A Response to the Ethical Pledge for Vein Doctors | Vein Magazine

A Response to the Ethical Pledge for Vein Doctors | Vein Magazine

Ethical Apocalypse Now – Redux: Here’s a Better Solution

Recently, a respectable medical journal, Vein Magazine, published an article suggesting that all vein doctors should take an actual ethical pledge not to abuse their own patients.

It was entitled, The Pledge: An Ethical Commitment.

The article was picked up by the Wall St Journal in the June 25-26, 2016 week end edition on Ask Ariely: Dan Ariely.

In the article, there were optimistic opinions from respected vein cognoscenti (read: smart vein experts) who all seconded the motion with great enthusiasm.

Wait, whaaat?

Vein doctors are being asked to take a pledge to act ethically?

The reason for the pledge is that although they would vigorously deny it, entrepreneurial vein doctors often treat each patient as an opportunity to make money.

Anyway, the pledge is moot because doctors would resist it like a cat resists a bath.

Research has shown that physicians quickly evolve their treatment choices if the fees they get paid change. Reductions in varicose vein reimbursements are commonplace.

The field of treating venous disease has become a huge veritable cesspool of unethical physicians – full as a tick – ordering unnecessary Doppler tests that are then falsified to enable them to perform equally unnecessary procedures.

Ethics and Phlebology

Phlebology (the specialty of treating venous disease) from an ethical standpoint is spiraling out of control partly due to an increasing entrepreneurial spirit and a decreasing sense of what is right and wrong.

In my opinion, the idea that vein doctors should take a pledge not to cheat the system and their trusting patients would be a pointless, brainless and idiotic waste of effort and time.

An ethical pledge in the hopes that bad vein doctors will stop abusing the system for profit is simply an exercise of futility and not worth the paper it is written on.

Think about it for a minute.

They want the equivalent of a habitual crack head to promise not to use cocaine.

The experts who believe this are either naive or not thinking clearly with a lot of Venn overlap in between.

Perhaps only if someone promised to pay the thieves to not to abuse their patient’s trust, these charlatans might lay off – for a little while.

You can sense from my tone that beneath my mild-mannered exterior, I am a raging cynic of the pledge solution.

That’s because I have personally witnessed abuses on patients coming for second opinions. It’s always from the same offending doctors – who are lower than a snake’s belly in a wagon rut. It’s habitual.

I’m sure that they are primarily motivated by profits just like in the business world.

A pox on them.

Ethics in Gastroenterology from the New York Times

Let’s examine another medical specialty for a little perspective.

Take the Joan Rivers case, the famous comedienne’s death, as reported in the New York Times as an example.

Sedated endoscopy, for example, which is used by gastroenterologists to treat conditions like acid reflux and to perform colonoscopies, carries significant risks of adverse effects, including mortality. Joan River’s death from the procedure was not a one-in-a-million complication. Reported death rates vary considerably, but one rigorous study suggests that the death rate is 1 in 9,000. Since approximately 18 million sedated endoscopies are done each year in the United States, “routine endoscopies” may cause 2,000 deaths a year.

And yet, for acid reflux, there is a safer, cheaper and equally accurate procedure available called trans nasal endoscopy; unfortunately, doctors rarely employ it, presumably because it doesn’t pay as well.

It doesn’t pay as well.


Could it just be the way that some of us are programmed from before birth?

But what it boils down to is what Dr. Edward MacKay, a respected vascular surgeon, wrote about the moral state of the vein profession, “You either have ethics or you don’t.”

It’s become as plain as a pig on a sofa.

I realize that medicine has degenerated into a big business proposition with insurance companies running the show.

After all, it’s the insurance companies that determine medical necessity and later do everything in their power to subterfuge, delay, and refuse to pony up promised payments after previously authorizing treatment plans and treatment.

I get it but grope for words.

Contemptible, ignoble, and despicable come to mind.

Doximity.com, a social network for doctors, has published an article for like-minded doctors to rent their own cars part time when they’re not using it and selling insurance as a side hustle to make a little extra scratch.

Do other professionals rent their own cars when they’re not using them? Well I declare, I have to admit I have never heard that one before.

Surely, they can’t be serious. (I know, don’t call me Shirley.)

Yeah, those are the suggested options from recent articles on Doximity.com to pay off those massive college and med school loans.

Ethical Issues Abound in the Vein World

Unnecessary varicose vein surgery has become a worldwide problem. Even in Slovenia it’s a growing problem.

Here are a few examples from my area.

Another patient came in today for a second opinion.

Spider veins only.

They were told that they needed multiple saphenous veins ablated – unnecessarily. I checked their saphenous veins myself with Doppler ultrasound. They were all completely normal.

This is not an isolated example. It happens every week.

Another patient recently had 7 vein ablations in one leg and didn’t notice any difference so they finally came to me for a second opinion. They chose the first place because that office was located near their home.

Dr. Jose Almeida addressed ethical issues in his opening address at the International Vein Conference in 2016 and touched on the proliferation of this problem during subsequent panel discussions.

Southern Florida is the center of this mess.

Pittsburgh isn’t far behind.

Rant just beginning.

Another ethical issue that needs to be addressed is disclosing the patient’s final financial responsibility after insurance has paid their part.

All doctors including vein doctors should give full disclosure (if possible) of all procedural costs up front. Presently, before a medical procedure, patients are asked to sign multiple documents and consent forms. That includes a promise that they will pay whatever is not covered by insurance. The problem is that the patients have no way of knowing what the procedure/s will actually cost.

Another problem is that all insurance companies reimburse the same procedure differently and are constantly changing their payments. Although the patient’s insurance may cover 80 or 90 percent, they liable for the remaining 10 or 20 percent of final bill totaling thousands of dollars.

Facts You Need to Know about Before You Have Your Veins Treated

In Pittsburgh, many vein patients are being told that the insurance companies would pay for their spider vein treatment (no insurance company does) if they had their saphenous veins closed off first.

Don’t fall for it.

#1. You may need your saphenous veins for bypass surgery.

#2. Saphenous veins can be used for heart bypasses and shouldn’t be closed off if all you have are spider veins.

#3. Saphenous veins rarely need treated and are rarely abnormal if you have only spider veins. Peter Lawrence MD discussed this in his presidential address to the Society of Vascular Surgery.

# 4. 95 % of veins are not covered by insurance as one franchise in Pittsburgh claims.

Proposed Solutions to the Ethical Issues

Some vein experts have recommended:

  • Report the bad apples to the state medical board
  • Call the offenders (in a nice way) yourself to put them on notice
  • Report them to the Intersocietal Accreditation Commission
  • Report them to the insurance company
  • Have the patient report them to the insurance company
  • Ask patients to write reviews on the Internet
  • Write articles on the Internet to educate the public

A Better Approach to Solve the Ethical Vein Problem

Here is a better idea.

Wait hear me out on this. It’s from doctors at Harvard.

Let’s pause to genuflect.

An electronic ethical nudge on doctor’s EMRs by comparing them to their peers.

It’s similar to what doctors get when overprescribing antibiotics for colds and viruses.

It can only work in conjunction with registries compiled from the American Venous Forum and possibly the American College of Phlebology.

While the first intervention had no statistically significant effect, both accountable justification and peer comparison led to statistically significant reductions in inappropriate antibiotic prescribing. Peer comparison helped reduce prescriptions that weren’t warranted from 20% to 4% as doctors got monthly individual feedback about their own performance for 18 months.

“Information must be accurate, presented to physicians at the right moment, perceived by them to be of high value and must make it easier for them to do the next step,” Dr. Singh says.

Dr. Singh has studied use of electronic “trigger alerts” that act as a backup to catch important test results doctors may have missed. A study he co-wrote, published in 2015 in the Journal of Clinical Oncology, found such alerts reduced the time it took for doctors to evaluate patients with abnormal test results for lung, colorectal and prostate cancer, and increased the proportion who received follow-up.

“You can imagine a bunch of doctors at Harvard being told ‘You aren’t a top performer,’” Dr. Linder says. “We expected and got a lot of pushback, but it was the most effective intervention”.

About The Author

Dr. John Happel

Dr. John Happel has been in practice as a surgeon since 1986 in the Pittsburgh region. He specializes in vascular surgery and has subspecialized in the treatment of varicose and spider veins since 1999. Dr. Happel is board certified in vascular surgery and recertified in vascular surgery in 2012. He was chosen in 1985 to fulfill the position for the vascular surgical fellowship at the world renowned Mayo Clinic.