The New Health Dialogue

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Shannon Brownlee is the Acting Director of the New America Foundation Health Policy Program and the author of the groundbreaking book, "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer." For a cardiologist's perspective on the need to reduce overdiagnosis, check out the companion piece by Dr. Vikas Saini entitled, "The Price of Avoidable Care."

If you ever want a reason to question your cardiologist very closely when he or she recommends you undergo an angiogram, the imaging test that precedes an angioplasty or stent, read this paper by Grace Lin and Rita Redberg, cardiologists at the University of California, San Francisco. Lin and Redberg conducted three focus groups, where they gathered groups of cardiologists and asked them to talk about three hypothetical patients. All three patients had heart disease, but none would benefit from getting an angioplasty or stent – and that’s according to guidelines created by cardiologists themselves.

Nevertheless, nearly all of the cardiologists who participated said they would go ahead and give the patients a stent or angioplasty. They overestimated the benefits of their procedures, and ignored the evidence from multiple studies.

The really unsettling part of Lin and Redberg’s paper? The conversation they quote among the cardiologists from one of the focus groups that suggests that once a patient is in their clutches, he or she is going to get a procedure. One cardiologist says, “There’s no chance of escaping.” Another responds, “That’s the end of it. He [the patient] is not going to get out [...] without a stent.”

Redberg was the doctor that a woman named Elaine Lissner called for a second opinion when she learned that her father was scheduled to undergo an angiogram. After Lissner spoke to Redberg, her father took a less invasive route to managing his heart disease, including losing 15 pounds and getting more exercise.  

Lissner also happens to be the president of the Parsemus Foundation, a family foundation. She made a small donation to support the “Less is More” series, published by the medical journal Archives of Internal Medicine, and edited by Redberg. The “Less is More” project publishes medical articles intended to highlight the vast quantities of avoidable care delivered in the American health care system.

Apparently, this donation is not sitting well with some cardiologists. Lissner’s experience and the donation from the Parsemus Foundation appeared in a story in TheHeart.org, an online source of information for cardiologists published by WebMD. The story quotes Arjay Kirtane, a cardiologist at Columbia University, in New York, who takes offense at the idea of a medical journal taking money from a foundation that has the gall to suggest that there’s a lot of unnecessary cardiology procedures being done, that maybe cardiologist are doing things to patients they shouldn’t.

C’mon. According to two recent papers, about 1 in 8 angioplasties and stents done in the U.S. are performed on inappropriate patients – patients who by cardiologists’ own studies and by their own guidelines don’t stand a ghost of a chance of benefiting from the procedure, but who are nevertheless exposed to its risks. Those risks aren’t high, but they’re serious, including heart attack, stroke and death. Not to mention the fact that we’re spending more than $3 billion a year (that’s billion with a B) on those unnecessary procedures. 

Maybe Upton Sinclair had it right: It’s difficult to get a man to understand something when his income depends on not understanding it.

By the way, Lissner’s father is fine.