Two years ago, a trio of Bloomberg journalists reported that Mount Sinai Hospital in New York City was scheduling "emergencies-by-appointment" for patients to get stents, because, the report said, insurance is more likely to cover the procedure in an emergency situation. (For a patient who is having a heart attack, a stent can be life-saving.) Mount Sinai's catheter lab features annual reports that boast of how many stents are implanted, alongside patient testimonials, like one from 77-year-old Nelly Rodriguez, who notes that her doctor "reassures me that as long as I follow his instructions, eat healthy, and remain smoke-free, the stents he has put into my arteries over the years should last and I will feel well." In most cases, every word of that sentence between "smoke-free" and "I will feel well" could be deleted and it would be just as true.
It is, of course, hard to get people in any profession to do the right thing when they're paid to do the wrong thing. But there's more to this than market perversion. On a recent snowy St. Louis morning, Brown gave a grand-rounds lecture to about 80 doctors at Barnes Jewish Hospital. Early in the talk, he showed results from medical tests on the executive he treated, the one who avoided a stent. He then presented data from thousands of patients in randomized controlled trials of stents versus noninvasive treatments, and it showed that stents yielded no benefit for stable patients. He asked the doctors in the room to raise their hands if they would still send a patient with the same diagnostic findings as the executive for a catheterization, which would almost surely lead to a stent. At least half of the hands in the room went up, some of them sheepishly. Brown expressed surprise at the honesty in the room. "Well," one of the attendees told him, "we know what we do." But why?
In 2007, after a seminal study, the COURAGE trial, showed that stents did not prevent heart attacks or death in stable patients, a trio of doctors at the University of California, San Francisco, conducted 90-minute focus groups with cardiologists to answer that question. They presented the cardiologists with fictional scenarios of patients who had at least one narrowed artery but no symptoms and asked them if they would recommend a stent.
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