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The Uncut Version

The rise of low-invasion techniques—and the doctors who specialize in them—has made the competition for surgical patients, well, cutthroat.

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A tidy number of Robert Rosen’s fellow doctors no longer speak to him. We’re talking colleagues and friends of twenty years’ standing, people he socialized with, broke bread with, and now, pfttt, with Gamma Knife precision, they’re cutting Rosen dead in the corridors of NYU Medical Center, where he’s the director of interventional radiology and endovascular surgery. “They don’t speak to me, and I don’t speak to them,” he says.

It’s no trivial spat involving money and ego (though money and ego are certainly factors). The fight is about nothing less than survival, about doctors attempting to hold on to their turf—or claim a bit more territory—amid the shifting sands of contemporary medicine.

Over the past decade or so, the trend has been toward less and less invasive treatment—laparoscopic surgery instead of open-body surgery. Now enter so-called interventional cardiologists, who perform angioplasty and deploy stents (small mesh tubes that act as scaffolds inside an artery) to treat coronary-artery disease, in place of cardiac surgeons scrubbing in for a bypass. Indeed, since 1994, such surgeries have fallen more than 20 percent, to fewer than 300,000 annually. And then there are interventional radiologists wielding catheters and stents to deal with, say, carotid-artery disease, in place of vascular surgeons reporting for duty, scalpel in hand.

“It’s like the Wild West, the turf wars with the vascular surgeons,” says Alejandro Berenstein, an interventional neuro-radiologist at Beth Israel Medical Center. “You’ve got interventional cardiologists, interventional neuroradiologists, interventional neurologists all wanting in.”

“Cardiologists are now trying to co-opt our patients,” adds NYU Medical Center vascular surgeon Thomas Riles.

But the new specialists aren’t just wresting business from the surgeons; they’re moving into different specialties as well. “Interventional cardiologists are saying, ‘If I can put a catheter in someone’s coronary artery, I can certainly put one in an artery someplace else in the body’—like kidney vessels or the femoral artery, which before would have been done by a vascular surgeon or an interventional radiologist,” says Stephen G. Baum, chairman of medicine at Beth Israel.

This situation is becoming more common as techniques and tools have become better and better, leading to conflicts between physicians who were trained in the classical surgical approach and those who have faster, cheaper—and, they would say, better— ways of doing a procedure.

“There used to be more than enough work for everyone, so turf issues weren’t so important,” says Rosen. “Usually, there was agreement among doctors about what procedure was best for the patient. But now it’s like putting rats in a box that is getting smaller and smaller. Things have gotten tighter, and reimbursements are less, and doctors are getting paranoid about their practices.”

Consequently, there’s been a scramble among certain doctors to branch out big-time, in some instances “to get involved in procedures they haven’t been involved with before, because that’s where they see the future going,” Rosen argues. “The surgeon’s temperament is that if someone else can do it, he can do it. He’d say, ‘I’m a specialist, and who knows more about blood vessels than me? And if I can do vascular surgery, I can certainly blow up a balloon in an artery.’ But these are vastly differently skill sets.”

“It’s like the Wild, Wild West, the turf wars with the vascular surgeons.”

Surgeons, unsurprisingly, have a different take on the situation. They understand that given a choice between having your chest cut open and having your artery dilated and fitted with a mesh stent, you’d go straight for stretch and stent. “But what if there are complications?” asks one of the city’s most eminent neurosurgeons. “It’s not just the procedure. It’s the post-procedure care. You’re dealing with sick people, and a surgeon has spent his or her entire career taking care of them, and an interventionalist hasn’t necessarily.”

This neurosurgeon also expresses concern about the long-term prognosis for a patient whose aneurysm has been treated with coils (a less invasive treatment performed by an interventional radiologist) or a patient whose aneurysm has been clipped (a procedure done by neurosurgeons). “I know clipping is a cure,” he says. “But the data on the interventional approach is short-term.” And some surgeons fret that interventionalists have a bit too much of the cowboy in their souls.

“It concerns me that the most aggressive doctors may not realize the risk in what they do,” says Robert F. Tranbaugh, chief of cardiac surgery at Beth Israel. “They look at images and X-rays, but I don’t think they understand pathophysiology.”

This is, inevitably, one of those “it depends on whose ox is being gored” stories. Vascular surgeon Tom Riles acknowledges the important role of interventionalists, and his own often successful experiences working with them. He does, however, have stories about bailing overreaching interventionalists out of “some mishaps.” Rosen, on the other hand, recalls with disgust the vascular-surgery case that ran for five hours with the patient under general anesthesia, yet could have been dealt with by an interventionalist in 45 minutes under a local.

A cardiac surgeon, who requested anonymity, just performed triple-bypass surgery on a 51-year-old diabetic, formerly the patient of an interventional cardiologist. “He’d had way too many stenting procedures, and his arteries were scarred and blocked,” says the surgeon. “I’m concerned about his long-term prospects because his arteries were so badly damaged.”

“For every one of those patients, I could cite you ten who’ve been messed up through bypass surgery,” says Jeffrey Moses, chief of interventional cardiology at Lenox Hill Hospital. “I could give surgeons tit for tat.” Data, he asserts, speaks louder than anecdotes.

All doctors insist that they just want to do what’s right for their patients. Surgeons claim they make referrals to interventionalists if appropriate, and vice versa. Invariably, however, money talks. “If I do the procedure, I get the fee,” says interventionalist Alejandro Berenstein. “If you do the procedure, you get the fee.”

And according to Moses, there are certain medical centers around the city that push surgeries “because the economics are more favorable and they want to get their numbers up. I’d like to put up a sign in Times Square: IF YOU’VE BEEN RECOMMENDED FOR BYPASS SURGERY, LET US LOOK AT YOUR FILMS.”

The solution, many doctors say, is to develop criteria that carefully spell out which conditions call for which procedures and—this is key—to make certain that the practitioner who first sees a patient is knowledgeable about all treatment options: surgical, interventional, medication, lifestyle modification, the whole deal. Some doctors talk about the desirability of establishing multidisciplinary practices with surgeons and interventionalists on staff so patients have one-stop shopping, the money goes into one pot, and there is no financial incentive to push one therapy or practitioner over another.

“Several years ago, there was an idea to have cardiology and vascular centers,” says Rosen. “There were lots of seminars. Every time you turned around, you got a brochure about another meeting. It was like the Middle East when people were talking. There are now, at best, a handful of these centers around the country because conflicts broke out everywhere.

“All of this,” he adds, “is an unfortunate result of the state of American medicine. Everyone has been so much under the gun with hospital politics and reimbursements that there’s a ruthless, no-holds-barred approach. It’s like the business model of the eighties. It may mean doing things you’re not qualified to do. The question is, how much of a learning curve should patients have to deal with?”


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