Doctors Disagree About Effectiveness, Cost Of Stents For policymakers to cut medical spending, they must persuade doctors that some procedures are unnecessary. A friendly debate between two cardiologists over using stents to unclog arteries shows how hard it may be to achieve that consensus.
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Doctors Disagree About Effectiveness, Cost Of Stents

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Doctors Disagree About Effectiveness, Cost Of Stents

Doctors Disagree About Effectiveness, Cost Of Stents

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One idea to find savings in the health care system goes like this: get doctors to quit ordering unnecessary procedures and tests. There's just one problem. What seems unnecessary to some doctors is standard procedure for others.

NPR's Chana Joffe-Walt from our Planet Money team introduces us to two doctors now: same specialty, same city, same hospital, very different points of view.

CHANA JOFFE-WALT: So I called Dr. Paul Teirstein on his cell phone and I say, your colleague, Dr. Eric Topol, recommended I talk to you. And he goes, huh, Eric. Yeah, that guy. I disagree with everything he stands for.

Dr. ERIC TOPOL (Cardiologist, Scripps Health, San Diego): Well, that's a exaggeration.

JOFFE-WALT: This is Eric, Dr. Eric Topol, disagreeing with Dr. Paul Teirstein that they disagree on everything.

And here's Dr. Paul Teirstein.

Dr. PAUL TEIRSTEIN (Cardiologist, Scripps Health, San Diego): Well, we do disagree a lot. I don't disagree with everything he believes in. That was somewhat a hyperbole. Just a, you know, I find him challenging.

JOFFE-WALT: Challenging about all sorts of things, especially stents. We'll get to that in one sec.

Eric and Paul, I'm just going to go with first names here. No disrespect to the doctors. It's just their last names are easy to mix up.

Eric and Paul are both interventional cardiologists in San Diego. So, say, you go to a cardiologist with some chest pain, there are a couple of things they can do for you: they can do nothing, they can relieve chest pain with drugs, or they can relieve chest pain with stents. And stents are these tiny little pieces of metal. They look like springs. Cardiologists use them to open up arteries.

And Dr. Eric Topol says too many cardiologists use them to open up arteries, even sometimes when patients don't have chest pain.

Dr. TOPOL: So, yes, there's unquestionably more procedures that are being done than need to be done.

Dr. TEIRSTEIN: Well, I definitely have a bias toward stents because I have a lot of experience with stents, and I've seen patients do so much better.

JOFFE-WALT: I wanted to see.

Dr. TEIRSTEIN: Just take the stent up to 10.

Unidentified Man: Going up into 10.

JOFFE-WALT: I thought it'd be hard timing it, so I'd be in San Diego when Paul happened to have a stent procedure. No. One Wednesday, one normal Wednesday, Paul had six procedures. He puts in 10 stents altogether. And it's an incredible process to watch.

First thing in the morning, he inserts a catheter into an artery in a woman's leg, threads it all the way up to her heart, puts a stent in. And you can watch right away on the screen the artery opens.


Dr. TEIRSTEIN: So you see the difference, right?


Dr. TEIRSTEIN: It's not a subtle difference. So your reaction was exactly the allure of stenting - it's an instant fix. And she should feel a lot better.

JOFFE-WALT: So what's Eric's problem with this? Okay, he says that woman Paul treated probably did need stents. A lot of people do. But that instant fix thing, that immediacy that wowed me, Eric says that can easily lead to overuse. Cardiologists see a blockage and it's just so satisfying to take care of it.

Dr. TOPOL: Sometimes there's a tendency to believe in your procedures too much. And most of the time, intervention cardiologists are like that. They're going to say, well, I can fix the artery. The question, of course, is in some cases, should you?

JOFFE-WALT: Paul is in the room when Eric says this and not surprisingly disagrees. He questions studies that have shown that cardiologists use stents more often than needed. Well, Eric says, having done a lot of those studies myself, I remain convinced.

Dr. TEIRSTEIN: I just haven't seen that.

Dr. TOPOL: You know, that's the difference, I think you have a rose-colored glass view.

JOFFE-WALT: They go back and forth nonstop, until I asked about money. Stents are expensive and cardiologists get paid per procedure. Do they think cardiologists are doing more than is needed to make more money? There's a couple seconds of silence.

Dr. TOPOL: You know, I'll take this because I'm not trying to be a hero to my fellow physicians. I'm trying to tell it like it is.

JOFFE-WALT: So - but not - sounds like you're saying not financially motivated.

Dr. TOPOL: Some of it's financially motivated. Some of it's financially motivated, but at a subconscious level.

Dr. TEIRSTEIN: Well, I strongly disagree with you on this. I mean, I really do. I think that financial incentive is the last thing you think about.

JOFFE-WALT: Paul and Eric actually agree on what to me seems like the most important point: They both want these decisions to be in the hands of doctors. No disagreement.

So if the goal is to save money, curb overuse, doctors have to believe there is overuse. They have to synthesize available research and make choices. Neither Paul nor Eric want the government or insurers telling them what to do. They prefer instead to tell each other what to do.

Chana Joffe-Walt, NPR News.

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