THE WALL STREET JOURNAL. Wednesday, September 11, 2019 |A
BYJOHNJURGENSEN
NOW THATunnecessary heart-
stent procedures happen signifi-
cantly less often, doctors are flag-
ging a new area of concern:
unnecessary leg stents.
Some physicians are stenting leg
arteries and removing plaque at
alarming rates, these doctors say.
The often-avoidable procedures
could put patients at risk of compli-
cations and worsening disease.
Johns Hopkins researchers pub-
lished a study in June in the Jour-
nal of Vascular Surgery analyzing
national data from the Centers for
Medicare and Medicaid Services
(CMS), the federal agency that ad-
ministers the Medicare program.
The research identified 320 physi-
cians whose rates for conducting
such procedures in patients newly
diagnosed with leg pain were 14%
or higher. The mean rate of all
5,664 physicians was 3.5%.
“We are very concerned about
these outlier physicians and the
harm they may be inflicting on pa-
tients,” wrote Marty Makary, a
professor of surgery at Johns Hop-
kins University School of Medicine,
and Caitlin Hicks, an assistant pro-
fessor there, in a letter sent to
CMS and the Society for Vascular
Surgery this summer. “Some may
represent a serious and immediate
threat to public safety.”
Dr. Hicks says performing un-
necessary leg procedures like
stenting can make vascular disease
worse, creating blockage in narrow
arteries or causing an artery to
rupture. She says patients with
Pranay Ramdev, a vascular sur-
geon in Florida, is among the doc-
tors the researchers found to have
a 100% atherectomy rate. He says
atherectomy as a first-line treat-
ment benefits his patients. He de-
scribes them as mostly elderly,
with severely blocked arteries or
with ulcers or gangrene, and pos-
sibly at risk of limb loss due to
poor blood flow. Dr. Ramdev
agrees that some doctors perform
unnecessary peripheral vascular
procedures. But he calls claims
that atherectomy isn’t effective
“utter nonsense.”
Other doctors say that the vol-
ume of these procedures is an in-
herent problem, as most people
with these conditions can manage
them with exercise and medication.
Sridhar Chatrathi, an interventional
cardiologist in Greenbelt, Md.,
raised the problem of unnecessary
leg procedures and church health-
fair screenings to Dr. Makary.
Dr. Chatrathi says he knows of
at least six outpatient vascular
labs in his area that do peripheral
vascular interventions like stent-
ing. But he says most leg pain isn’t
related to vascular disease. “When
you see this many labs in such a
small geographical area, you know
there’s something fishy,” he says.
SVS president Dr. Hodgson says
patients who make positive lifestyle
changes often never need a proce-
dure or can forestall getting one by
five to 10 years. “We like to start
that clock ticking as late in life as
possible,” he says.early leg pain have a 1% to 2% risk
of limb loss after five years. But
aggressive procedures increase
that risk to 5% to 10%.
Dr. Makary examines the prac-
tice of performing unnecessary
vascular procedures in a chapter
of his new book, “The Price We
Pay,” published
Tuesday. In it,
he describes
what seems to
be the “preda-
tory” practice of
some doctors
seeking out pa-
tients at health
screenings in
churches.
The doctor
adds that no one
without real leg
symptoms
should be
screened for
conditions in the
legs that lead to
stenting and bal-
looning, known
as peripheral
vascular interventions.
“Almost every 80-year-old in
the U.S. has plaque in their leg ar-
tery and there is no clinical signif-
icance unless you have symptoms,”
he says. “But some doctors will
balloon and stent any plaque.”
Kim Hodgson, president of the
Society for Vascular Surgery
(SVS), a professional association of
vascular medical professionals,
says the organization is concernedabout the overuse of procedures
highlighted in the letter. SVS
guidelines recommend peripheral
vascular interventions only after
patients who have leg pain when
they walk have failed medical and
exercise therapy and have life-
style-limiting symptoms.The letter also lists 10 doctors
paid by CMS who use atherectomy
as the first intervention for periph-
eral artery disease in 100% of pa-
tients. Atherectomy is a procedure
that many doctors say should be
used selectively, since there’s no
conclusive data to support its effec-
tiveness, Dr. Hicks says.
“Of course there are rare situa-
tions when you need to do this,
but to do it routinely is a clear-cut, egregious practice pattern,”
Dr. Makary says.
Dr. Hicks says the average rate
of atherectomy as a first option
was 55% among doctors paid by
CMS. There were 114 out of 1,
doctors with a 100% atherectomy
rate. The lack of data around the
procedure,
combined with
how much Med-
icaid reim-
burses for it,
make it “a
setup for over-
use,” she says.
Among vas-
cular surgeons
surveyed in
their registry,
the average
rate of atherec-
tomy is about
17%. “We re-
coiled when we
saw 100%, be-
cause it goes
against every-
thing we know,”
Dr. Hodgson
says.
CMS has several tools and pro-
grams to ensure that its providers
are providing high-quality care, ac-
cording to an agency statement.
The agency also sends comparative
billing reports to providers to allow
them to compare their billing pat-
terns on specific procedures to
peers to hold them accountable.
The agency didn’t say if it is exam-
ining the issues raised in the letter.TIM ROBINSONYOUR HEALTH| SUMATHI REDDY
Doctors Sound an Alarm Over Leg-Stent Surgery
B
ill Gates, one of the
first faces of the per-
sonal computer, has
seen several reboots
of his public image.
The Microsoft co-
founder became the whizkid of
software in the 1980s, and the per-
sonal-computing industry’s first
billionaire at age 31. In the ’90s, he
was accused of putting a strangle-
hold on the world’s computers and
his competition. Now, at age 63
and 19 years after stepping down
as Microsoft’s CEO, he’s known for
marshaling his massive wealth to
try to solve intractable problems
on a global level.
A new documentary series at-
tempts to reconcile the many fac-
ets of Mr. Gates. Directed by Davis
Guggenheim, “Inside Bill’s Brain:
Decoding Bill Gates,” is a three-
part profile premiering on Netflix
Sept. 20. Each episode connects
chapters in his personal history to
his current work with the Bill &
Melinda Gates Foundation, with a
focus on several philanthropy proj-
ects that have experienced chal-
lenges. The Gates foundation has
made more than $50 billion in to-
tal grant payments since the
founding of the first Gates family
philanthropy, originally named for
Mr. Gates’s father, in 1994.
Home movies capture the Seat-
tle upbringing of a willful, fiercely
intelligent boy in an episode that
also follows Mr. Gates’s quest to
curb deadly sanitation issues with
a new toilet design. His path from
high-school computer lab to Mi-
crosoft’s founding is juxtaposed in
episode two with the foundation’s
effort to wipe out polio. The third
episode explores Mr. Gates’s bruis-
ing battle with the U.S. govern-
ment during its antitrust suit
against Microsoft, and also docu-
ments his work with experts try-
ing to introduce a safer nuclear
power plant.
“He’s not just a giant brain. He
does have big passions, but he’s not
steered by emotions,” says series
director Mr. Guggenheim, known for
documentaries including “An Incon-
venient Truth,” “Waiting for ‘Super-
man’” and “He Named Me Malala.”
Mr. Gates spoke to the Journal.
Here are edited excerpts.
Did you enjoy the self reflection re-
quired for the documentary, or was
it a means to an end for your and
Melinda’s work with the foundation?
I got to talk to Warren [Buffett]
about how he thinks about things
and it was fun to hear Melinda talk
about how she sees my mind as
chaotic. Some family footage that I
had never seen before got pulled
out, and that was great. But polio
eradication, climate change, sanita-
tion, those are things I was en-
thused to talk about it. All the
problems I take on require a lot of
participation, whether it’s scien-
tists, or governments, or brilliant
people in the field. They won’t suc-
ceed unless you can talk to broad
audiences and shift perceptions.
It must be frustrating that these
epic projects often hang on human
factors that fly in the face of the
rational way that you think.
Eradicating polio depends on
stability in Afghanistan and the
political priority we get in Paki-
stan. Nigeria required a lot of su-
per intense work, particularly in
the northeast where Boko Haram
showed up. Any time you do a dis-
ease eradication you’ll end up in
the most unstable and difficult
places in the world. We didn’t re-
ally expect that. But you adjust
and focus in. That’s why you need
to build these teams with gigantic,
diverse skillsets. I’m good at think-
ing how the pieces fit together
conceptually but then there’s mas-
sive amounts of work and commu-
nication required.You were hailed as a tech wunder-
kind and then experienced a back-
lash against Microsoft. Is that simi-
lar to what’s happening for today’s
tech titans like Jeff Bezos or Mark
Zuckerberg?
As soon as tech became impor-
tant, with the personal computer
and the internet, there was cer-
tainly a duality where people were
saying, “Oh my God, this is bril-
liant stuff,” but they were also
looking at me, or other leaders in
the industry, and saying, “What
motivates their work? Do they un-
derstand the potential negative
side effects?” I’m sort of the
poster boy of that original duality.
By some measures I was extremelyscope of my life, I’m not somebody
who’s in a position to complain
about anything. Those aren’t my
favorite moments and I can still
explain to you why the govern-
ment was completely wrong, but
that’s really old news at this point.
For me personally, it did accelerate
my move into that next phase, two
to five years sooner, of shifting my
focus over to the foundation. So
explaining to people why that [the
lawsuit] wasn’t fair to me? I better
skip that part.You’ve recently been in the news
for another reason: You’re one of
many high-profile wealthy people
alleged to have had an association
with Jeffrey Epstein. Can you de-
scribe your relationship with him?
I met him. I didn’t have any
business relationship or friendship
with him. I didn’t go to New Mex-
ico or Florida or Palm Beach or
any of that. There were people
around him who were saying, hey,
if you want to raise money for
global health and get more philan-
thropy, he knows a lot of rich peo-
ple. Every meeting where I was
with him were meetings with men.
I was never at any parties or any-
thing like that. He never donated
any money to anything that I know
about.
[A New Yorker article published
after this interview took place re-
ported that Epstein directed a $
million donation by Mr. Gates to
MIT’s Media Lab. A representative
for Mr. Gates said in a statement,
“Although Epstein pursued Bill
Gates aggressively, any account of
a business partnership or personal
relationship between the two is
simply not true. And any claim
that Epstein directed any program-
matic or personal grantmaking for
Bill Gates is completely false.”]In the documentary you say, “It’s
not my goal to be inspiring.” Is that
a problem in our society: it’s not
enough to have a smart idea, you
have to inspire people with it too?
Some things, like eradicating
polio, are inherently inspiring.
People want some moral center, to
be involved in something bigger
than the size of their paycheck.
I’m lucky to work in a lot of
things like climate change or im-
proving urban slums that can
draw in a level of talent that the
economics wouldn’t command, but
a sense of purpose can. But I my-
self am not a preacher. I’ve
learned a little bit about public
speaking, and how to articulate
how to solve these problems over
time. I’ve gotten OK on that in a
certain sense. Steve Jobs was al-
ways more of a natural at that. He
could talk about what, in the case
of NeXT Computer [his follow-up
after being ousted from Apple],
was not that good of a machine,
yet mesmerize people to death if
they happened to be in the audito-
rium. I wish I could be as magical
because I have causes that are in
some ways more impactful and I
need to make sure they don’t get
ignored. And particularly as coun-
tries are turning inward, we
have a huge challenge to maintain
a commitment to these global
issues.popular and by some measures I
was extremely—you know, people
worried what Microsoft was up to.
What’s happening now is more of
a mainstream thing. The concerns
are legitimate, and they’re touch-
ing more areas of life now.Was it painful to revisit the foot-
age from your deposition during
the antitrust trial against Micro-
soft?
It’s all online. My son watched
every minute and said, “Hey Dad,
don’tyou think you could have
done a better job?” Yeah, I guess I
could have. Look, there were some
elements of that whole thing that I
consider unfair, but if you take theClockwise from top: ‘Inside Bill’s
Brain: Decoding Bill Gates’ premieres
Sept. 20; in Nigeria as part of efforts
to eradicate polio; back in 1985.LIFE & ARTS
CLOCKWISE FROM TOP: ASSOCIATED PRESS; BILL & MELINDA GATES FOUNDATION; GETTY IMAGESIn Bill Gates’s Mind,
A Life of Processing
A new documentary profiles the titan-turned-philanthropist