The Good, The Bad, And The Ugly: Stents In The News Reply

Three big stent stories were in the news today. You’d never know that all 3 were about the same topic.

 

The Ugly

 

The ugly side of stents is emphasized in David Armstrong’s Bloomberg News story on Mehmood Patel, the Louisiana interventional cardiologist serving a 10-year prison sentence for Medicare fraud. These days Patel “leads health-conscious inmates on a morning walk, then cracks open one of the medical journals on his prison-approved reading list. Counseling fellow convicts to keep their blood pressure down is about the extent of the doctoring done by the man who once boasted he was the busiest cardiologist in the nation.”

 

The Bad

 

Unlike Patel, Mark Midei, the poster-boy of overstenting, never faced criminal charges, but he did lose his medical license and faced an avalanche of lawsuits. Many have been settled our of court, but an important decision was reached yesterday in one very large remaining case. Jessica Anderson reports in the Baltimore Sun that a jury ruled that Midei “improperly placed three stents in the heart of a prominent businessman who didn’t need them.” The businessman is suing Midei and the former owners of his hospital, St. Joseph Medical Center, for $150 million. The businessman claims that he “lost millions of dollars after scaling back his career” after “Midei falsely led him to believe that he had serious coronary artery disease requiring stents.”

 

The Good

 

But it’s not all bad news for stents. In the New Yorker‘s Elements blog, cardiology fellow Lisa Rosenbaum adopts a much more nuanced view of stents. She writes that “stories about cardiologists behaving badly validate the conviction, common among both policymakers and the public, that misaligned financial incentives drive doctors to do things that they shouldn’t.”

 

But, she argues, the conservative view, based largely on the well known COURAGE trial, that medical therapy is just as good as a stent, “is a colossal oversimplification.”

 

Successful conservative management, however, depends on seeing patients regularly, so that you can titrate their medications and make sure that their cardiovascular risk factors are controlled. But Sun Kim didn’t come back.

 

Click here to read the full story on Forbes.

 

The Good, the Bad and the Ugly is a well-known...

 

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400 Patients Sue Kentucky Hospital and 11 Cardiologists Over Unnecessary Procedures Reply

After undergoing more than two dozen cardiac procedures over a period of twenty years at St. Joseph Hospital in London, Kentucky, a patient was told by an outside cardiologist in Lexington that a recent procedure had been performed unnecessarily on an artery that was barely blocked.

“I would have not carried out this procedure,” the cardiologist, Michael R. Jones, wrote in a letter to the patient. The story is recounted  in an article published on Sunday in USA Today and the Louisville Courier-Journal, about the latest and perhaps the biggest case yet to surface over unnecessary cardiac procedures.

Comment: By sheer coincidence, on the same day, the New York Times published a news analysis by Barry Meier about the scandal over Johnson & Johnson’s hip implant. “Doctors Who Don’t Speak Out” focuses on the failure of physicians to report problems with devices and drugs, but clearly the issue has even larger implications. A quote from Harlan Krumholz in the story– “Questioning the status quo in medicine is not easy”– could easily apply to the many recent cases of egregious overuse of cardiac procedures and devices. Imagine how recent history might have been different if colleagues of  Sandesh Patil and Mark Midei had raised earlier questions about borderline procedures. Cardiologists and other physicians complain about the intrusive and burdensome role played by the legal system, regulators, and insurance companies, but they have only themselves to blame if they refuse to police their own ranks, and indeed tacitly participate in a system that provides lucrative compensation to high-volume proceduralists.

Click here to read the entire post on Forbes.

Kentucky

One Reader’s Negative View Of Mark Midei Reply

A few months ago I posted a lengthy piece about Mark Midei, the interventional cardiologist from Maryland who had his medical license suspended last year following a lengthy scandal in which he became the poster-boy (or scapegoat, depending on whom you ask) for all that’s wrong with interventional cardiology in the US. Although I was highly critical of Midei in my piece, I also expressed sympathy for his situation. Now a reader– Ohio MD– has written a response on the Forbes CardioBrief feed to my original post, taking me to task for being “entirely too sympathetic” to Midei. I think his position is worth bringing to more general attention, though I continue to believe that it is possible to simultaneously believe that Midei is guilty as charged and yet feel sympathy for his situation.

Here is the comment by Ohio MD:

I think the article is entirely too sympathetic to the doctor. As a physician myself, I am absolutely appalled at the acts perpetrated by this man upon his patients. It is all too easy to point at rates of success in terms of claimed lives saved and numbers who survived the intervention. Realistically, many of those who underwent procedures were destined to do well without cardiac interventional procedures. Testimony and review of the Maryland Board of Medicine and a review by Midei’s own institution suggest a systematic process of overstating severity of coronary disease to justify needless interventions. One must also consider that these interventions carry with them not only substantial cost, but the burden of carrying a needlessly implanted device, potential need for chronic medication to prevent device-related complications, and not-inconsequentially, the stigma of the diagnosis of severe coronary artery disease. How many of the affected patients went on to higher insurance costs, potential loss of job positions, limitations of lifestyle, etc.?
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Mark Midei Can’t Get a Job Taking Blood Pressure At A Walmart 8

Earlier this year I had the extraordinary experience of spending several hours on the phone with Mark Midei, the poster-boy (or scapegoat, depending on whom you ask) for all that’s wrong with interventional cardiology in the US. I approached the conversation with some trepidation and discomfort. I’d followed his story closely– but not obsessively– and had written harshly about him. I wasn’t sure why he wanted to speak with me.

It turns out he wanted to get his side of the story across to cardiologists and others interested in the case. I listened to Midei with interest and astonishment, and over the course of our two long phone conversations I found it hard not to feel a certain amount of sympathy for the man. In his absolute fall from a position of enormous success to the disgrace and humiliation of a widely reviled public figure, I saw the elements of a tragic figure. Once a highly successful and admired physician, he was now, in his own words, a man who couldn’t get a job taking blood pressures at a Walmart. On the other hand, it was clear that Midei still refused to accept responsibility for his own role in his downfall. He painted a portrait of himself as a victim, but no matter what you ultimately think of his case, he was always much more than a passive victim of circumstances.

In the first part of this post I will try to summarize Midei’s story from his perspective, as he told it to me. Along the way I will inject some additional information and commentary as seems necessary and appropriate. In the second part I will offer my thoughts on his story.

PART ONE: Midei’s Story

Midei began by talking about his long career at MidAtlantic Cardiovascular Associates, which for many years had been the dominant cardiology group in Maryland, and where he had achieved a position as the premiere interventional cardiologist in the state.

The extraordinarily successful MidAtlantic was formed in 1995. The seeds of the current case, Midei claims, were planted when the MidAtlantic cardiologists and the cardiac surgery group at St. Joseph’s Hospital, where Midei mostly worked, had a bitter falling out after a failed merger attempt. Midei says that he played no significant role in this episode. “I wasn’t involved– I was a junior partner at that time,” he told me. (It should be noted here, however, that Midei was one of the four founding partners of MidAtlantic, and was always considered the dominant figure in the group.)

“So we shook hands and walked away from them and we hired four surgeons who joined our group,” said Midei. “And if you could point to one thing that led to all this, this is it.” Midei’s view is that the embittered surgeons then complained to federal investigators about illegal ties between MidAtlantic and St. Joseph’s, thereby initiating the federal probe that ultimately led to his spectacular fall.

(In his comments to me Midei glossed over the extraordinarily bitter turf war sparked by MidAtlantic’s effort to achieve dominance in the cardiovascular marketplace in the Baltimore region. By all accounts, MidAtlantic engaged in a highly aggressive campaign to take business from the surgeons, and in 2010 St. Joseph’s agreed to pay $22 million to resolve a Federal investigation, based on the surgeons’ complaints, that the hospital had provided kickbacks to MidAtlantic.)

But before those allegations surfaced, MidAtlantic “became disaffected with St Joe for various reasons,” according to Midei. In 2006 MidAtlantic began to develop closer relations with a rival hospital, Union Memorial. Midei was disappointed by this development. “I had a big emotional attachment” to St. Joseph’s and “had moved my family” to be near the hospital, he explained.

Although he was the dominant figure in this group, he told me: “I didn’t really have a great deal of influence, and the group began a much closer affiliation with Union Memorial.” The CEO of MidAtlantic had a close relationship with Union Memorial and in 2008 Union Memorial started negotiations to purchase MidAtlantic. According to Midei, the negotiations were completely in the hands of the two CEOs, and he felt left out. “In late 2008 I became almost despondent” about the deal.

Midei then learned that the “whole deal was contingent on my moving from St Joe to Union Memorial. That was made clear to me: if this [deal] happened I was going to have to go” to Union Memorial. “I didn’t feel like I had an option. Although I was despondent, I was more or less resigned, I didn’t take any action to prevent it, other than tell my partners that I wasn’t happy about it.”

(One important piece of background information here is that all the MidAtlantic partners were paid equally. According to a reliable source, MidAtlantic partners received $600,000 per year at the time of these events. This is at the high end for most cardiologists, but clearly Midei could have commanded a far greater salary on his own.)

In late November 2008 Midei said he was approached by St Joseph leadership for “a private conversation.” They outlined a plan to hire Midei  because “they really wanted me to stay at St Joe’s.” To Midei “it was like a gift from God, they offered to triple my salary… and I could stay at St Joe.”

Midei soon reached an agreement with St. Joseph, and this effectively scuttled the midAtlantic deal with Union Memorial. In court records, the MidAtlantic CEO was quoted as saying at that time that he would “make it my mission to destroy him [Midei] personally and professionally.”

Midei claims that he “didn’t realize it at the time how disturbing it was to members of my group. Others had left and nobody batted an eye, but when I did it it was like Armageddon.” (I have much more to say about this episode in the second part of this post.)

Six months after Midei moved, St. Joseph received a subpoena from the federal government for records of the hospital’s contracts with MidAtlantic physicians. Midei says he was not concerned at the time by the subpoena. “I was certain that this was a whistleblower suit filed by the disgruntled surgeons who were not having any luck with St Joe’s.” (But another plausible scenario is that it might have been an embittered cardiologist or administrator at MidAtlantic. The Baltimore Sun reported that the investigation began when “a MidAtlantic cardiologist informs one of Midei’s patients — an St. Joseph’s employee — that his stent was unnecessary. The man reports the concern to hospital staff.”)
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