Clinician-Patient Mismatch: How to Get Past the Imbalance in Knowledge (and Power)

HOLLYWOOD, FL—Physicians armed with years of training and much expertise often find themselves in the sticky position of treating patients with less knowledge about their condition and options. But according to one speaker at the recent International Symposium on Endovascular Therapy (ISET) 2018, there are ways to surmount this power imbalance that’s skewing healthcare decision-making.

“What is a conflict of interest? Very simply, it can be defined as any situation in which a person is in a position to derive personal benefit from actions or decisions made in one’s official capacity,” S. Scott Tapper, MD (Symmetry Laser Vein Center, Stuart, FL), said in a session devoted to the future of aortic therapies.

“ISET is all about the latest and greatest in whizbang technology,” Tapper told TCTMD, “but when it’s abused, then it’s really not helping us. I’m a little bit jaded, but I think it’s abused more often than we really want to know.” Tapper cited the story of one Florida cardiologist who billed Medicare more than $18 million in 2012 for doing peripheral procedures and later was brought to task over alleged false billings.

Introducing the “principal agent dilemma” as a lens through which to see doctor-patient interactions, Tapper explained in his talk that the principal is someone who seeks the expert services of the agent. For example, much like an investor hires a stock broker or a divorcing spouse gets a lawyer, a patient goes to his or her physician.

“What’s the dynamic here? What’s the tension? The tension here is information asymmetry,” Tapper said. While in all these relationships both parties want to get the most they can out of the arrangement, those with more information could, if unethical, sway things toward their advantage at the expense of the less informed, without ever being discovered.

Some doctors are treating patients like ATMs, just cashing in on procedure after procedure. S. Scott Tapper

A prime example lies in the treatment of varicose veins, he stressed. “[People] are bombarded by TV ads, radio ads, and direct mailing, so patients might go to a so-called expert,” bypassing their primary care physician and possibly missing out on unbiased advice. “Because of universal fear of blood clots, it makes it easy for an ‘expert’ to coerce patients into unnecessary treatment,” he said. “Patients can’t distinguish the training, quality, outcomes, or ethics of some providers.”

To TCTMD, Tapper said in daily practice at his center he sees “time and time again patients who have simple spider veins and get expensive endovenous ablation procedures by unqualified or unscrupulous physicians.” He said he’s gone so far as to write letters to Florida’s attorney general and health insurance CEOs. “I think patients are being attacked and being criminally abused. Some doctors are treating patients like ATMs, just cashing in on procedure after procedure.”

Tapper said he wants his own patients “to know as much as possible about their disease or about what I’m going to do, what their alternatives are. And if somebody [has done] something wrong to them, I’m not going to hide it. I’m going to give them a complaint form.

“The bad actors,” he stressed, “have to be eliminated, because it reflects poorly on all of us.”

On the flip side, patients also have a responsibility to be aware. “I try to get my patients to engage in their treatment. I find it very difficult if they’re not engaged,” Tapper said. “So when a patient comes to me on 15 medicines and they don’t even have a list of them, I kind of say, ‘This is your responsibility. You need to know what medicines you’re on.’” More engaged patients, he added, tend to ask more questions.

Staying Ethical When No One’s Watching

What makes the financial temptations in this field particularly strong is that so many endovascular procedures are done in lucrative office-based settings with no oversight, Tapper emphasized in his presentation. “We as endovascular specialists are really vulnerable here.” Payers and regulators aren’t keeping watch, so patients can’t either, he said.

“By exploiting information asymmetry, unethical providers put patients through unnecessary interventions to boost profits, and this unnecssary care wastes our resources and hurts patients,” Tapper observed, adding, “Clearly this dynamic is not in the best interest of our profession.”

Healthcare is plagued by “lemons,” he noted. “We have complications, errors, delays, inefficiences, undertreatment, overtreatment, excessive costs, and high-profile fraud cases, all of which lead to patient frustration. And patients are increasingly questioning whether or not we have their best interests at heart.”