I heard a report on National Public Radio last Friday that made me squeamishly uncomfortable. The way you get squeamishly uncomfortable when you are out to a fancy restaurant with important people and your child blurts out a sensitive family secret or begins flicking peas across the room with his spoon.  You wish you could make the whole thing just disappear.

It was a story highlighting a relatively famous interventional cardiologist in California as he placed a stent into the coronary artery of a patient.  The reporter brought a microphone into the lab and captured the doctor’s interaction with his staff as he was plowing through the equipment at his disposal.  Here’s an excerpt:

Teirstein holds up a single small piece of metal — it costs $2,000, and it's destined for one of her arteries. He turns the overhead lights on to better show the stent. "They're very small," he says, "and very flexible."

Teirstein turns his attention to a screen showing the patient's arteries. They look like narrow, winding tree roots. Teirstein has to put this stent somewhere in there. He assesses the size of the problem and calls for a 23-millimeter stent. Someone repeats the order, then hands it to him. Teirstein threads it around a bend and up the clogged artery.

He looks back at the screen. "Too big, I think," he says aloud. "What do you guys think? A little bit too long? Want to try an 18?"

Teirstein pulls the stent back down out of the patient's artery and tosses it aside. He calls for an 18-millimeter stent and starts over.

"It's one of the advantages of having a lot of different stents in your cabinet," he says, noting that he can try several sizes to find the best fit.

Teirstein is casual not just with stents but with all his tools. When a tiny wire that looks like it belongs in a piano annoys him during the procedure, he gets rid of it. The wire costs $50.

Then a catheter doesn't sit right in an artery. He calls for another. "You really need a lot of tools to do this procedure," Teirstein says. "They're all kind of expensive. This catheter is probably about $60." It's just a piece of plastic, but it's an FDA-approved piece of plastic that has to bend in the right away and perform its role exactly.

It feels bizarre to stand here not as the patient and not as the doctor but as a sort of accountant. Teirstein goes through five of these $60 plastic tubes in an hour, and three of the $2,000 stents.

The story is entitled “A Medical Mystery: Why Health Care Is So Expensive.”  I believe the intent was to highlight the idea that complex medical equipment and procedures are expensive, and that American health care is so expensive because American health care is so technologically advanced.

But if you listen to the actual playback of the story (click on the multimedia button on their website) you’ll come to a different conclusion.  Note the cavalier manner with which Dr. Teirstein glibly samples stents and other equipment with the same nonchalance that you’d see in a child tossing away someone else’s money in a candy shop.

The unintended gist of the story, as it hit me on a visceral level, is that health care is so expensive because we doctors are so amazingly wasteful.  The cardiologist seems almost proud to be able to show off how many catheters and wires he can burn through in a case.

I am no interventional cardiologist (one who specializes in the repair of narrowed coronary arteries) but I do spend my share of time in the cardiac catheterization lab and know a thing or two about using expensive equipment.  I would never approach the use of costly supplies with that degree of dispassion.  This vignette of wanton waste appalled me to a degree that surprised even me.  And it wasn’t just me—I also spread this story around to a couple of interventional cardiologists in my group and got the same response.  Why couldn’t Dr. Teirstein measure the length of the blockage prior to opening the stent? The ability to accurately measure a lesion is available in every lab in America.  Are five catheters really needed for each case?  I’ve found that 90% of my cases can be done with three or fewer.

We are now truly in a health care crisis, and every huge crisis is nothing more than a thousand small ones stacked up.  Each test we order, each prescription we write, and indeed each catheter, wire and stent we reach for costs someone money.  In the end that debt is borne by us and future generations.  We have an obligation to reign in costs at every level and in most cases we can accomplish this with absolutely no impact on the quality of the care we provide.

I can reassure you, the patient—the consumer of our product—, that most cardiologists do not approach your procedure with the type of disregard that Dr. Teirstein exhibits.  We care how much resource we use.  We care what kind of bill you get from your hospitalization.  We care about your finances and the financial well being of our country.   Trust me—Dr. Teirstein is not the norm.  He’s just a spoiled kid we wish we hadn’t brought to dinner.

I came across an interesting article in Time magazine this last week.  Apparently a company has hit upon a way to better track the use of sponges in surgical procedures.  As you may know doctors use sponges (ranging from small gauze pads to cloth towels the size of dishrags) to soak up blood and other fluids in small and large body cavities.  I’m no surgeon, but I recall from my medical school surgery rotations the scrub nurse laying out dozens of used, bloodied rags on the ground so that she could keep close count of them.  At the beginning and end of each surgery the staff members are required to count the sponges to insure that none are left inside the patient after the incision is closed.  Apparently this is a relatively rare occurrence, but since hospital use hundreds of thousands of sponges each year even rare events can stack up.

There’s actually a medical term for this problem: gossypiboma (seriously—look it up).  The misplaced sponge problem occurs about 3,000 to 5,000 times yearly in the U.S.  This seems like a lot, but when you take into consideration that over 30 million major surgeries are done annually, retained sponges complicate surgeries in less than 2 one-hundredths of a percent of cases.  In other words, the surgical staff accurately accounts for the sponge number more than 99.98% of the time.

Now back to the article I read.  The company ClearCount has devised a way to insert a small electronic chip into each sponge and employ radio frequency technology to track sponges as they enter and exit the surgical field.  They claim they can dramatically improve the accuracy of sponge counts and decrease the rate of gossypiboma (they never actually used that term, but I like it so much I wanted to repeat it).

Currently the price tag for a couple packs of sponges is a drop in the bucket of the entire surgery bill.  This new technology, as you can imagine, would dramatically increase the amount paid out for an otherwise low-cost item—the sponges themselves are pricey, as are the devices that do the actually counting, at $15,000 a pop.  The upside is that they can prevent the nasty side effects that go along with unwanted surgical souvenirs.

Now don’t get me wrong.  I’m all for cutting the rate of medical mistakes and this sounds like a very reliable way to decrease a relatively rare but potentially disastrous problem.  My concern is with the with the cost-benefit ratio.

This whole issue reminds me of a doctor I knew while I was in residency.  He was a novice cyclist with a healthy reserve of disposable income who bought a high-end road bike for a few thousand dollars and began entering local road races.  After each race he took his bike back to the shop to have various stock parts—cranks, stem, forks—replaced by lighter, but much more expensive, titanium and carbon-fiber parts.  This seemingly lavish behavior is not uncommon in the biking world—as the weight of the bike drops, your speed (theoretically) improves, so you change out a $30 part for a $100 upgrade and shave a couple ounces off.  Ultimately you reach a point where it costs hundreds of dollars to subtract each additional gram of bicycle weight.  This is what they call the law of diminishing returns.

But while the value of this doctor’s bike rose to stratospheric levels his performance didn’t seem to budge much.  The problem didn’t lie in the weight of his titanium seat post but in the weight of his seat.  You see, he was carrying about 35 pounds of extra flab around his midsection—thousands of grams of excess weight that could come off for free if he were to simply eat less and ride more.

This is how I look at some health care costs.  The company ClearCount wants to sell us a system that potentially costs the economy a hundred million extra dollars year (for the sponges alone—this doesn’t take into account the equipment cost), with the promise that we can improve our rate of gossypiboma-free surgery from 99.98% to 99.99%.

If we lived in a world with unlimited resources I would be in favor of spending exponentially more for improvements that offer an exponentially smaller impact.  To the contrary, President Obama has correctly stated that tackling the spiraling costs of is our most important domestic challenge and that we need to make serious sacrifices in order to create a system of universal coverage.  So the question arises: What are the cheap, easy changes we can make that will have a big impact on costs and shouldn’t we address these before we start splurging on expensive technologies that offer only minimal incremental benefit?

I guess I shouldn’t single out ClearCount and their product as examples of medical dollars poorly spent—there are untold other areas where money should be redirected—but theirs seems like a pretty extreme example of diminishing returns in an environment where every single dollar is going to have to be counted as closely as sponges.