MAMMACTIVISTS KILLING THE MAMMOGRAM

There is a reality radiologists have faced for several years: Mammography, performed and interpreted by experts, can not survive. It is a technology besieged by conglomerate forces that will drive it into extinction, with many other important procedures and technologies to follow. Radiologists see four major reasons for this destructive phenomenon: HMO’s, government regulations, special interest groups ( THE MAMMACTIVISTS) and trial lawyers.

President Clinton’s overblown health care crisis and ill-conceived reform project of the early ‘90’s catalyzed the conversion of fee-based private health insurance into the HMO chimera we now face. Positioned as middlemen – with profits their sole motivation-- HMO’s are driving down reimbursements to the point where it is no longer economically possible for reputable physicians to do mammography and balance the books.

MAMMACTIVISTS -- special interest groups fanatically focused on breast cancer -- have railroaded thousands of pages of Federal regulations and compliance requisites through Congress affecting every aspect of mammography. These disease-specific laws are enforced by regular inspections and audits; this, despite the fact that mammography is one of the most straightforward procedures in radiology and is little more complex than a chest X-ray. No such regulations exist for neurosurgery, heart transplant, treatment of pediatric malignancy, or any other medical procedure. These laws have increased operating costs of women’s centers significantly, yet neither the HMO’s nor the government recognizes this exigency with increased compensation. Micromanaging individual diseases with laws leads, at best, to inefficiency and inflated costs.

A mammogram is an inherently limited study with relatively low sensitivity and specificity. Unfortunately, the public does not understand these limitations because the exam has been oversold as a diagnostic modality (We are told this is for the public’s “own good”). As a result, people have a difficult time understanding why breast abnormalities are “missed” or “misinterpreted” during routine mammography. Personal injury lawyers ruthlessly take advantage of this dilemma by scavenging mammograms involved in breast cancer cases. They prey on this ignorance by holding radiologists to impossible standards bolstered with retrospective analyses of mammograms done by venal physicians in their stable of “experts”. As a result, mammography is the single highest liability risk for radiologists (and the second highest risk in all of medicine). For a $15 reading fee, radiologists can face multi-million dollar lawsuits.

In their practices, the few radiologists left who interpret mammograms are seriously considering abandoning the procedure. Some argue that radiologists have an ethical obligation to do the procedure. This may be so, but radiologists cannot be the sole bearers of this obligation. If the businessmen, the politicians, the lobbyists, and the lawyers cannot share in this ethical challenge then radiologists will increasingly refuse to shoulder the burden alone.

Comments

[jb]

I'm intrigued by your statement that "some argue that radiologists have an ethical obligation to do the procedure [mammography]" I don't recognize any ethical obligation to do anything for or to a patient unless I specifically agree with that patient to do something. Any ethical or moral obligations that any physician may have been under have been replaced by >100K pages of federal regulations, guidelines, and requirements, not to mention what the legal hyenas force us into not doing. Like many docs, in order to preserve my practice, I have to restrict what I do and to whom I do it. I didn't create this problem, but I have to live with it.

[CBB MD]

JB:

I certainly agree.

However, if you try to explain that to the public, straight up, they won't hear the rest of what you are saying. Then no message gets across.

The public believe that physicians have all sorts of moral and ethical obligations and duties that are ill-defined yet supremely governing of what we do and why. This perception is steeped in a moral soup that originates from a defunct pact we, the doctors, made with patients in an era when we had skills that were little greater than barbering. To obscure what we were unable to do (and to bide us time to explore, discover, and otherwise empirically claw our way into modern medical science), we invoked the whole "art of medicine" ruse and cloaked it in a mysticism that, at one time, had doctors rated second only to clergy in levels of public respect. I think that was a major tactical (and ethical) error of our forefathers. We should have been frank and to the point from the beginning.

This phenomenon was compounded by the system of health-insurance-provided-as-work-benefit that arose during WWII when wages were frozen and businesses needed to attract workers -- so they offered free health insurance.

The presence of "free health care" (it's free when you don't pay for it) combined with the continuing thread of moral obligations and ethical duties has put us between a rock and a stiletto tip. Now that health care is actually WORTH something and is getting REALLY good, the traditional payers are punking out. They don't really care about anyone's health, so, the less care involved, the less expense, the better for them. Since insurance companies, HMO's, private hospitals and the government are not perceived to be morally obligated at anywhere near the same level as the physicians, (who are unable to regulate their own fees), doctors are are chosen to be the moral chumps -- elected to take the fall (and not coincidentally softening up the public for overhaul of the health care system and its MD-profiteers) as payers ratchet down care.

You are certainly correct that we do not have an a priori ethical obligation; however, the public don't believe this and won't buy it. And legislators will not hesitate to use the concept out of context to crucify us.

This is one of the very essential reasons I started this blog. It is the intention of politicians to establish the rubric and rhetoric of a health care crisis -- during what should be the golden age of medicine -- by creating subterfuge that demonizes doctors and blames the health care system for problems intrinsic to society and thus catalyze a system-wide top-down change that we leave you and me, in our senescence (and then our children) at the hands of second-rate physicians trained to palliate and procrastinate while they maneuver us through a health care system that will make the motor vehicle department seem like a Donald Trump Spa. Thank you for reading my blog.

Sincerely,

Tom Boyle

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