Friday, August 9, 2013

The Rodeo is Over: Why I put the Bronchy Donkey Out to Pasture

Photo compliments of Jan Aberegg:  A mini donkey in Ohio.
They say that when you have a hammer, everything looks like a nail.  And when you are a pulmonologist, everything looks like a reason to "saddle up the Bronchy Donkey", my tongue-in-cheek reference to the bronchoscope, a device used to look into a patient's airways.

In the four years that I have been in the world of private practice as an intensivist and inpatient consulting pulmonologist I have performed elective bronchoscopies (outside of emergency airway management and tracheostomy placement) only two times.  Herein I will describe the reasons why this is so, and why many others continue to ride the Bronchy Donkey into the ground.

The first reason is because this is Utah, and nobody smokes here.  That's an exaggeration, but it's not far from the truth.  So there is less lung cancer, especially in the young.  The next, related reason is because there's not that much AIDS here either.  The bronchoscope is essential in diagnosing opportunistic infections in patients with HIV/AIDS and other causes of immunosuppression.  The next related reason is that I'm in the community now, not an academic center where immunosuppression related to organ transplantation, treatment of inflammatory diseases and cancer is common.  No doubt I would do more bronchoscopies if I were at the University of Utah.

The next reason, and this is pivotal, is because I'm mostly salaried and I don't earn much extra money if I do a bunch of "bronchs". I only do a bronch if it is essential to patient care in a given case.  I was recently informed by another pulmonologist that medicare pays less than $150 for a bronch nowadays.  (Here's a reference.)  As a result, she said that she has gone from doing 30-40 a month in the old days to one or two a month now.  I have witnessed this same transformation when a physician or group goes from a private practice model to a salaried model - elective and quasi-useful procedures drop off precipitously, and alternatives are sought.  These observations foreshadow what I think will be sweeping changes (specifically, contractions) in medical service utilization as more and more physicians become employees - as opposed to the "eat what you kill" fee-for-service model.  Upton Sinclair said it best:  "It is hard to get a man to understand something when his salary depends on his not understanding it."

If there is a background financial incentive for pulmonologists to ride around on the bucking bronchoscope, it has the effect of lowering the threshold to do them. Somebody says lung, a pulmonologist thinks bronch (and bank).  But the alacrity to do a bronchoscopy starts in fellowship, before there are any personal financial incentives favoring bronchoscopy.  There are other incentives in fellowship.  Internal Medicine trainees are procedure-hungry - pocedures are cool.  And you need to log 100 bronchoscopies to be considered proficient at the end of fellowship.  Well and good.  But the eagerness to find opportunities to do bronchs while in training surely molds later practice patterns.

Another factor favoring [excessive] bronchoscopies is that practitioners without pulmonary training are unlikely to fully understand the utility and limitations of bronchoscopy in a given case, and thus have a tendency to over-request bronchoscopy (which the unscrupulous pulmonologist will gladly provide).  The charge of a good pulmonologist is to determine whether a bronch is the optimal approach and to suggest an alternative if it is not.  But the requesters often persist and protest vociferously.  They want the bronch - period.  So, we had a saying in fellowship (coinage secret to protect the coiners, who were high in the hierarchy) - we would do what we called a "shut-up bronch."  The point of this bronch is to get the requesters to shut up about it, so we could move on to more pressing matters and consults.

The most perverse degree of eagerness to do a bronch for a bronch's sake alone is sadly and ironically found among interventional pulmonologists, those whose entire career centers on the use of bronchoscopy for diagnostic and therapeutic (and purely experimental:  see Bronchial Thermoplasty; and  Bronchial Valves) purposes.  (Here's a recent published example in which the authors have conveniently described what billing codes you can use for the procedures..)  I have witnessed egregiously misordered priorities in the judgment and decision making of interventional pulmonologists who have a "procedure first" mentality, such as the patient in the [name witheld] Cancer Center who died within 30 minutes of an ill-fated and ill-begotten interventional bronshoscopy.  When all you have is a hammer....

The background incentives, financial and otherwise, lead the uncritical (or undisciplined or ulterior motivated) pulmonologist to reorder the list of diagnostic and therapeutic options such that bronchoscopy rises to the top.  After the heuristic "bronch first" emerges and becomes entrenched, the critical thinking stops.  And when the critical thinking stops, evidence is ignored and so are alternatives.  What are the alternatives?

Many times, it is best to cut to the chase and bypass the bronch altogether.  When a lesion abuts the chest wall, a transthoracic needle aspiration in interventional radiology is almost always a safer and higher yield alternative to a bronch.  Similarly, if there are bone lesions, adrenal lesions, enlarged lymph nodes, etc., needle biopsy of these will allow simultaneous diagnosis and staging without the gratuitous risks of conscious sedation - killing two birds with one stone, as it were.  When there is pleural fluid, its sampling will often provide the diagnosis, staging, and relief from dyspnea with minimal morbidity - three birds in the hand, none in the bush.  Sometimes, proceeding directly to surgery or mediastinoscopy is warranted, as in cases of solitary pulmonary nodule or surgical lung biopsy for BOOP/COP/IPF.  When the prognosis is otherwise exceedingly poor, or the lesion of interest is unlikely to be treatable, foregoing diagnosis altogether may be indicated, especially if the treatment, e.g. palliative, would be declined by the patient.

It goes without saying that, in appropriate circumstances (airway lesions, foreign body removal, TBNA in easily accessible nodes, all cases of immunosuppression and pulmonary infiltrates, unexplained lobar atelectasis, etc.), the bronchoscope is a very useful tool indeed.  My contention, and the message for patients who may be reading this, is that this tool is grossly overutilized.  Perhaps the bronchocentric worldview engendered during fellowship and the heuristics it spawns will wither as the financial incentives to perform bronchoscopies (and other procedures) are curtailed.  And when the rodeo is finally over, the bucking bronchoscope, the Bronchy Donkey, will be put out to pasture.

3 comments:

  1. I have had such bad experience since I came out from the world of fellowship to practice. PCP' s calling - " mr x is admitted with copd exacerbation, can u scope him and clean him out? The last time they did it , he felt better immediAtely".
    I couldn't believe my ears. Patients come in from their primary physician's office expecting a bronchoscopy.

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  2. Ah, tragic music to my ears. It takes a good deal of time and effort to undo these unrealistic and misguided expectations. But it is worth it.

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