My Doctor Says: Get a Boob Job

PUBLISHED ON  August 18, 2009

WRITTEN BY  Roni Zeiger

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My wife, my children, and I are all patients at the Palo Alto Medical Foundation (PAMF). I am grateful for the world-class care that we all receive there, and I continue to refer many friends and colleagues there.

We recently received a mailer from PAMF, addressed to my wife and personalized with her name showing what they think her summer to do list should include. (I’ve blacked out her name in the photo of the mailer below.) The list ends with: “Do something REALLY special for myself!”

My Doctor Says: Get a Boob Job

Cute, I thought, and wondered what would be inside. Perhaps some tips on exercise or eating smart, or a reminder to get caught up on important screening tests. My jaw dropped when I opened the pamphlet and saw: “To look and feel your best, you don’t have to look far”, and listed the following services:

– Breast Reshaping
– Tummy Tuck
– Face, Eye, and Neck Lift
– Liposuction
– Rhinoplasty (Nose Reshaping)
– Laser Skin Rejuvination

I think it is entirely appropriate that PAMF offers these services. However, I am deeply concerned that they are advertising them as the way — for a woman in particular — to do something really special for herself and feel her best. Body image issues aside, what does this say about our physicians? PAMF represents my wife’s primary care doctor (and mine), and I suspect many patients see this type of promotion as coming from their doctor. Did she approve this, we wondered? If so, what should we think when she recommends a mammogram or a colonoscopy? It begs the question of whether the primary goal is my health or profit for the health care provider.

I’ve commented previously on Atul Gawande’s eye-opening piece in the New Yorker about McAllen, Texas, a town where health care costs are among the highest in the country, while the quality of care is no better than average. Gawande explains:

About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.

Perhaps we are asking too much of physicians. They should have only my well-being in mind, while at the same time their decisions about my care often impact whether they can afford to send their kids to college. In case you’re worried about your own bills, don’t worry — as you see in the screenshot below, for these procedures you can get a FREE private consultation and financing options are available.

Ideally, it won’t be long before we get much better at measuring the quality of care, and physicians will get payed for delivering quality. In the meantime, demand the facts and make informed decisions.

P.S. I originally posted this on Huffington Post. I couldn’t export the comments and there were some great ones, so feel free to read the comments there.


Who Is the Most Important Stakeholder in Health Care?

PUBLISHED ON  June 17, 2009

WRITTEN BY  Roni Zeiger

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Like many other doctors, patients, and President Obama, I’ve been thinking about Atul Gawande’s brilliant piece in the New Yorker on the root causes of spiraling health care costs in the U.S. One aspect that has not yet been given enough air-time is what role patients should play in this discussion. Gawande describes a thought experiment performed by him and a cardiac surgeon:

A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.” — that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”

I’m not naive enough to think that we will do well if patients negotiate on price for how many of their coronary arteries should get un-clogged. And while few patients are ready to use a microscope to diagnosis their own Crohn’s disease, those that do should remind us who has the biggest incentive for sustainable, high quality health care. It is critical that patients be a part of this conversation.

When the best treatment is well understood, and should not vary by the patient’s values or preferences, then our traditional paternalistic system works well for many consumers: Doc, tell me what to do, and let’s do it. However, in the many cases where the best data says there are two or more equally good options — e.g., whether to have surgery for low back pain — then we need more innovation and thought leadership on how to have these conversations effectively. How do patients best understand risks? How can we organize data about effectiveness of treatments for the top 100 conditions so that average doctors can keep up and discuss options with their patients? These are solvable problems.

It is awesome that Peter Orszag himself (Director of OMB) offered a thoughtful and data-rich response to Gawande’s article on the official Whitehouse website. Let’s also keep front and center the need for the consumer to be part of the conversation, and that doctors and patients alike need better access to basic data about what works and what doesn’t. Doctors should increasingly expect patients to ask: “What is the likely outcome if we choose this option?”, and patients should expect an answer.

Risks vs. Benefits: Get the Evidence or Fire Your Doctor

PUBLISHED ON  April 14, 2009

WRITTEN BY  Roni Zeiger

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Gone are the days where you should believe what your doctor tells you simply because he or she is a doctor. Medicine can be complicated, and it changes all the time: new drugs, new resistant bugs, and new scientific studies that teach us that sometimes what we once thought was good is in fact killing people. Your job as an informed consumer of healthcare is to make sure that the benefits outweigh the risks. The stakes are too high for you to assume that your doctor knows this.

Risks vs. Benefits: Get the Evidence or Fire Your Doctor
We love talking about benefits — that’s the part of the commercial with smiling lovers and chirping birds. But talking about risks is scary, so we avoid it or mention them really fast when the credits are rolling. When is the last time YOU asked about the risks of a treatment or a test?

Case 1: The doctor says: “You should have a colonoscopy.” How can you decide if this makes sense for you if she doesn’t also tell you that there is a 1 in 14,000 chance you will die from complications of the colonoscopy? This doesn’t mean you shouldn’t do it. It means there had better be a greater than 1 in 14,000 chance that it will save your life or make you healthier. (And your doctor should tell you that for colon cancer screening, the benefits indeed outweigh the risks for adults between 50 and 75 years old.)

Case 2: “There’s a spot on your chest x-ray. It’s probably nothing, but let’s get a CT scan to make sure.” Wow, what a caring doctor. What will you say to him? That’s right, you should ask: “What are the benefits and risks?” If he explains them, including the fact that repeated CT scans increase your risk for cancer — great. If she says, “I don’t know, but let’s find out” — great. If he just wants you to go ahead with the treatment based only on his experience, fire him.

For doctors, it’s quite difficult to find out the actual risks and benefits of the tests and treatments we recommend. You might expect that there is a regularly updated database of the top 100 treatments and invasive tests, which quantifies the risks and benefits for each of them. It doesn’t exist! Most of the data needed to create such a database does exist, but it’s scattered across many research articles and textbooks. I’m willing to bet that if more of you demand this information from your doctors, that database will soon exist. And I know it will help me practice better medicine.

Demand the facts and make informed decisions. Your life depends on it.