just to be clear, I do believe that checklists have their role and that “The Checklist Manifesto” by Atul Gawande should be required reading for all hospitalists.

But I have digressed before I even started to state my point. From a patient’s perspective, our current practice is analogous to what happens when you take your car to a mechanic. You think you’re stopping in for a routine check-up, but before you have unbuckled your seatbelt, you find you need a total overhaul. At least, this is my personal experience, and it’s something that I keep in mind to try and appreciate what it must be like for my patients when they stare up at me from their bed. They are left to trust that I know what I am doing and have their best interest at heart.

In what might serve as a strange juxtaposition: I am not familiar with the indications for a surgical breast biopsy vs. a needle biopsy; this isn’t on my radar screen in terms of my practice as a hospitalist. But given its clinical importance, one might assume that patients undergoing the much more invasive surgical procedure would want to feel completely confident that they were receiving the best practice. But it turns out that, shamefully, that is not the case.

A study in the American Journal of Surgery found that 30% of biopsies were done surgically when guidelines call for that number to be less than 10%. This was consistent with a study done at Beth Israel Medical Center in 2009, which found that surgeons employed by the hospital had surgical biopsy rates of 10% while breast surgeons in private practice had rates in the 35% range. (General surgeons had an even higher rate: 37%.)

The lead author of the Beth Israel study was Susan Boolbol, who explained the results by noting that the doctor’s knowledge of (or ignorance about) best practice was a major factor. As for the elephant in the room, which is the idea that the real motivation behind so many surgical biopsies is to reap surgical fees, she had this to say: “A huge part of me doesn’t want to believe it’s true.”

As a practicing physician for over 10 years, a gigantic part of me knows this to be true, even though I share her wish that it wasn’t. My discomfort with my physician colleagues certainly pales in comparison to what a woman with a needlessly deformed breast must feel.

Every first grader probably fully understands this central tenet of our existence: Human behavior is driven by incentives. And just about any behavior can be incentivized to keep happening, no matter how ethical a group of people may be.

To which I say: Thank goodness I am a hospitalist. I can look back at my career and know that I have never attempted to maximize my financial well-being at the expense of the patients I care for. Am I the living embodiment of high moral standards? Hardly, but I can rest easy knowing that I am primarily incentivized to provide quality care. While that may not be universally true, most hospitalists are employed, like me, and are either directly or indirectly aligned with the quality goals of their hospital. The $100,000 subsidy being paid on average per hospitalist is money well spent in a field in which the term “money well spent” is not uttered often.

It’s not my intention here to bash surgeons. While I am certain some surgeons cannot be readily absolved of questionable practice decisions, they did not create our fee-for-service system, which can unduly influence and blind even the most ethical of practitioners.

And I’m also not suggesting that fee-for-service is evil. People can be very productive when financially motivated. But, and this goes without saying, the system must motivate doctors to practice in patients’ best interests or practice may run amok.

In the end, regardless of the payment system in which we practice, if the evidence is clear that a treatment is not indicated, then hospitals, payers and professional societies all have a responsibility to help mold appropriate behavior. Kudos to the surgeons who performed the study and published the results, which can only improve accountability.

I will let Dr. Silverstein, another breast surgeon quoted in the New York Times article referenced above, have the final word: “Maybe we have to get patients to say, ‘This guy took a big chunk out of me and I didn’t even have cancer, and now I’m deformed.’ Who just overthrew Mubarak? The people. This is exactly the same thing.”