Does AI communicate better than real doctors? If so, why is that?

The New York Times recently ran an article titled “Empathetic, Available, Cheap: When A.I. Offers What Doctors Don’t”, which should be very concerning to the medical profession as it emphasizes three things that they are often not. But probably won’t concern the real decision makers in healthcare – the corporate owners, “health systems”, insurance companies, and private equity. After all, their concern is solely making money, and they are doing just fine, thank you.

The article indicates that AI seems to be responsive to and nice to people, and seems to show respect, concern, and empathy; “seems to” is important, because these are computer programs, not people, and they don’t have any feelings. Nonetheless, people feel better when they are addressed with respect, concern, and compassion. Even if it is programmed and not real. The truth is that doctors and other actual people do not always do so, for a variety of reasons. And they don’t even have the chance to if the patient cannot contact them, which is so common as to be routine these days

For many years, I told medical students that, while they had worked very hard to master the language of medicine, learning idioms, jargon, eponyms, and acronyms so they could fit in and impress their seniors, residents and attending physicians, regular people would not understand them if they spoke like that. They had to be able to translate that back into their first language, English (or whatever their vernacular was). This is an important skill, for without it people (“patients”) won’t understand what you are saying, and won’t know what is going on with them. And that is important. It takes effort, and it takes intentionality – you must want the person to understand what you are saying. That’s is true even if what you are telling them is bad news, something that will make them upset or unhappy.

I thought about this after a recent conversation with a couple of current medical students. I made the points above, about the importance of communicating in a way people can understand, and observed that, in fact, often people did not understand. This was based on, among other things, the number of times I had to try to explain to my patients, as a family doctor, what their specialist was saying. And the number of times I had to try to figure out, as a family member or friend, what my family member or friend’s doctor had been telling them that led them come away with what seemed to be an incorrect understanding of the situation. I have even said “If you assume that no one ever understands anything their doctor tells them, you will be correct a distressing percent of the time”.

The students agreed, but when they gave examples from their experience, I became more concerned.

A surgeon I worked with was unable to get all of the cancer out, but when telling the patient used all kinds of technical and unfamiliar terms, like ‘clean margins’. It was like they were trying to not lie, but to obfuscate what they were saying by talking in words and phrases that were technically true but not meaningful to the patient. I was left, after the surgeon had gone, to try to respond to the patient who asked me ‘What did they just say?’”

Obviously, this should not be the job of the medical student, but of the surgeon. And while it is tempting to say, “Well, they’re surgeons; communication is not their strength” (and while, as a family doctor, I like to think we are better at it), most or all doctors are guilty of this sometimes. (It is also true that it is even harder when you have to acknowledge that the bad news may, in fact, be the result of something you did wrong, but this is a separate area.)

I have recently had experience with close family members who had complications during procedures. One, during an endoscopy, had their blood oxygen level drop and had to have a breathing treatment afterwards, receiving a new diagnosis of asthma. This was upsetting, but at least they were told everything. Another, in a much more concerning episode, had major lung surgery. After the surgery, they had terrible, persistent pain which was not adequately treated. Several months later, visiting another doctor (not the surgeon), they were told that their oxygen level had also dropped severely, as a result of having a pneumothorax, a serious, potentially dangerous condition where air gets into the chest cavity and can partially collapse the lung. More relevant, it can be terribly painful. This might explain why the nurses, following their pain-management algorithms, did not give the patient sufficient pain medication. It is still not clear if they were told their patient had a pneumothorax, but it is definitely clear that the patient, my family member, was not told. They should, of course, have been.

There are a lot of potential problems with AI providing people medical information, some of which are discussed in theTimes article. For one thing, it could be wrong. It doesn’t really know you, and part of the reason that you are consulting the medical AI (or real clinician) is that you don’t actually know either exactly what is wrong with you, or how to put it in terms that will get you the correct answer to your question even if the AI is capable of getting the correct answer. Of course, sadly, the same can be true of real doctors, especially when you don’t actually speak to them; the article leads with the story of a person who wanted advice on how to increase the protein in their diet, and received generic – and unhelpful – answers from the physician on line (presumably a “patient portal”). For all we know, they could have been AI produced.

It would be much better – some of us would say essential – for doctors to communicate fully and honestly with their patients, using language that they can understand, even when the news is not good. And for them to be there, being, well, patient, while their patient tries to formulate questions, and answer them. But there are a lot of reasons that they don’t, or can’t.

A part of it may be that they are poor communicators, or uninterested in having their patients understand everything, especially if it could be embarrassing or take a lot of time. But AI doesn’t have that problem. It is not paid by the patient, and it has no set number of people it has to see in a given amount of time the way that real clinicians do. These actual clinicians often work in hamster-wheel conditions (time spent not only seeing patients but having to do electronic charting aimed at maximizing profit via upcoding as much as possible) which are not the fault of the doctor, but of their employers who are interested in “throughput” to make as much money as possible. Saliently, procedures are relatively well reimbursed but spending the time necessary to talk to a person to be sure that they completely understand what is going on is not. Of course, this is also part of the reason that there are fewer students entering primary care and more are entering better-paid procedure-based specialties.

Having a health care system that valued, and paid for, communication would be good. It would have to start with a system designed to maximize the health of our people, not corporate profit. Yes, there would still be some doctors who communicated poorly, and even made poor medical decisions, but those could be dealt with as individuals, rather than having them intrinsically encouraged by the system.

Doctors could and should do better, and maybe there is a place for AI. But there is no place for profit in healthcare.

Culture and Medical Culture: Understanding to increase benefit and reduce harm

Culture is often understood, at least by that culture that is in a majority in a given place, as a characteristic of others. That is, we are “regular”, they have a culture. The greater the disproportion between the dominant group and others in terms of numbers, the less diverse a community is, the more this – incorrect – assumption prevails. In the 19^th century, before the work of Bronislaw Malinowski and Margaret Mead, who actually spent time in the places and cultures they were studying,  cultural analysis of the world by anthropologists was often done “offline” by what have become known as “armchair anthropologists”. All European, they ranked cultures from least to most civilized, and guess what: European, and especially Western European, cultures were always at the top!

It should be needless to say that this was wrong. In addition to all the examples that can be given of other non-European cultures were far more advanced (think the Arab world for mathematics and science, China for all kinds of things), all cultures are different. They do not just have “strengths” and “weaknesses”, or areas in which one is “better”, but differences which have developed to serve the needs that existed where they lived. Weather, for a start, makes a difference in the types of crops grown or how housing is designed. In addition, of course, different cultures share many similarities. This allows for, for example, religious ecumenism, in which folks of different religions can come together based upon the values that they share. In the US today, we have seen great advances in understanding not only that differences between cultures do not mean one is better than another, but also that similarities between people usually exceed differences. Recently, we are seeing great strides against racism, sexism, jingoism, and all the other “isms” that promote hatred instead of understanding. Unfortunately, however, we also see a backlash from people who feel threatened by the idea that other people, whom they have disparaged and discounted, are indeed their equals. This has gone beyond attitudes; it has led not only to violence, but to legislation enshrining prejudice, hatred, and discrimination. I hope this will get better, but it might get worse first.

One way that we have on tried to address this issue in medical education has been discussions between small groups of students about how they see common phenomena in the world, in their communities, in families, and relationships. The more diverse a class is, the richer these discussions become and the more the students learn that what they think of as “regular” is in fact just as much a cultural belief as that of other people. Of course, this also can reveal assumptions that they may make about what is “normal” that are not normal for others, particularly regarding financial and socioeconomic issues. Or, for instance, whether the police are seen as your protectors or your persecutors.

This becomes an important entry point for examining medical culture, which certainly exists and carries its own beliefs and prejudices, as do most professions. These beliefs are no more, or less, “true” than sociocultural beliefs. Because medicine involves not only extensive interaction with other people who are not immersed in the culture but, even more, extensive power over the lives and health of those people, coming to grips with what you (and your teachers) believe because, well, we all believe it, rather than what is based in evidence, is important. This is more difficult because a big part of the socialization to a profession such as medicine is for a novice who is from outside that culture to learn the jargon, way of thinking, and indeed prejudices that characterize it, and this can have negative as well as positive results.

For example, our medical students usually enter perfectly capable of speaking English (and perhaps other languages) and conversing with others and communicating ideas and information. As part of becoming doctors, they learn new language, new terms, new acronyms, new meanings, and eagerly repeat them as evidence of their acculturation. Unfortunately, this can become an obstacle to communication with their patients, who do not speak this language. One example: a couple of sentences ago, I used “positive” and “negative” in their usual English senses of “good” and “bad”. However, when doing medical tests (lab, imaging, biopsies) a positive result is usually bad, and a negative result is good. But when a doctor, or student, informs a patient that their results are negative, it is common for the patient to react with fear, since this sounds like a bad thing. We urge them to say “normal”. Whew, that’s a relief!

Some other issues of medical culture are address in an Op-Ed by Robert Pearl in the Los Angeles Times of May 16, 2021, “How doctor culture sinks US health care”. A big part of Dr. Pearl’s critique in the distinct bias, not only in physician attitudes but in medical journal articles, towards intervention and procedures rather than prevention. This, he notes correctly, is very much tied to money, since physicians and hospitals and health systems (which are increasingly the physicians’ employers) stand to make much more money from them. Medical journals are more likely to print articles with positive (there is that word again!) results, demonstrating that a procedure had benefit, than negative results, demonstrating that, actually, compared to something – or nothing – else, something (or nothing) that was easier, cheaper, less interventive, and less dangerous, it had no better outcomes. Of course, anyone can see that knowing this information, that doing something is not worthwhile, is at least as important as knowing that something works well.

However, the inclination (or perhaps prejudice) among most physicians is to do something, to intervene; aside from making money, it makes them feel that they have skills, are justified, are important. Unfortunately, this is also an attitude quite prevalent among their patients, who want something done to help their problem – to cure their disease, or increase their lifespan, or improve the quality of that life, and in particular to ease their pain. But doing something does not always improve things, and can definitely increase the risk of harm. We need to know what works (and what doesn’t), and in what circumstances, and what the dangers are, and what the alternatives are, and their potential benefits and risks, and then have discussions together about what, in the specific circumstance a specific person is in, what would be the best choice for them.

This effort is likely to overlap with more traditional sociocultural and religious beliefs, which can have an influence on what a person thinks would be best for them. Communication around this requires care, and a real effort on the part of the medical professional to understand and to make their own thoughts clear and clearly expressed. This is even more complicated when, as is the case, physicians are from a pretty narrow slice of the American population, racially, culturally, and economically (and, again, a good argument for increasing its diversity). As in all situations where there is a power differential (and in medical care, the greater power lies with the physicians and health systems) it is incumbent on those with greater power to make the effort to understand those with less. And, at least as important, to not make decisions for and about people based on only your understanding – or worse, assumptions – about what they want, or are because of race, religion, gender, national origin, etc. Doctors, even when they are well-meaning (and all of them are not always) too often allow themselves to fall victim to the ecological fallacy, and confuse “condition X is more common in population Y” with “the patient is a member of group Y so probably has condition X”.

It is, of course, also very important to recognize that all interventions and procedures are not a bad idea; indeed, they are often the best treatment. And, also, that not everything sold as “preventive” is really so; plenty of tests and treatments called preventive are not proven to prevent anything. It is not easy to overcome prejudices and beliefs.

But understanding that we all have culture, and trying to not be bound by it and doing our best to understand that of others, is a good start.

Hospitals post their charges: almost indecipherable, but important!

The recent Trump administration order to have hospitals post their prices has been widely covered in the media, along with both headlines and articles that make it clear that these prices list are far from…clear! For example, Robert Pear’s article in the NY Times on January 13, 2019, titled “Hospitals Must Now Post Prices. But It May Take a Brain Surgeon to Decipher Them” , starts:

‘Vanderbilt University Medical Center, responding to a new Trump administration order to begin posting all hospital prices, listed a charge of $42,569 for a cardiology procedure described as “HC PTC CLOS PAT DUCT ART.”

Baptist Health in Miami helpfully told consumers that an “Embolza Protect 5.5” would cost them $9,818 while a “Visceral selective angio rad” runs a mere $5,538.’

The Arizona Star piece on Tucson hospitals had a more moderate title, “Hospitals post prices, but public can find it confusing”, but made the same points. As a physician (if not a brain surgeon!) I think I can figure out what most of these mean, but the point that they are making is that they are hard for almost everyone to understand. The reason, of course, is that they have simply posted online their “chargemasters”, the price list that they supply to insurers (including Medicare and Medicaid), which are based on the nationally used “procedure codes”; these are numbers which identify different treatments that are abbreviated as above. So, the charge at Baptist for a radiologist injecting dye into an artery supplying your intestines is only a little over $5,000, while Vanderbilt charges over $42,000 to do a surgical procedure to close a shunt artery in your heart that is vital to fetal circulation but normally closes spontaneously after birth. The question is, what does all this mean? And what are you and I supposed to do with this information?

Elisabeth Rosenthal, the emergency room physician turned NY Times reporter turned editor of Kaiser Health News, is more optimistic in her Times Op-Ed on January 22, 2019, “Donald Trump did something right”. She acknowledges the opacity of the posted charges to most people, but says it is a great step forward, because they are accessible, at least to those who are academic experts, and can be compared, both one hospital to another (“Maybe, just maybe, a hospital will think twice before charging a $6,000 “operating room fee” for a routine colonoscopy if its competitor down the street is listing its price at $1,000”), and to alternative treatments (“With access to list prices on your phone, you could reject the $300 sling in the emergency room and instead order one for one-tenth of the price on Amazon.”) Obviously, these would not be easily available on your phone now, but her hope and expectation is that third parties will develop apps that will take this nearly impenetrable information and make it easily accessible to people, as apps such as GoodRx® have done for drug prices. She emphasizes the magnitude of this change, since before now these prices have been closely-guarded secrets.

Rosenthal makes a number of other important points that illustrate the fact that this system is not only opaque, but deeply morally corrupt. Hospitals are run as businesses, to make money, even when they are ostensibly “non-profit”. Their CEOs and other executives are mostly businessmen, CPAs and MBAs – even when they are physicians, which sometimes happens, they are usually also MBAs – and are hired for their ability to run a money-making operation that happens to sell health care. And sell it, to your insurance company, at what often seems like deeply discounted prices because they are based on absurdly inflated chargemasters. “You don’t really want to change your charges if you have a Saudi sheikh come in with a suitcase full of cash who’s going to pay full charges,” says one CEO. More important, it allows them to reach agreements with insurers to pay a lot less than the official “price”, which in turn allows those insurance companies to brag to you about how much money they saved you. Rosenthal notes this is farcical, raising prices to make you think that you got a discount (‘If a supposedly $1,000 TV is “on sale” for $80, it’s not really a discount. It’s an absurd list price’), and that it emulates practices in other arenas, such as airlines overestimating their flight times to make it seem like they have a better on-time percent.

At a higher level, Rosenthal points out what is wrong is that these inflated charges do make a difference. Your co-pays and deductibles, if you are insured, are based upon the amount that your insurer pays, so that if they have agreed to pay only 20% of the listed charge, $200 for the TV set instead of $1000, you still may pay more than if you bought it for $80 cash. And certainly more than if the insurer were paying 20% of the old list price, say $500. You pay. You always pay. (See, for example, how insulin manufacturers and insurance companies and pharmacy benefit managers, each following their own profit incentives, have made insulin – a life saving treatment for millions of people with diabetes – often unaffordable: Danielle Ofri, “The Insulin Wars”.)

And, of course, there is the nasty little glitch that it is the most vulnerable and most needy, those who are uninsured as well as sick, and often poor, that get charged the full list price, the $1000 for the TV, or the ostensible “uninsured discount”:

When Wanda Wickizer had a brain hemorrhage in 2013, a Virginia hospital billed her $286,000 after a 20 percent “uninsured” discount on a hospital bill of $357,000 — the list price, according to chargemaster charges. Medicare would have paid less than $100,000 for her treatment.

Wait. Medicare? Medicare would have paid a quarter of their list price and a third of what this uninsured person got billed with the “discount”? Yes. And that is a place to start. Hospitals – or the third-party app developers that will let you see these prices on your phone – should be required to list the Medicare-approved payment right next to what they will charge you, or your insurer. That would measurably increase the “light of day”.

Of course, some doctors and hospitals do not want to accept Medicare for this reason – they can charge more money to insurance companies, who pass it on to you in premiums (in addition to your co-pays and deductibles) while claiming to be saving you money. There is a solution to this also, although Rosenthal does not mention it. It is to have everyone in the same insurance program, a single payer, an improved and expanded Medicare for All. This would set the rates and pay them, without co-pays or deductibles for necessary services. Everyone in the same plan would mean that the better educated, wealthier, and generally more empowered would ensure that it worked for them – and thus would work for everyone else, middle-class, poor, and even homeless.

Yes, hospitals and other service providers (physicians, nursing homes, etc.) and drug companies and insurance companies would make less profit. I’m sure that your heart goes out to them (maybe the next requirement could be the posting of the salaries of the C-suite executives at hospitals…). But, after all, what the health care system should be run for, and is run for in every other developed country, is the health of the people, not the profit of corporations.

Amazing, huh? And it could be that way here!

Medicare payments to doctors: the big issue is the underpayment for primary care

The Center for Medicare and Medicaid Services (CMS) just published how much money individual doctors get paid from Medicare. This initial version is without names, but undoubtedly the names will eventually be revealed. Enough information is available for Reed Abelson and Sarah Cohen, who wrote the article for the New York Times on April 9, 2014 “Sliver of Medicare Doctors Get Big Share of Payouts”,   to identify many of the specialties and locations. About ¼ of all Medicare payments, the article tells us, go to about 2% of all doctors. “In 2012, 100 doctors received a total of $610 million, ranging from a Florida ophthalmologist who was paid $21 million by Medicare to dozens of doctors, eye and cancer specialists chief among them, who received more than $4 million each that year.” The largest amount of money was accounted for by office visits, $12B, but this was for 214M visits, with an average reimbursement of $57, in contrast to the Florida ophthalmologist, or to the “Fewer than 1,000 radiation oncologists, for example, received payments totaling $1.1 billion.”

Much of the discussion in the article, and in the comments attached, relates to why so few doctors get so much of the $77B Medicare pays out each year. There are, obviously, concerns about fraud; not only is Medicare seemingly fixated on looking for fraud everywhere but there is good evidence that it has occurred, at least historically. For example a highly paid (by Medicare) Florida ophthalmologist is apparently linked to a previous Medicare fraud scandal in which there was some implication of New Jersey Senator Robert Menendez. “The Office of Inspector General for the Department of Health and Human Services, which serves as a federal watchdog on fraud and abuse for the agency, released a report in December recommending greater scrutiny of those physicians who were Medicare’s highest billers.” I would have to say that this is a much wiser, fairer, and probably more productive strategy than simply trying to find largely unintentional errors in coding for outpatient visits, or checking each hospital admission to see if it could have been an “observation”, which is reimbursed less because it is considered outpatient status, as is done by Medicare’s Recovery Audit Contractors (RACs, or as I have called them, bounty hunters). Also, as I have previously discussed, these efforts are harmful to the patient in a direct financial way; as an “outpatient”, a Medicare recipient in the hospital has much higher out-of-pocket costs than if they are admitted as an inpatient. This is, of course, why CMS wishes to limit some stays, but if a person medically needs to be in the hospital, Medicare should pay for a hospitalization, and not play these games that not only financially penalize the hospital and doctors but more importantly the patient.

The other big area discussed is whether, if not exactly fraud, there is substantial difference in practice (e.g., getting CTs before each procedure, using more expensive drugs, etc.) that some specialists who are highly reimbursed by Medicare are doing more of than others. In addition, the question is “are they doing more procedures” or doing procedures with less strict indications? It is worth looking at; there is no guarantee that, even if some doctors are doing more procedures, having looser criteria for them, using more expensive drugs and tests, that this is not the better way to practice, but there is no guarantee that it is the better way to practice. If some doctors are outliers in their specialty, and their practice characteristics “happen” to end up making them a LOT more money than others, then this is certainly a reasonable basis on which to look more closely at how they are practicing, and what is the evidence basis of appropriate practice.

A third issue is that many of the recipients of the most money from Medicare, particularly oncologists (cancer doctors) and ophthalmologists are using very expensive drugs, which they have to buy first and which Medicare reimburses them for. Thus, this skews their reimbursement upward even though the money (or most of it) does not go to the doctor, but rather to the pharmaceutical company. The article refers to a drug called ranibizumab, injected into the eye by ophthalmologists monthly for age-related macular degeneration. It is very expensive, as are many drugs which are made through recombinant DNA (a lot end in “-ab”) used by oncologists, neurologists, rheumatologists, and gastroenterologists as well. One comment notes that he as a physician only makes 3% on the drug. While it can be argued that this is a significant markup (for example, making $3000 on a $100,000 drug), and that this doesn’t include the doctor’s fee for administering it (substantial), it is unfair to count the full cost of the drug as income for the doctor. Of course, it is income for someone (the pharmaceutical company) which suggests there needs to be substantial investigation into pricing of these drugs. And, of course, if a physician is found to be using a lot of a drug where he (or she) makes a 3% markup rather than prescribing an equally effective drug (if there is one) where there is no markup profit, this would be a bad thing.

However, the most important thing revealed by this data, I believe, is the enormously skewed reimbursement by specialty. It is an excellent window into the incredible differences in reimbursement for different specialties, with the ophthalmologists, radiation oncologists, etc. making huge incomes while primary care doctors (and nurse practitioners) are making $57 for an office visit. This is major. The fact that Medicare pays so fantastically much more for procedures (and, as a note, it is likely that all of the doctors, including the 202 family doctors in the highest-paid 2%, are getting it for doing a lot of procedures) leads to private insurers paying similarly more. And makes these specialties very attractive to medical students because they are lucrative (and often, though not in the case of many surgical specialties, involve fewer hours of work). Which leads to fewer primary care doctors, and a dramatic shortage in this country.

Medicare could change this. It could dramatically, not a little bit, change the reimbursement for cognitive visits to be closer to the payment for these procedures. If it did, so would private insurers. If the income of primary care doctors was 70% of that of specialists (instead of say, 30%) data from Altarum researchers and from Canada suggest that the influence of income on specialty choice would largely disappear. More students would enter primary care, and in time we would begin to see a physician workforce that would be closer to what this country needs, about 50% doctors actually practicing primary care.

It is fine if CMS and the OIG look at these highest billing doctors to make sure that they are not committing overt fraud. It is also fine to look at them and see if they are using criteria for procedures that are not supported by current evidence, or doing too many other tests, or taking kickbacks. It is also a good idea to look at the cost of drugs, especially the portion going to the drug company, as well as the markup for physicians, and to re-present the data excluding that portion of the money the doctor does not get (goes to the pharmaceutical company) from their income.

But the most important result of this report should be to be shocked at the way Medicare enables the continued practice of reimbursing for procedures at such high levels, and to kickstart a complete revision of the Medicare fee schedule to bring reimbursement for different specialties into better balance.

That would be a great outcome!

Performing procedures: Who is capable and how should we pay?

A recent article in the British Medical Journal reported on a comparison between physicians and nurses performing endoscopy in the UK.[1] They specifically looked at “upper endoscopy” (esophago-gastro-duodenoscopy) and flexible sigmoidoscopy, not full colonoscopy which has largely replaced flexible sigmoidoscopy as a screening tool. Their conclusions show that there were no differences in outcomes at 1 day, 1 month, or 1 year in the two populations, and that the patients of the nurses indicated greater satisfaction, particularly with the teaching and explanation that they received. This study is consistent with the findings of one published in 1994 in the New England Journal of Medicine by William Maule.[2] Nursing journals and other advocates have pointed to the latest study as indicating that nurses are, or can be, as “good as” doctors[3]; certainly within the limits of the study it does provide such evidence. The editorial accompanying the BMJ article discusses many of the limitations of the study, which I will not go into here, except to say that none of them particularly indicate that nurses trained to do endoscopy do not perform as well as physicians.[4]

I don’t doubt that this is encouraging to nurses, and to nurse educators, who have frequently been disparaged by implications that their education and training did not provide them with the background to perform as well as physicians. However, the important point here is not a nurse/doctor one, but rather the fact that endoscopy, like many medical procedures, is essentially a psychomotor skill, which should be able to be successfully taught to anyone who is moderately intelligent and moderately dexterous. In Britain, they have taught this skill to a large number of nurses, who apparently do it very well, as did the nurses in the US reported upon by Maule 15 years ago. But why should such training be limited to nurses? It is obvious that many procedures, including endoscopy, require significantly less psychomotor skill (and probably knowledge) than complex automobile mechanics, such as, say, rebuilding a transmission. Yet our automobile mechanics, even transmission specialists, while well trained, are not required to even attend college, not to mention receiving education and training as rigorous as nursing or medical school. Not to mention the 4 years of college, 4 years of medical school, 3 years of internal medicine residency, and 2 years of gastroenterology fellowship that are required in the US for a physician to become a GI specialist, the primary group doing endoscopy. For those who wish to note that working on a car is less serious than working on a person, I suggest that there is likely much greater risk to the health of the people riding in a car with a poorly rebuilt transmission or other major mechanical work than from a poorly done colonoscopy.

It seems obvious that adequate – even excellent – training could be received by those attending a two-year community college course, comparable to those training our radiology and laboratory technicians. A well-trained technician doing 10 or 20 endoscopic procedures a day would be very good indeed, and would free the well-trained gastroenterologist to make the complex medical decisions that do require a great deal of medical knowledge, skill and experience rather than spend their time performing relatively simple procedures. So why don’t we do it that way? Why do superbly educated gastroenterologic physicians choose to spend their time doing these procedures?

The answer, of course, is money, and the perverted, inappropriate and nonsensical way that we reimburse for health care in this country, in which the value assigned to procedures of any kind far exceeds that assigned to thinking and caring and talking and decision making (so-called “evaluation and management”, or E&M, care). In the US system of assigning value to different numeric codes, representing the work done for a patient, E&M “codes” are routinely, and absurdly, assigned a lower number of “relative value units” (RVUs) and thus reimbursed at much lower rate than procedural “codes”. For example, for approximately 30 minutes spent by a physician doing a visit with an established patient Medicare (2007) would pay $94.20, while the payment for a colonoscopy would be $203 and for a cataract removal, $670! This does not just apply to major surgical procedures, or even relatively large non-surgical procedures such as endoscopy. A physician can collect more money for cleaning the wax from a person’s ears (a procedure!) than for the entire well-person visit! Spending 5 minutes wrapping a gel-infused elastic bandage (“Unna’s boot”) around a foot with an ulcer on a person with diabetes will pay several times more than the entire visit listening to, examining, educating, and prescribing treatment for the patient. What utter nonsense!

The most important point made about the article in BMJ is a relatively minor sentence in the editorial: “Nurse led services in the United Kingdom have been encouraged by government policy, a shortage of doctors, a willingness of nurses to adopt expanded roles, and a salaried NHS workforce where professionals re not in competition for income from patients” (my emphasis). This is the heart of the matter. Where absurd reimbursement systems are not driving inappropriate use of resources, incenting highly trained physicians to do what could be done by nurses or, as I suggest, by well-trained technicians, we could actually decide what kind of care should be done by whom, and how much time should be spent on it, by what was in the best interest of people’s health.

[1] Williams J, Russell I, Durai D, et. al., “Effectiveness of nurse delivered endoscopy: findings from randomized mult-institution nurse endoscopy trial (MINuET), BMJ 2009;338:b231
[2] Maule WF, Screening for Colorectal Cancer by Nurse Endoscopists, NEJM Jan201994;330(3):183-87.
[3] Lomas C, “Endoscopy nurses 'equal' doctors”, NursingTimes.net, Feb 16, 2009 http://www.nursingtimes.net/news/breakingnews/2009/02/endoscopy_nurses_equal_doctors.html
[4] Norton C, Grieve A, Vance M, Editorial: Nurse-delivered colonoscopy, BMJ 2009;338:a3049