Responding to a case of skewed journalism

An article published on the New York Times last weekend has been circulating widely on the Internet, and I feel that more than ever, physician voices are needed to reach the public and counter certain misconceptions put forth by the media. The article, titled “Patients’ Costs Skyrocket; Specialists’ Incomes Soar,” charts the growth of specialist incomes in the past decade, using the case of a patient from Arkansas who had a $25,000 medical bill for Mohs surgery to demonstrate the prevalence of unnecessary and costly procedures. It isn’t all bad – one big pro of this article written by internist Dr. Elisabeth Rosenthal is opening the line of communication between physician and patient regarding transparency of cost and necessity of certain procedures. That’s a great thing, and for doctors out there who are taking advantage of the system, perhaps this article can make them change their ways. That being said, I think the article was at times unfair and depicted a distorted view of dermatology and other subspecialty fields. There are a few important points to address here in response to the article, and a few things I would have liked to see as a response from the physician community.

The process of Mohs surgery

First, the article simultaneously vilified and minimized the role of Mohs surgery in treating skin cancer. The Mohs technique, invented in 1938 by general surgeon Dr. Mohs while he was still a medical student at University of Wisconsin-Madison, is a process where thin layers of cancerous tissue are sliced off and immediately studied under the microscope. The surgery stops when the tissues are completely free of cancer at all borders. This process helps to ensure that the cancer is absolutely removed while taking the minimal amount of skin necessary to do so. Mohs has been proven in certain cancers such as recurrent basal cell carcinoma to be  more effective than excision, and there is no doubt that it has saved countless lives while preserving tissue for reconstruction. The AAD put out guidelines in 2012 to classify which lesions require Mohs surgery to remove – certain types of tumors in certain types of patient populations, tumors that are very deep, in sensitive areas on the face or ear, or ones that are very large. The article instead characterizes Mohs instead as a “go to procedure,” a sort of money making machine. It does not go into the details that many Mohs procedures take several hours to complete, as you go through and take stage after stage of tissue. It does not go into the fact that this procedure can be lifesaving. Most of all, this article implies that Mohs is unnecessary, which can have hugely dangerous implications for patients out there with early stage skin cancer.

Not all patients are like Ms Little either. The patient in the article had a small basal cell carcinoma which was excised via Mohs surgery, and then she was sent to an oculoplastic surgeon for the repair. Her bill was over $25,000 because she was treated by a Mohs surgeon, an oculoplastic surgeon, and an anesthesiologist. She was billed $1,833 for the Mohs, $14,407 for the plastic surgeon, $1000 for the anesthesia, and $8774 in hospital costs. She later got the costs down to $1400 for the Mohs procedure, $1,375 for the plastic surgeon, $765 for the anesthesia, and $1050 in hospital costs. Take a second and think about these numbers. The plastic surgeon cost was able to be reduced by 90%…? Why exactly is this article targeting the Mohs surgeon again?  Aside from that fact, there are many patients who receive Mohs who do not have to get a repair from a plastic surgeon with an anesthesiologist. In fact, the norm is for Mohs surgeons to do the repair themselves. They are trained in it, and that is their job – they only refer out if they cannot handle the repair alone. I can’t speak for Ms Little’s Mohs surgeon (and apparently, he can’t either, as he did not comment in the NYTimes article), but most Mohs surgery clinics are a one-stop shop for excision and repair.

The article also lumps all payments together as if what you’re billed for is what the doctor pockets. That cannot be further from the truth. The article cites examples of a $915.46 bill for a mole removal in Oregon or a $500 wart freezing treatment at NYU Medical Center. I spoke to two dermatologists from Stanford who laughed and said they would never see payments like that in their practices at an academic center. That money goes into paying for nurses, hospital administrators, dermatologists, medical assistants, medical record handling, and much more. What needs fixing in this system isn’t the physician salaries, but rather, more transparency of cost. If patients can get a more truthful breakdown of costs, they would realize that the physician is not the greedy money-hungry one in this scenario.  It takes a lot more to run a medical center than meets the eye.

To be honest, I have been disappointed in the response from the physician community thus far. Dr. Dirk Elston, the President of the American Academy of Dermatology, wrote a “Letter to the Editor” that appeared on the New York Times. Dr. Fosko of the American College of Mohs Surgery also wrote a letter to the editor on the same page.  The responses are well written and full of information, and are great for other physicians to read. However, I don’t think it is the best way to reach the public. If I’ve learned anything at NBC, it is that you have to tell a patient story. Find a patient, one who has had his life saved and his world changed by Mohs surgery. It can’t be hard to find one; there are stories like this around the country. Interview him. Interview his family and his physician. Interview many Mohs surgeons. Put statistics in the piece but they can’t be the focus; numbers are fleeting but a patient story makes an impression.  And really show the world how much good Mohs surgery can do. I know it, dermatologists and other physicians know it, but now it’s up to us to convince the rest of the world that it is a worthwhile and lifesaving procedure.

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4 responses to “Responding to a case of skewed journalism

  1. you didn’t read the article very carefully. The whole thrust of the article is about physicians insistence on inflating $$ procedures to an unnecessary and medically unsupported degree and how the patient is powerless (other than getting up and leaving w/o clothing) in the hands of these slim-ball con artists. I myself have experienced a surgeon and clinic trying to turn a $250 office procedure into a $4,000 full on surgery procedure. Since I had the same issue 15 years earlier I had a complete understanding of the recognized method of diagnosis and treatment. I got up and left and will not return to that clinic/hospital complex. I these folks were auto mechanics (at least in California) they would loose their license to do business. But doctors police themselves so there really is no standard of ethical behavior that is enforced. The Mohs procedure was only an example of a much wider problem of corruption. It is all part of the general banality of evil that can be found everywhere in our society.

    • Harold, thank you for commenting. I’m sorry that you had a bad experience with a surgeon, and it’s admirable that you knew enough about the procedures and the costs to choose a different option. I think the NYTimes article does hint at the root of the problem – overinflation of medical costs – but I don’t believe that all the blame should be put on physicians. I don’t think it’s the majority of Mohs cases where the surgeon doesn’t do the repair himself and instead refers to a plastic surgeon who charges several times more than the Mohs surgeon. I have spoken to a dozen Mohs surgeon since the article came out, and they all told me that at academic institutions they always do the procedure from beginning to end, unless it is unsafe for the patient for them to do the closure. But that being said, at the end of the day, you are right. There is a problem of overuse of medical procedures not just in dermatology but in all health fields. Do you think all cavities need immediate filling (http://www.nytimes.com/2011/11/29/health/a-closer-look-at-teeth-may-mean-more-fillings-by-dentists.html?pagewanted=all&_r=0)? Across the board, what we need are more guidelines, and more precise definitions, to help physicians determine what procedures are necessary. And if these guidelines are publicly available and well communicated to the patients, then they too can be a part of the conversation.

      • Unfortunately we all WANT to believe the best of folks that handle our healthcare, especially because many of them protect and save lives on a daily basis. All too often that faith is extended when it shouldn’t be. Guidelines don’t have much affect on greed or incompetence. Revue by colleagues tend to be (if not rubber stampish) easy on the one being revued, for a whole host of reasons. But, finally, if there are no real penalties for unethical behavior there is no fear of retribution and the behavior continues. I would return to my example of the auto mechanic losing his license to do business. Since the comoditization and corporatization of the health industry we really can’t give anyone in health the benefit of the doubt, anymore than we would Bankers, Wall Street brokers, politicians, Google or Target.
        I’m not sure whether this is real any worse than it has ever been. I only know that it is the sad state of human affairs and the world we live in. I’ve come to appreciate the phrase from Ronald Reagan; “Trust but verify”.

  2. Pingback: Two Sides To Every Story | rbV3.com·

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