‘Cowboy’ Doctors Could Be A Half-A-Trillion-Dollar American Problem


When Dartmouth economics professor Jonathan Skinner was speaking recently at the University of Texas about the “cowboy doctor” problem, an audience member objected: “You have a problem with cowboys?”

Well, actually, we all have a problem with cowboys — when they’re doctors. Including the Texans. New research written up in a National Bureau of Economic Research paper finds that “cowboy” doctors — who deviate from professional guidelines, often providing more aggressive care than is recommended — are responsible for a surprisingly big portion of America’s skyrocketing health costs. The paper concludes that “36 percent of end-of-life spending, and 17 percent of U.S. health care spending, are associated with physician beliefs unsupported by clinical evidence.”

Whoa, Nelly. That means cowboy doctors are a half-a-trillion-dollar problem. But mightn’t they also be good? Wouldn’t many of us want a go-for-broke maverick when we’re in dire medical straits? I asked Prof. Skinner, who’s also a researcher at the Dartmouth Atlas of Health Care, to elaborate. Our conversation, lightly edited:

So how would you define a cowboy doctor?

Cowboys go it alone. They have developed their own rules and they don’t necessarily adapt those rules to what the clinical evidence would suggest. So if you actually talked to what we term a ‘cowboy doctor,’ he or she would say, ‘I get good results with this procedure for this type of patient.’ That’s why we found it so interesting: they go beyond what the professional guidelines recommend. And it’s not as if they were out there before the professional guidelines got there. Sometimes pioneers are doing things that the guidelines haven’t figured out yet. But we found no suggestion that subsequent guidelines were consistent with what these physicians were actually doing.

So is it stubbornness, then?

I don’t know if it’s stubbornness but it’s individuality. It’s the individual craftsman versus the member of a team. And you could say, ‘Well, but these are the pioneers.’ But they’re less likely to be board-certified; there’s no evidence that what they’re doing is leading to better outcomes. So we conclude that this is a characteristic of a profession that’s torn between the artisan, the single Marcus Welby who knows everything, versus the idea of doctors who adapt to clinical evidence and who may drop procedures that have been shown not to be effective.

This graph shows 64  hospital referral regions, with the size of the blob proportional to the number of doctors surveyed. It shows  that in regions with a larger share of “cowboys,”  risk-adjusted end-of-life Medicare spending is higher.(Courtesy Jonathan Skinner)

This graph shows 64 hospital referral regions, with the size of the blob proportional to the number of doctors surveyed. It shows that in regions with a larger share of “cowboys,” risk-adjusted end-of-life Medicare spending is higher. (Courtesy)

Yes, the extent of the variation in medical practice is striking. But I was most struck in your paper by how big a piece of the health-cost problem this could be. Can you quantify that?

We were surprised, too. What we show is that the opinions of these physicians — in particular, opinions that are outside of the clinical guidelines — explain as much as 17 percent of total variation in health care spending, which is, roughly speaking, 3 percent of GDP.

Wow. What is that in billions?

The association we found suggests it’s almost half a trillion dollars.

Can you give me a concrete example of how a cowboy doctor could drive up costs? Continue reading

WSJ: Everything You Need To Know About New Cholesterol Guidelines

It’s so very disconcerting when deeply entrenched health wisdom is suddenly flipped on its head. But that’s the way it often goes in this arena.

The Comedian/flickr

The Comedian/flickr

So, with such widespread confusion over the new guidelines on cholesterol and statins, cholesterol-lowering drugs, I was relieved to see that veteran health reporter (and my former colleague) Ron Winslow at The Wall Street Journal offered a just-the-facts-ma’am Q & A on exactly what you need to know about the new guidelines. It’s got everything from LDLs to the new risk calculator — which was down when I checked this morning. (What’s going on with all the bugs in our critcal health care sites??)

Here’s a snippet from Winslow:

The new tack recommended by the American Heart Association and the American College of Cardiology is to prescribe moderate to high doses of cholesterol-lowering drugs called statins to patients who fall into one of four risk groups regardless of their LDL status. Here is a look at the implications:

Q. Why get rid of the LDL targets?

A. The targets lack strong scientific evidence. The expert panel that developed the guidelines concluded that by focusing on an individual patient’s overall risk rather than a relatively arbitrary set of LDL targets, the strategy to prevent heart attacks and strokes will be more effective and more personally tailored to the needs and preferences of each patient.

Q. What should patients do in response?

A. Patients already on cholesterol-lowering medication should ask their doctors at their next appointment whether they are on the most appropriate therapy to reduce their heart-attack and stroke risk, says Neil Stone, a cardiologist at Northwestern University who headed the panel that wrote the cholesterol guideline.

For people not on cholesterol drugs, a new risk calculator is available online. If you have a 7.5% chance of having a heart attack over the next 10 years, you are a candidate for treatment with a statin no matter your LDL level under the new guidelines.

Q. I have no heart problems and my LDL was 90 in a recent cholesterol test. Is it possible I should be on a statin anyway? Continue reading

Don’t Miss: Why Mass. Needs Law On Screening Newborn Oxygen Levels


When a pediatric cardiologist tells me we need a law requiring hospitals to screen newborns’ oxygen levels to detect potentially dangerous heart defects, I listen.

Cardiologist and author Darshak Sanghavi writes on WBUR’s Cognoscenti today that the Massachusetts legislature held a hearing last week on making “pulse oximetry tests” for newborns mandatory in the state — as several other states have already done. He writes:

The results have been dramatic. Hours after the law was passed in New Jersey, for example, it saved a newborn’s life.

But Massachusetts, a leader in health care innovation, and home to some of the nation’s best health care centers, hasn’t followed suit. Instead, the state Department of Public Health decided earlier this year the screening shouldn’t be mandatory. They reasoned that doctors and hospitals would do the right thing on their own.

But that’s an incorrect assumption. According to a state-sponsored 2012 survey of Massachusetts birthing facilities, only one-quarter were performing the screening, even though the federal recommendation had been out for almost a year.

Read the full post on Cognoscenti: A Simple Test. Newborn Lives Saved. What’s The Holdup?

Get To Know Your Likely Killer: ‘Tangled History’ Of Heart Disease

(Wikimedia Commons)

(Wikimedia Commons)

Chances are, heart disease is going to get you. It’s eternally America’s number one killer, estimated to cause about 600,000 deaths a year.

If you want to get a better grasp on your likeliest executioner, don’t miss this fascinating piece, titled “A Cardiac Conundrum,” in the latest Harvard Magazine. It features Dr. David Jones, a Harvard professor of the culture of medicine, and his recent book, “Broken Hearts: The Tangled History of Cardiac Care.

Jones discusses the shaky evidence base for many of the most common heart disease treatments, from bypass surgery to angioplasty and stents.

…“Patients are wildly enthusiastic about these treatments,” he says. “There’ve been focus groups with prospective patients who have stunningly exaggerated expectations of efficacy. Some believed that angioplasty would extend their life expectancy by 10 years! Angioplasty can save the lives of heart-attack patients. But for patients with stable coronary disease, who comprise a large share of angioplasty patients? It has not been shown to extend life expectancy by a day, let alone 10 years—and it’s done a million times a year in this country.” Jones adds wryly, “If anyone does come up with a treatment that can extend anyone’s life expectancy by 10 years, let me know where I can invest.”

“The gap between what patients and doctors expect from these procedures, and the benefit that they actually provide, shows the profound impact of a certain kind of mechanical logic in medicine,” he explains. “Even though doctors value randomized clinical trials and evidence-based medicine, they are powerfully influenced by ideas about how diseases and treatments work. If doctors think a treatment should work, they come to believe that it does work, even when the clinical evidence isn’t there.”

And another key passage: Continue reading

Why To Exercise Today: At 73, Zelda Runs Her Fifteenth Tufts 10K

In honor of Monday’s race, a Boston institution that is now in its 36th year and draws thousands of women every fall, we offer a bit of inspiration today from Zelda Jacobson Schwartz. She will be running her fifteenth Tufts Health Plan10K For Women at the age of 73. We may not all be able to run for miles in our seventies — or our twenties, for that matter — but we can all draw strength from the memorable wisdom she shares: “It’s okay to be at the back of the pack. It’s thrilling just to be there,” and “The miracle is not that we finished, but that we had the courage to start.”

By Zelda Jacobson Schwartz
Guest contributor

73-year-old Zelda Schwartz is running her 15th Tufts 10K

When people ask me why I am running my 15th Tufts Health Plan 10K for Women as a 73-year-old, I answer: “Because I’m so lucky I can!”

I started running when I was 40 at the same time I gave up smoking, not realizing I’d be giving up a dreadful addiction for a really marvelous one that would form the structure of each of my days.

I ran for many years as a ”master” (age 40-49). During those early years, I ran two “Bonnie Bell 10Ks”; my proudest moment came in 1982 when I clocked a time of 44 minutes. Now, 30 years later, that race is called the Tufts Health Plan 10K for Women and I’m called a “veteran” (age 70-79), and I will need an hour more as I walk most of it. Continue reading

To Watch The Boston Marathon Responsibly, Watch This Video First

I hate to be a spoiler. After all, for me at least, one of the great joys of watching from the Boston Marathon sidelines as the heroically suffering runners pass by is the sheer “better you than me” schadenfreude. I admire the runners and revel in the pure, not-running passivity of being a spectator at the same time.

So it’s with deep chagrin that I report that recent research by Dr. Aaron Baggish of Massachusetts General Hospital and others suggests that we spectators can’t be quite so passive anymore, because when nearby crowd members or runners know CPR and rush to the aid of a collapsed runner, they really can save lives. (And I don’t want to think about how many collapses may be caused by heat now predicted to rise into the eighties on Monday.)  In a January paper in The New England Journal of Medicine, Dr. Baggish and colleagues write:

The strongest predictors of survival of cardiac arrest were initiation of bystander-administered cardiopulmonary resuscitation (CPR) (P=0.01 by Fisher’s exact test) and an underlying diagnosis other than hypertrophic cardiomyopathy (P = 0.01 by Fisher’s exact test).

Of course, as Dr. Baggish points out, that’s good news because it suggests action could help: broader CPR training. There are even special Marathon-oriented training sessions this weekend. If you don’t have time to take a course, the video above offers the basics of the relatively new dogma on “Hands-only” CPR, and just to review my favorite tip, if you need to do CPR on someone, the best beat comes from Queen’s “Another One Bites the Dust” (but maybe you shouldn’t sing it aloud to the patient…)

Follow-Up On Cool-Downs: What To Do And Why You Really Should

A triathlete cools down

My boss, chief John Davidow, tells me I ruined his life with this post on the danger zone after exercise, written in the wake of Kara Kennedy’s recent death. Used to be, he’d play his boisterous morning game of basketball, then assume that his body was cooling itself down naturally as he shaved. Now he still shaves right after playing, but as he does, he worries that he’ll drop dead from a heart attack with a white beard of cream still on his face.

Now, I’d rather not have “life-ruining” appear on my next performance review. Also, I don’t want John to die with a foamy face. And I figure if he’s left with concerns, probably so are many others. So I asked Dr. Aaron Baggish of Massachusetts General Hospital for a follow-up conversation to help clear up exactly what constitutes an adequate cool-down and why it’s so important. He’s an expert on the effects of exercise on the heart and cardiovascular system. (Also himself a competitive runner, and the cardiologist for the Boston Marathon.) His conversation with John, edited and distilled:

John: So are you kidding me? Do I really have to warm up and cool down?

‘Tell them to wait. It’s much better they all jog with you than have to wait while they’re calling the ambulance.’

Aaron: I’m not kidding you. The issue is this: That we know, and have known probably for 30 or 35 years, that routine physical exercise reduces your risk of heart trouble. That story is very clear. But it comes at a price: If you’re going to run into trouble, it’s going to be while or after you’re exercising. If you’re going to exercise — and you should — you have to know how to do it right: You have to let your body warm up and cool down. Your body doesn’t like sudden changes.

So why do I see studies saying, ‘Oh, don’t bother stretching’? Continue reading

Why To Exercise Today: ‘The Delights Of The Healthiest Elixir’

Dr. John Mandrola, a cardiologist in Louisville, surely understands the mechanics of how exercise helps the heart. But in this lovely recent post on his “Dr. John M” blog, he also writes about the effects of exercise on the metaphorical heart — what I would call the glory of it.

‘Fess up, hard exercisers: sometimes, you feel something akin to ecstasy, don’t you? Here, he tries to capture that:


Yes I am a little giddy.

I just finished riding my bike in mud and grass. There were many other people — nice ones, with good hearts (and legs). People trying to be — almost “normal.”

It was just a Wednesday cyclocross practice.

Did I say there was an orangy sunset, a cool autumn breeze and happy animals buzzing around too? The dogs and squirrels seemed to look at us with envy.

An aging cardiologist, a realtor, a litigator, a new Dad got to duel with high-schoolers. The omega and the alpha. “Go bike, Go.!” Word has it there was even a philosophy major in attendance. Lest you think we cyclists are witless, or Conservative.

So why can’t I convince my patients of the wonders of what their body could do? They don’t have to ride in mud, or slog through an Ironman, or calcify their coronaries by running like Forest Gump. All they have to do is something that makes them sweat — every day that they eat. Something fun.

No pills; just the sweet elixir of trying hard, moving fast, being alive. Check the p-value on that!

Heart Med Study Cited As Example Of Problematic Financial Ties

Alison Bass

Alison Bass’s past as a crack Globe reporter is showing. Now an author and journalism teacher, she shows on her blog today that she can still do a bang-up super-fast write-up. She reports on a Harvard event last night titled “Dollars For Doctors: Who Owns Your Physician?” and pointed remarks at the forum by Dr. Arnold Relman, former editor of The New England Journal of Medicine.

The issue: how conflict of interest in medicine drives up costs by increasing the use of expensive new drugs when cheaper generics would do. Alison writes:

It was left to Dr. Arnold Relman, professor emeritus at Harvard Medical School, to showcase a fresh-off-the-page example of how studies that are funded by drug makers and conducted by researchers who have financial ties to the industry present skewed research results that favor expensive new drugs over generics.

His case in point: The New England Journal of Medicine published a study last week concluding that a new anticoagulant known as apixiban (brand name: Eliquis) was superior to the generic drug warfarin in preventing stroke and deaths in patients with atrial fibrillation (abnormal heart rhythm). The study was funded by Bristol Myers Squibb and Pfizer, which jointly manufacture Eliquis, and featured a lengthy roster of authors, many of whom have extensive financial ties to the drug industry (in the form of speaking and consulting fees). At least three of the authors were Bristol Myers Squibb employees, as the fine print at the end of the study disclosed. Continue reading

Yes, Time To Learn New ‘Hands-Only’ CPR

The new CPR guidelines from the American Heart Association are not due out until next week. But Dr. Aaron Baggish of Massachusetts General Hospital — and many other cardiologists — have no doubt about what’s coming: A recommendation that everyone learn the new “hands-only” CPR.

See our earlier post on the technique and its nuances here.

The new guidelines are eagerly awaited, Dr. Baggish said, and based on extensive research showing that the new “compression-only” technique is twice as effective as the old standby. (The latest study came out just yesterday in The Lancet. It’s here.)

“The new guidelines are going to emphasize the importance of early chest compression as the important first step in CPR.” he said. “And this is a major change in the paradigm. For a long time, we’ve tried to get air into people before worrying about chest compressions, and for a number of reasons, it’s now clear that’s not the best thing.” Continue reading