Maximum Medicine

In Lubbock, Texas, A Weak Heart Gets the Full Treatment
Its Doctors Like Angioplasty, and Who is to Say the Patient Doesn't Need It?

by George Anders
Staff Reporter, The Wall Street Journal

Reprinted with permission

    Lubbock, Texas - No one relocated here because of the scenery or the weather. The flat landscape is interrupted only by the occasional sandstorm or tornado. But in the late 1980s, when heart doctor Robert Wey needed another partner in his seven-physician group, he ran a tiny classified ad in the New England Journal of Medicine that captivated doctors across the US.

    "Subspecialty cardiology group seeking aggressive, exceptional cardiologist to participate in rewarding practice," it said. Potential yearly earnings: more than $1 million.

    The phone started ringing. "Are you really making that much money?" an excited doctor in California asked. "I said yes," Dr. Wey recalls.  The next thing he wanted to know was, "When can I move out and join you?"

    This West Texas city of 200,000 has become the heart-care industrys El Dorado. Cardiologists here are rich enough to buy Cessna jets and breed Arabian horses. Pacemaker salesmen covet the territory. Although Lubbock is too small for any more than a minor-league baseball team, its main hospital is among the 20 busiest heart centers in the US.

Local Tastes

    Such showcase cities are becoming famous - or notorious - in the treatment of many major ills. People with weak hearts, sore backs or breast cancer may think their symptoms alone decide their care. Not so. A patients odds of getting a major, invasive procedure can be swayed by something else: his or her zip code.

    A study by Dartmouth Medical School and the American Hospital Association found huge regional fluctuations in the way medicine is practiced. Boulder, Colorado, leads the nation in prostate-cancer surgery per 1,000 residents. In Rapid City, South Dakota, breast-cancer surgery is almost certain to be a radical mastectomy, not a lumpectomy. Provo, Utah, is the back-surgery capital. And in Lubbock, cardiologists perform two major heart procedures about twice as often as the national average.

    To public-health experts, such treatment patterns constitute something close to a medical scandal. "These high rates arent just of interest to insurance companies," says Dartmouth investigator John Wennberg in Hanover, New Hampshire. "This matters to patients as well. They may be getting treatments where the risks exceed the benefits."

    Regulatory files in Texas are packed with accusations that patients got unneeded pacemakers, back surgeries and other procedures. But such charges "are very difficult cases to prove," says Tim Weitz, chief counsel at the Texas State Board of Medical Examiners. "Maybe nine out of 10 doctors will disagree with what the physician did. Maybe in hindsight he shouldnt have done the procedure." But if doctors can produce expert witnesses justifying a procedure, regulators will be hardpressed to prevail in a disciplinary case.

Cardiac Costs

    The stakes are highest in the treatment of heart disease, the nations costliest illness and its No. 1 killer. Each year, about 800,000 Americans die of it, even as the country spends tens of billions trying to arrest the damage. Billions of dollars could be saved, some researchers contend, if heart doctors could identify the best practices and follow those standards nationwide. Instead, each medical community has its own norms.

    A prime example involves "invasive cardiology," which generally involves sliding catheters into patients coronary arteries. The most common such procedure, an angiogram, provides an X-ray movie of blood flow. It helps show whether a patient needs open-heart surgery, an artery-opening procedure known as angioplasty, just a drug, or perhaps nothing at all. Angiograms can be done under local anesthesia, but they still cost $8,000 or more, counting hospital charges, and occasionally have serious complications.

    Both angiograms and angioplasty are done at an unusually high rate in Lubbock, according to the Dartmouth study. And last year, the New England Journal of Medicine reported that Texas doctors did angiograms on 45% of Medicare patients following heart attacks, while New York doctors did them in only 30% of cases. The greater frequency in Texas didnt, on the whole, save lives or improve patients well-being, says Edward Guadagnoli, a Harvard Medical School professor who led the study. (Bypass operations arent performed at an unusually high rate in Lubbock; they can be done only by surgeons, not by cardiologists.)

Lubbock Style

    So how do these pockets of maximum medicine arise? And who wins or loses when one part of the US practices medicine so differently?

    In Lubbock, aggressive treatment of heart disease began in the 1970s as a personal mission of a few local doctors. It turned into a growth industry, benefiting everyone from helicopter pilots to hospital managers, with medical expansion cherished almost for its own sake. A Lubbock style of medicine took hold - aided by the arrival of out-of-state cardiologists angling for the big money.

    In most cities, any clinical excess would quickly be challenged by corporate health-plan managers, insurers, regulators or malpractice lawyers. But in Lubbock, such restraints are scarce. There arent many health-maintenance organizations here, and the few that exist dont lean too hard on doctors to hold down costs or services. Most efforts to prevent medical overuse in Texas are concentrated on the big population centers, Dallas and Houston.

    Lubbocks leading cardiologists defend their practice style. "Were a strong role model in appropriateness of procedures," says Paul Walter, president of Cardiology Associates of Lubbock. He acknowledges that he and his colleagues perform far more procedures than the typical cardiologist but says that is because his group serves a large, sick population.

    Even so, some families here seethe about what they see as excess doctoring. Karen Vardy won a six-figure settlement from some Cardiology Associates doctors last year after an angiogram on her husband led to severe bleeding. He died 10 weeks later. Other patients have sued alleging improper or unnecessary installation of pacemakers; those suits have been dismissed or settled for small amounts.

    Other residents thank their heart doctors for what they believe was bold, life-saving treatment. "People in West Texas are extremely trusting of doctors," observes M. Wayne Cooper, a cardiologist who practiced in Lubbock in the 1980s, when he moved to the East Texas city of Tyler. "They think of physicians as deities. That power can be misused."

    For all its current sweep, heart medicine in Lubbock started small. Old-timers remember the citys first cardiologist, Harvard-trained William Gordon, who settled here in 1946 because the dry air allayed his wifes asthma. Patient care then was done mostly by stethoscope and prescription. Dr. Gordon bought an electrocardiograph, put it in his car and drove to small towns so he could analyze patients heartbeats.

    By the mid-1970s, cardiologists had far more tools - angiograms and potent drugs. Dr. Gordons practice grew into Cardiology Associates, with a new partner recruited every few years from the University of Colorado, a training ground for angiogram enthusiasts. Their high-tech style became part of the Lubbock way.

    They found patients galore. More than 500,000 people live within a 100-mile radius. Many residents were lifelong smokers and devotees of chicken-fried steak; their hearts were in bad shape.

    "The first weekend I got here in 1975, I had 20 cases," Dr. Wey recalls. "That was more than Id had for an entire month in training in Colorado. I thought Id died and gone to heaven."

What Do You Need?

    Soon, the two biggest hospitals in town were vying for the cardiologists business, courting them with an intensity hospitals more typically extend only to surgeons. St. Mary of the Plains built two catheterization labs. Methodist Hospital struck back with a six-story Heart Center, with six "cath labs" and $9 million of equipment.

    Local leaders were pleased. "One of the few driving forces in the Lubbock economy was medicine," Dr. Wey says. "The driving force of medicine was cardiology."

    Doctors whom Cardiology Associates hired from the East and West Coasts brought skills Lubbock hadnt seen before. They also arrived with a swagger that didnt always sit well. One new doctor annoyed his neighbors by turning his huge backyard into a pasture for six Arabian horses. Another decorated his office with full-length mirrors. A third became a collector of Mont Blanc pens.

    Dr. Wey, who headed Cardiology Associates in the early 1990s, urged colleagues to share not just in the "gravy" - procedures that could pay $1,000 for an hours work - but also in the "scut work" - office visits and lab tests at awkward times. His appeals didnt always work. One physician was overheard muttering, "Treadmill tests are the crabgrass of cardiology."

    Internal pay records show that in 1990, when the group had nine doctors, eight earned at least $1 million. Last year, 11 of the groups 14 doctors cleared the $1 million barrier - figures that astound cardiologists elsewhere.

    Paul Overlie earned nearly $1.3 million last year. He did 454 angiograms and 133 angioplasties at Methodist and scores more procedures at St. Mary. Some nurses and doctors call him Dr. Overplasty.

    "I dont overplasty," Dr. Overlie responds. He says that if a single artery is 60% closed, he wont open it, though he will intervene if it is 90% closed. He acknowledges that not all cardiologists would do angioplasty even then, but he thinks the cautious ones may be making a mistake. "I get their patients at night," after heart attacks, he says.

Pilot Project

    In the late 1980s, two Lubbock cardiologists leased helicopters to bring emergency cases from outlying farm towns. Of course, many of those burgs lacked helipads. "We hired contractors to pour concrete in at least 20 towns," says one of the doctors, Howard Hurd.

    Once again, West Texas developed its own practice style. In most of the US, tiny rural hospitals treated heart-attack patients on site, giving clot-busting drugs. But Lubbock cardiologists told rural doctors that patients ought to be flown to a cath lab for emergency angiograms and angioplasties. Result: a $3,000 helicopter bill per case, a $2,000 cardiologist fee and $12,000 or more for a Lubbock hospital.

    Lubbock cardiologists went all-out to make angioplasty seem like the wise choice. Doctors who relied on drugs, known as thrombolytics, were belittled as "thrombolunatics." Studies were circulated showing better survival rates for angioplasty. In some cases, Lubbock physicians jumped in the helicopter themselves, rather than rely on an air nurse and technicians to get the case started.

    Dr. Wey became a hero in Muleshoe, Texas, for flying out to rescue the father of town doctor Robert Purdy after a heart attack. The payoff was substantial: Dr. Purdy became a huge fan of the helicopter service and now sends at least 30 heart-attack cases a year to Lubbock.

    Emergency angioplasty isnt always a lifesaver. According to the Center for Health Industry Performance Studies in Columbus, Ohio, Lubbocks Methodist Hospital in 1994 had a 4.1% death rate for Medicare patients getting single-vessel angioplasty. That was nearly double the national average. Cardiology Associates, the main heart group practicing at Methodist, disputes the data and says most of its angioplasty deaths occurred in extremely grave heart-attack cases where other doctors might not have tried the procedure.

Lasers and Stents

    New techniques found favor in Lubbock. Delivery trucks in the early 1990s pulled into Methodist and St. Mary with cargoes of lasers, ultrasound probes, high speed "ablading" devices and wire-mesh stents to prop open arteries after angioplasty. Lubbocks heart doctors became co-investigators in many nationwide research trials, testing new treatments.

    "It was a heady time," Dr. Walter says. "There was this incredible enthusiasm that we could solve all sorts of problems that otherwise would have required surgery. With just a half-hour treatment, we could open an artery - and then have someone ready to go back to work the next week."

    Some new techniques lived up to their promise. Dr. Overlie inserted more than 100 stents a year, with impressive results. "Hes shown slides of my arteries at conferences around the world," boasts stent patient Hubert Setliff, 82.

    Other ideas flopped. Lubbock doctors for a while tried using lasers to burn away arterial plaque. They billed as much as $5,000 for a half-hour procedure, triple the rate for conventional balloon angioplasty. But one doctor who tried this 10 times abandoned it after deaths or complications in four cases.

    Norma Wines, age 70, underwent laser angioplasty in Lubbock. Her husband and daughters were so confident they went home after the procedure started to make a big pot of soup and wait for her to come home. She never did. Medical records show that Mrs. Wines sank into critical condition after the procedure, needed emergency surgery, and died.

    Three years later, her widower, Weldon, sits in his darkened kitchen and talks about the case. "I know how to build houses, and I know how to grow tomatoes," he says, "but I dont understand heart medicine. When they recommended this laser treatment, we just signed the papers." Mr. Wines has sued one of the doctors, Fawwaz Shoukfeh, in state court, alleging negligence and unwarranted treatment. Dr. Shoukfeh denies the charges. A trial was set for last fall.

Second Thoughts

    Dartmouth didnt measure pacemaker use, but Mark Riley, a salesman for Intermedics, a pacemaker firm, says, "Ive been in medical-equipment sales for a long time, and Ive never seen a town like this." He says Methodist Hospital buys as much of some common heart devices as the biggest hospital in Dallas, though Dallas has five times as big a population.

    Lately, a schism has developed between Lubbocks older heart doctors and new arrivals. Most of the veterans are native Texans who identify with the farmers, oilmen and ministers they serve and say they dont mind spending time on simple preventive counseling. They question whether some newer colleagues share those values. "I got tired of apologizing for my colleagues behavior," says Dr. Hurd, 52, who left Cardiology Associates to set up his own practice.

    Another alumnus, 64 year-old Sam King, says he is uneasy about other heart doctors fondness for angioplasty. "Its very lucrative," he remarks. "As far as the patients well-being, its not always the best thing." Frequently, he notes, arteries rapidly close again. "And every time you do one, theres myocardial loss. By the time patients are considered candidates for surgery, the heart ventricle isnt that good any more. You convert someone from a good surgical risk to a poor risk."

    So far, Lubbock has lagged far behind the rest of the US in feeling pressure from employers and managed-care companies to use health resources more frugally. The biggest private-sector employer here, Texas Instruments, Inc., says it is too busy overseeing medical costs in its larger Houston and Dallas sites to focus much on Lubbock.

    In the past few months, Lubbocks heart doctors have become worried that managed care will soon make inroads here. Cardiology Associates retained Ernst & Young to advise on ways to cut costs and be better positioned for managed care.

What Diet?

    Mostly, however, the citys heart-care juggernaut keeps rolling along. Elsewhere, health plans are trying to nudge heart patients into intensive diet and exercise programs; in Lubbock, patients keep queuing up at the cath labs. Waiting rooms are packed with anxious men and women, mostly 50 and over, wanting to know how bad off their hearts are.

    "These patients dont know much about hearts," says Frank Harmon, a former medical manager in Lubbock. "Theyre pretty much at the mercy of their doctors. And the doctors know that."

    Among Lubbocks grateful patients is 59 year-old Buddy Sexton, a retired school principal. Over 13 years, he has been a steady cardiology customer, undergoing 10 procedures, including five angioplasties. His arteries periodically renarrow; doctors respond with another angioplasty.

    Doctors have told Mr. Sexton that he is a poor risk for heart surgery. He is overweight, and his current cardiologist, Dr. Overlie, has told him to diet, but the advice hasnt been very practical. At one point, Dr. Overlie said: "I want you to eat nothing but salad until you turn into a salad." Mr. Sexton hasnt had much luck holding to a healthy diet and blames himself. Meanwhile, he praises Dr. Overlie for "prolonging my life."

    On a recent visit to the hospital, Mr. Sexton sheepishly asked a nurse, "Am I the only slob who cant stick to his diet?" The reply, he says, was as follows: "No. We have file cabinets of people like you. We wouldnt have a practice if everyone did what they were told."