Survival of the Fit

I recently interviewed a cardiac surgeon who wanted a job working entire weekends, day and night, Friday night through Monday morning, in one of our intensive care units. His story was an interesting cautionary tale about what evolutionarily unfit doctors can look forward to in the world of Life after Health Care Reform. Dr. Bryan Scherr (not his real name) had a blue-ribbon CV. He’d graduated from Yale University with a degree in physics and headed to Stanford University for medical school. Bryan had gone on to UCLA for an internship and back to Stanford for his surgical residency, eventually completing training in vascular and cardiothoracic surgery at UCLA and Stanford.

Dr. Scherr went on to enter a lucrative private practice in cardiac surgery in California. However, for reasons he didn’t explain, his private practice broke up toward the end of 2008. Now 62 years old, Scherr had found it impossible to find cardiac surgical work, so he adapted and began to work taking care of patients other surgeons had operated on. He found part-time jobs in an intensive care unit in New York, and another in California, and he had applied to work at our unit in Philadelphia as well.

There in my office that day I had a 62-year-old, highly trained heart surgeon with no obvious disabilities who had at one point worked his way to the very top of a heap consisting entirely of people who’d been plucked from the tops of other heaps, only to be reduced to flying around the country working nighttime shifts in a series of ICUs between airplane rides.

How, I asked myself, could this possibly have happened? It reminded me of those nature films where some once-proud king beast, perhaps now missing a few teeth or an antler, is up and ousted from the pack by a young, bold new competitor. If he survives the joust, he’s then forced to wander the land, feeding off scraps and carcasses.

The operations Bryan Scherr performed three or four times a week in his prime were probably a mix of heart valve replacements and coronary arterial bypass procedures, more popularly known as CABG or, in the layman’s vernacular, cabbages. The first CABGs were done in the early 1960s by pioneers like Dr. Rene Favalaro, an Argentinian from humble beginnings who trained and began his medical career in South America but eventually emigrated to the United States and Ohio’s famed Cleveland Clinic.

The operation eventually became so common that more than a million CABG operations were performed in the United States between 1988 and 2003. But, almost imperceptibly at first, something happened to change what had been a steadily increasing trend over the last few years of that 16-year period.

Most studies show that the number of CABGs peaked in about 1996. By this time, many ambitious community hospitals saw that the ability to advertise cardiac surgery as a service line represented an evolutionary edge over competitors. Whole teams were recruited to hospitals all over the US during the early 1990s, including cardiologists, cardiac surgeons, the perfusionists who run heart-lung bypass machines and intensive care staffs. But an interesting thing happened over the three- or four-year span between 1996 and 1999. The overall number of CABGs started to decrease, subtly at first, but quite clearly by 1999—yet the number of new cardiac programs kept on increasing.

The community hospital administrators who were building these new programs hadn’t cottoned to the fact that their food source was about to be in peril. By 1999, the majority of CABGs, by percentage, were being done at so-called low-volume hospitals, which typically have less-good outcomes. And because there were more programs doing CABGs every year while the number of patients needing them didn’t increase at the same rate, each program was doing fewer of these surgeries than they had a few years earlier. The more experienced, high-volume programs were getting hit harder as patients were being siphoned off to new low-volume hospitals, and reimbursement rates were being cut by insurers. In effect, what had been boom times with a reliable food source for cardiac surgeons, and the dependent consultative medical and nursing specialties, all of a sudden went bust. This all happened about midway through the career of the now-itinerant Dr. Bryan Scherr.

So why did the number of CABG surgeries start to decline? Was it because we stopped eating Cheese Whiz-covered fries that had been cooked in tasty trans fats? Were new cholesterol drugs working miraculous cures? Had everyone stopped smoking? In a word, no.

What really happened was that cardiologists got wise. For years they had been diagnosing patients with coronary disease, doing the angiograms, and then sending them off, one by one, to a prima donna cardiac surgeon who would “bang out” a few CABGs between golf games before retiring in his brand-new Mercedes to his multi-million-dollar home. The cardiologist, in turn, drove home hours later in his Honda to a much more modest, split-level home. During the commute, he perseverated about ways to level the playing field.

Then along came the revolutionary balloon coronary angioplasty, coronary roto-rooters, coronary vascular stents, and increasingly sophisticated ways for a cardiologist to “operate” on the heart without ever picking up a scalpel. These innovative cardiologists developed clever new techniques allowing them to reopen blocked heart vessels non-invasively, thereby eliminating the need for cardiac surgery in all but the most complicated cases.

By the late 1990s, with these new techniques, cardiologists had in effect figured out a way to steal the cardiac surgeon’s bacon. What ensued in many small hospitals over the succeeding decade was analogous to those televised scenes from the African veldt where some proud lion king is hunched down anxiously over the carcass of an animal that his queens have brought down and is surrounded by a pack of hungry, disrespectful hyenas. The dogs move ever closer, eyes sparkling in the night, making that eerie laughing sound that hyenas make. And in every show I’ve ever seen, the lion eventually gives it up as a bad job and skulks away.

Maybe, I said to myself as I ended my interview, this is what had happened to Dr. Bryan Scherr, the wandering cardiac surgeon.

Gastroenterologists have figured out non-operative ways to remove gallstones, cauterize bleeding ulcers, and reshape the stomach to treat obesity— traditionally all things that a general surgeon would do during an operation under anesthesia. Cardiologists are now working on ways to repair and replace heart valves using catheters inserted through the blood vessels very much like the ones they use to put stents in the coronaries. They are thereby finding another way to do the work of, and bedevil, cardiac surgeons who have always done these operations while a patient is on cardiopulmonary bypass and then only after cutting open his chest. Radiologists, gastroenterologists, and general surgeons all compete to do another procedure: placing a feeding tube through the skin into a patient’s stomach. And a variety of different surgical specialists insert tracheostomy breathing tubes into the neck. Everybody wants to “own” their own procedure.

Medicare has a reimbursement schedule that’s based on a system of what are called RVUs or relative value units, which is designed to characterize the work intensity of the things doctors do so as to prorate payments. The things with the highest relative values include heart, liver, and lung transplantation; intracranial blood vessel repair; hand reimplantation; and pancreas and esophagus removal. All of these procedures have relative values greater than 50, while the essential day-to-day activities of health care like office consultation, subsequent hospital care, and emergency department visits are valued at around 1. Put simply, a given hour of the higher-valued activity is, under the Medicare payment scheme, 50 times more valuable than an hour of what might well be preventive care. Under today’s reimbursement schemes, thinkers are paid less than doers. As one family practitioner put it, this is one of “the errors of traditional health care, namely paying more for such [things] as cutting, injecting, and imaging, than thinking.”

The Medicare valuation system was devised largely by a group of physicians, and while one may quibble, it’s a system that has stood the test of time and has adapted as new procedures have been developed. The highest-valued activities are the medical tours de force, procedures developed by doctors and procedures that only doctors will ever perform. But there’s a whole lot of competition at the lower end of the value scale.

Optometrists compete with ophthalmologists, and nurse midwives, with obstetricians. Nurse anesthetist organizations portray their members as just as good as, but less expensive than, physician anesthesiologists. The American Association of Nurse Anesthetists recently adopted a strategic plan requiring all of their newly credentialed nurses to become “Doctors of Nurse Anesthesia Practice.” And while the patient of the future will be wheeled off to the operating room by an anesthesia doctor, they’ll have no idea, unless they ask, whether their provider is a doctor-doctor or a nurse-doctor.

Nurse practitioners, too, are moving to mandatory “doctoral preparation.” The American Association of Nurse Practitioners has prepared their own strategic “roadmap” by which it will advance the “terminal degree for advanced practice nursing from the Master’s to the Doctor of Nursing Practice (DNP) by the year 2015.” As we’ll see, nurse practitioners can now be found in many medical offices, working side by side with doctors as well as in stand-alone urgent care centers and—in what may prove the most disruptive new model of medical care—drugstore walk-in clinics.

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FEATURE: The Other Health Care Revolutions By William Hanson
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