The ‘I’s have it: Ethics and the vascular community

I was consulted on a patient who exemplified this point. He had no complaints whatsoever but during a cardiac evaluation was found to have an absent dorsalis pedis pulse. For no apparent reason, he was taken to the privately-owned angiography suite where he had a pedal access procedure to atherectomize an occluded anterior tibial artery. This resulted in an anterior compartment syndrome, yet the interventionalist was still enriched by many thousands of dollars. Of course, Innovations such as atherectomy may be important clinically but they invariably spur increased utilization. There is pressure to be the first to bring a new advance to the community. This may be entirely ethical if one is well trained in the procedure, but is not so if the physician jumps on the bandwagon with minimal instruction. Furthermore, Industry may also be guilty in promoting overuse by advertising benefits beyond what is known about these new procedures and by encouraging adoption with minimal oversight as to credentials. I may be overly cynical but why should Industry care who uses its device as long as it is used?

Inefficient treatments with unacceptable long-term outcomes also pose an ethical dilemma. Perform a highly compensated atherectomy, angioplasty, and stent of a totally occluded tibial artery knowing that one will be back for the next procedure in the not-too-distant future? Alternatively, bypass the blocked artery with a less well paid and time-consuming autogenous vein graft that may last for years?

Further, at first glance you may wonder how I consider Indications as driving unnecessary procedures. But consider a procedure such as renal artery denervation for treatment of hypertension that has, as yet, not proved to be worthwhile.

Couldn’t a physician justify performing it until such time as it is shown to be inappropriate even if that physician may not have much faith in its benefits?

Dr. Lawrence also charged me with evaluating whether there were differences in ethical issues between employed physicians (at universities, for example) and those in community practice who are self-employed. I would suggest that there is such a difference, especially when we evaluate the I of Incentives. And here I refer specifically to relative-value units and academic promotion.

Although I do not have a better method of evaluating work, I believe that institutions that reward employed physicians based on RVUs cause a perverse incentive to do more. Certainly the single physician is not going to be enticed by this manufactured number. Academic promotion may also incentivize a surgeon to do more, especially if it is in the area of research for which the surgeon is renowned. The surgeon who has made a reputation studying surgery for small aneurysms may find the need to operate on ever smaller ones!

Perhaps one of the most important causes of ethical lapses is the absence of oversight in Independent outpatient environments separate from hospitals. This is where most bad things are happening. Here anyone can do anything and the intervention occurs only when a major complication sends the patient to a hospital or a negligent act results in a malpractice suit. As long as the government refuses to credential who can do what in the outpatient setting we may have poorly qualified, immoral doctors let loose on their unsuspecting prey. Physicians from almost every medical specialty are ablating saphenous veins in so-called "vein centers."

Further, some cardiologists without vascular training – and even some surgeons – with little indication are lasering tibials or inserting stents into every known artery in outpatient cath labs.

Fortunately, although the three I’s in the word Individual may explain unnecessary procedures, there is one I word derived from the single I in Ethics that denotes why almost all of us will do what is right. That word is Integrity – the quality of being honest and having strong moral principles – that will prevent us from doing what we know is wrong.

So this leads to Dr. Lawrence’s final charge to the speakers: to come up with three suggestions to help reduce unethical procedures. Although there must be many more, I would suggest the three most important would be the following:

• Only physicians who are board certified by a recognized specialty and who have been appropriately trained and credentialed should be allowed to perform procedures in hospitals and independent facilities.

• Payment must ultimately be based on outcomes where not only the result but also the indication needs to be taken into consideration.

• Medical schools need to provide courses in ethical behavior, which must be conceived as being equally as important as anatomy and physiology.