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Dr. George Sheldon — The rest of the story

gfsheldonDr. Sheldon is a UNC physician and was featured in a Sept. 23 News & Observer article about health reform, and he sounded skeptical of current proposals. He also testified in front of Congress on behalf of the American College of Surgeons. His themes are that health care is expensive but it’s because we get such good care; that we should increase the supply of high-priced surgeons; and that we should not have any of those pesky cost controls like a public option or limiting geographical variations in health care spending.

In his testimony before Congress, Sheldon showed that he isn’t above making dubious claims to advance his agenda.

He told legislators:

This is of course based on the Dartmouth work, respected investigators, but there are four other groups including ours that find different types of data. That would be Dr. Robert Berenson at The Urban Institute, Dr. Cooper at the Wharton School of Business at the University of Pennsylvania, and our data from Dr. Ricketts. In short, while there is some regional variation they’re only comparing Medicare, and Medicare is only 50 percent of the payers, so it’s like comparing apples and oranges. It’s not agreed upon enough to be a premise for health care reform.

Dartmouth researchers have produced highly respected reports for 30 years examining how some regions of the country deliver high volumes of expensive care without any better results or outcomes than more parsimonious regions. This data is threatening to Sheldon because he wants more money for more surgeons. And he wants more money for medical schools to produce more specialists.

But Dartmouth suggests that while there is a shortage of primary care doctors and there are maldistributions of some surgical specialties, we do not need to drastically increase the number of surgeons. Instead we need better coordination of care and we need to change incentives, which will limit unnecessary surgeries and procedures.

Sheldon cites research by Berenson at The Urban Institute, but here is what Berenson told Managed Care Magazine in February:

Robert Berenson, MD, a researcher at the Urban Institute, says that “there is no consensus about the extent of a shortage.” He adds that there is some agreement about a shortage of generalists, including general surgery, but there is no agreement on the need for more medical students. “I think we need more studies to determine if there is an absolute shortage, and then we need to agree on the policy levers to deal with it, particularly shortages among generalists.”

Not exactly a clarion call for more money going to medical schools to produce surgeons.

Sheldon also cites Richard Cooper who has taken a lead role in arguing for more surgeons and attacking Dartmouth. Health care blogger Maggie Mahar at The Century Foundation has more about Cooper here, including why he is banned from writing in the health policy world’s leading journal Health Affairs for five years. Sheldon has worked with Cooper in their mission to get more money for surgeons.

Cooper has tried to poke holes in the Dartmouth data, but was summarily shot down by the Dartmouth researchers. Cooper and Sheldon are recent critics who did not publicly take issue with Dartmouth until the current health reform campaign. It is preposterous to claim, as Sheldon did, that Dartmouth research is “not agreed upon enough to be a premise for health care reform.”

Sheldon also cites research by Tom Ricketts to support his position. Sheldon and Ricketts co-direct the American College of Surgeons Health Policy Institute, which is based at UNC. Normally I would be skeptical of research done by the American College of Surgeons showing that we need to give a bunch of new money to medical schools to produce surgeons. But Ricketts is highly respected and is the expert on physician supply.

But the information from Ricketts doesn’t really conflict with Dartmouth. Again, there is a maldistribution of some surgeons. And if we continue performing the same rate of surgeries given our population growth there could be a total shortage. But we have a much bigger problem with overtreatment and performing unnecessary tests and surgeries.

Sheldon obviously doesn’t think much of the evidence for overtreatment. He tells the N&O:

“In the 1950s, advanced coronary care was blood thinner, strict bed rest and you watch for arrhythmia,” he says, referring to the irregular heartbeat that can signal problems.
Now, he says, people are treated with any number of different drugs, depending on their problem. They can undergo a balloon catheter procedure to unclog blockages, get stents installed to prop open the artery and might even have bypass surgery.

Nationally respected UNC physician Nortin Hadler, and a rather smart chap at interpreting data, has another view of the great advances touted by Sheldon. In his book, Worried Sick: A Prescription for Health in an Overtreated America, Hadler writes:

I submit that interventional cardiology and cardiovascular surgery have written one of the bleakest chapters in the history of Western medicine. If there was never another CABG or angioplasty performed or stent placed, patients with heart disease would be better off.

I’m sure Dr. George Sheldon is a great guy and a good surgeon. And the American College of Surgeons presumably pays him to push its line. But his ideas about health reform are harmful and unsustainable. And Sheldon does not only work for the American College of Surgeons, he is also a professor at our state’s flagship public university. In that position his willingness to misrepresent research is troubling. And the media should recognize Dr. Sheldon’s conflicts when reporting on his opinions.

3 Comments

  1. Paul Slobodian

    September 27, 2009 at 1:41 pm

    Your citation of Nortin Hadler is on point. His books, most recently Worried Sick explain in detail the problems of many commonly accepted interventions….especially our “prevention” strategies that rely on notoriously unreliable tests which lead to expensive interventions and numerous harmful side effects….all for very limited benefits.

    There is already an effective solution…..health savings accounts put the control back in the hands of patients and doctors and provide the incentive for patients to decide whether to pay for many wasteful procedures and interventions. These plans provide catastrohic coverage and are inexpensive (and would be even more so if people were free to buy them across state lines and avoid paying for the state mandates that drive up the costs of insurance).

    Paul
    http://www.pivotconsultingllc.com

  2. AdamL

    September 28, 2009 at 12:04 pm

    Health Saving Accounts wouldn’t put much of a dent in needless procedures. When a physician recommends you get bypass surgery to treat your coronary artery disease most patients aren’t going to request a stent to save money — they are going to take their doc’s advice. An HSA might prevent you from getting a needless strep test but that’s not exactly a major cost driver.

  3. Paul Slobodian

    November 26, 2009 at 8:04 am

    Adam,

    I know the common wisdom is that most of the high health costs are the “big” procedures….but I am not so sure.

    My catastrophic family plan costs 500 per month. The traditional coverage would be about 1400 a month.

    I think the 900 per month difference reflects the carriers actuaries calculations of how much the day to day small stuff costs on average for all their insured.

    Because of our hsa coverage we think twice about going to the doctor and when we go we ask about the cost benefits of additional procedures. My son had a sports injury and the doc did an xray and said it would get better with rest….then he wanted to do an mri….we asked why and he couldn’t give a coherent answer about the benefits….we said “no thank you”.

    Freedom for docs to set rates and for patients to make decisions re what doc to use and what procedures to buy works…..as seen in opthamology and plastic surgery…..where per procedure rates have dropped dramatically over the years unlike all the other regulated/heavily insured specialties.

    Paul