Monday, February 22, 2016

Procedure Meat: How Procedural Lust Imperils Patients

I'll start with a macabre anecdote of crassness, to get everyone's attention.  It is apropos because procedural lust has crass and macabre consequences.

It was about 17 years ago, while I was in training, that an attending accepted a moribund woman from a faraway place in the hinterlands.  She had multiple hepatitides and uncontrolled bleeding from esophageal varices.  A collective groan among the housestaff met notification of the incoming transfer which would keep everybody up all night with the inevitable death forestalled only briefly, and in a streak of his usual candor, the attending admitted that he accepted her not because he thought there was anything that could be done to help or save her, but because she would serve as good "procedure meat for the interns."  And the interns were like:

There are a lot of problems with that entire episode as I reflect upon it, and I won't dissect them all here.  I've been thinking about procedure meat because I so often see physicians feasting on it, to the peril of the patients.  Ideally, each and every procedure that is done ought to be done because it is in the patient's best interest to have it done.  All too often, ulterior motives and unstated goals creep into decision frameworks and lead to unnecessary procedures and therapeutic misadventures.  To combat this problem, we need to start nudging physicians to consider and patients to ask directly, "Is this procedure the best thing for me?  Are there alternatives?  Do the expected benefits outweigh the costs and risks?  Where will I be in six days, six weeks, six months, and six years as a result of the proposed procedure?  Where will I be at those times without it?"