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Cathing the 27-Year-Old

July 16, 2012

I’m back from the big annual TAFP meeting, and once again my colleagues tell me stories of crazy practices in the private sector. Here is one from a doctor in Plano.

A 27-year-old male patient of his went to the ER with chest pain. The EKG showed early repolarization and the cardiac enzymes were normal. The stupid ER board-certified doctor activated the cardiac cath team based on the EKG.

Stupid is a strong word, but apropos in this case. For the non-physicians, this is a classic EKG pattern seen most commonly in young men that in some ways can look like an acute heart attack, but is so well recognized that it is taught as a common mimic of a heart attack in medical schools and residencies. He should have known better.

The cardiac cath team arrived quickly. The cardiologist on call had to drive for about 30 minutes and was the last member of the cath team to arrive. He interpreted the EKG as early repolarization also, but went ahead and performed the cardiac cath procedure, which of course was normal.

My health economist friends interpret these kinds of stories as proof that the fee-for-service system for hospitals and doctors is broken and explains all U.S. healthcare cost evils. In high dollar procedures, the inflated payments approved by CMS and the insurance companies is a huge factor in overutilization, but I think there are more factors. Here are a few:

  • Quality Indicators – Hospitals are rated by agencies with their quality scores posted on multiple websites. Door-to-balloon time – the time it takes a patient from when he hits the ER door to the cardiac cath balloon in a lesion – is one of the contributing measures to this score. Cautiously cathing only patients with whopping heart attacks to minimize overuse is not rewarded.
  • Teamwork – Part of the reason the cardiologist went ahead with the procedure (we-re pretty sure) is that the entire cath team had been called out. So between the possibility they would not have been paid as much for their trip, or perhaps at all if he called it off, and the fact they were all standing there ready to go, contributed to the decision to just go ahead and do it.
  • The patient – After the procedure, the patient’s family physician talked to him about the episode and tried to tactfully suggest that the patient was actually exposed to unjustifiable risk by undergoing the procedure. The patient would have none of that argument. He was so pleased that he was more empowered with information and had the extra certainty that his pain was not caused by his heart.

Eliminating fee-for-service U.S. medicine will help in some ways to reduce healthcare costs, but it’s not enough. Our entire medical culture has to change, including attitudes of the American people. Or as we doctors call them, our patients.

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3 Responses to Cathing the 27-Year-Old

  1. Tracie Updike MD on July 17, 2012 at 6:16 am

    Thank you so much. The American attitude on healthcare is unrealistic. Patients need to understand that more is not better. What would have happened to this young man if the cardiologist had of torn an artery? I think his health insurance should investigate and not pay anything.

  2. Terri W. on July 22, 2012 at 6:11 pm

    Great report in today’s Austin American Statesman on our insane system. Even shopping for routine MRI procedures here in Fort Worth has been a nightmare.

    This quote really stands out:

    “We are asked to be good consumers of health care,” said Dr. David Goodman, director of the Center for Health Policy Research at the Dartmouth Institute, “but because the cost of health care has risen so dramatically and an increasing proportion of the population is vulnerable to costs … what was once an afterthought may be whether you declare bankruptcy or not.”


    • Richard Young MD on July 22, 2012 at 6:37 pm


      There are so many reasons consumer-directed plans are doomed to under-perform in reducing costs. A lack of transparency in costs is a huge contributor to this. Thanks for sharing.


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