Posted by Bill Sandweg on 23 September 2019.
There is a saying no patient should ever forget, “Just because a doctor says it, doesn’t make it true.” As I have often remarked before, medicine is a business, and a big one at that, and we are its customers. Doctors sell us their services. While most doctors have their patient’s best interests at heart, there are those who are in it for the money and want to sell as much product as they can. A good example can be found in a recent story which appeared in the Wall Street Journal.
Heart stents used to be a big money maker for some doctors. They were placing them even though the science did not show that they were effective in treating coronary artery disease. Over time, the medical consensus that they were not effective became so strong that the number of coronary artery stents being placed declined significantly. However, much like the old “whack-a-mole” game, stents have now popped up in a new location. Now some doctors are unnecessarily placing stents in leg arteries and risking the health of their patients by doing so.
When placed in leg arteries, stents are a form of peripheral vascular intervention. Another aggressive intervention in the legs is an atherectomy, which is a procedure to remove plaque from an artery. Both procedures address plaque deposits in arteries of the leg. Almost every person in the United States who is 80 years old has some plaque deposits in the arteries of their legs. It is only when those deposits become large enough to interfere with blood flow and cause pain that intervention should be considered. Some doctors don’t want to wait that long.
The WSJ story was based on a study published in the Journal of Vascular Surgery which found that some physicians were placing stents in leg arteries and removing plaque at rates 4 to 5 times the national average. The authors of the study examined Medicare records to determine the rates at which various doctors performed the procedure and discovered the large discrepancy between the average doctor and about 320 physicians, who were far more aggressive. One doctor, who was part of the research team, went so far as to write a letter to the Centers for Medicare and Medicaid Services in which he claimed that these “outlier” physicians “may represent a serious and immediate threat to public safety.”
According to research on the subject, patients who have early leg pain due to narrowing of arteries in the leg have a 1% to 2% risk of limb loss in the next five years. Aggressive procedures increase that risk to 5% to 10% because they may create blockages in narrow arteries or cause treated arteries to rupture. The Society for Vascular Surgery has published guidelines which recommend these types of aggressive interventions only after patients who have leg pain when they walk have failed medical and exercise therapy and are experiencing symptoms which limit their activities.
The president of the Society for Vascular Surgery has offered the opinion that patients with leg pain who make positive lifestyle changes may never need aggressive vascular interventions or, if they do, can put them off for many years. As he notes, the later in life a patient needs an aggressive peripheral vascular procedure, the better.
Be an informed consumer. Get second opinions. When a doctor recommends surgery or an operative procedure, ask about less aggressive, less invasive alternatives. Ask about your doctor. Look at her or his record at the state Medical Board. Ask how often he or she performs the procedure being recommended and what the complication rate has been. You can never guarantee that you won’t be victimized by the medical profession but you can give yourself the best chance of a good outcome by being careful and asking questions.