Medical Ethics vein clinic example

An appointment for a consultation with an MD was made recently (referred by
GP for some moderate edema in the lower legs) and, before meeting with the
doctor and without warning or explanation, the patient suddenly found
himself on a table with a sonographer--whom he first assumed was an
RN--scanning his legs.

Neither the GP's RN (who originally scheduled the consult) nor the patient
(when he rescheduled) remembers any caveat regarding the need for an
expensive sonogram.

The bill total was over $800 US for the sonogram and the consult and before
the patient could leave, the office assistants were trying to set up an
appointment for both saphenous veins to receive a "Closure" procedure using
an RF emitting catheter (see www.vnus.com). As might be expected, the
calendar was rather full and only one date was available for the next
several weeks. Additionally, the procedure's success rate was stated as 99%
(this may be correct but one might not be surprised to learn this number is
on the high side).

Despite a request to not submit to insurance for pre-authorization until
advised, the office (which had offered to do immediately) did it anyway.

The patient is not going to have this or any other procedure done without at
least one additional opinion and is interested to know if he should be
advised to avoid this particular MD regardless of his extensive experience
and credentials.

The doctor's office was not paid (the bill wasn't ready and they we told not
to bill insurance); the patient intends to tell insurance to hold claims
until this is resolved. Of course, it is assumed the sonogram results
belong to the patient and that they could be requested by another
practitioner so it isn't likely there will be lack of payment unless a
sonogram clearly was not indicated based on the state of the medical
condition. In any event, the patient got a sense he was being given the
bum's rush; maybe what one might experience on a visit a high-powered
chiropractic office.

Any opinions on the ethics involved here would be appreciated.


Regards,

P H

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This sonogram-without-consultation case sounds like poor communication by clinicians and/or poor understanding by the patient. To infer an analogy, last time I went to the dentist, the office crew fiddled-around in my mouth and took x-rays before I even saw the dentist.

I bet this patient was referred to one of them new commercialized "vein clinics" we've seen popping up all over with the full page newspaper ads and tv/radio commercials. It would be pretty common, I suspect, for a vein clinic to sonograph a GP-referred patients legs at the first visit. And, unfortunately, we've come to a day when many specialty clinics give the impression they want to see your insurance card and talk to your insurance before they want to see or talk to you.

So, this case scenario might be more of a quality care versus blatant breech of ethics issue. However, I think much of what I've seen with vein clinics goes beyond poor patient interaction and becomes a good example of poor medical ethics. Coil embolization of the saphenous vein via VNUS RF catheter technique seems to be a primary staple for income for these specialty vein clinics. It almost gets to the point where anyone who steps foot into the vein clinic is going to have an indication for this, and/or equally intensive vein procedures. Patients eventually get rubber-stamp treatment despite any disparity in clinical history or presentation. This is a gray and dangerous area in regards to medical ethics. But, I bet the risk for this isn't anywhere unique to vein clinics in the larger medical community.

N-