When Incentives Become Instinct

Medicine trains us to recognize pathology. It rarely trains us to recognize the incentives shaping our own behavior.

This is a story about that recognition.

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“You have a few options,” I say, glancing at the familiar insurer section in the EMR, right below the patient’s name and date of birth.

My eyes connect with the patient’s again. “One option is to open your sinuses in the operating room. The other is to open them right here in the office.”

“Is there a difference?” she asks.

“The process is different, but the final result is the same. I can do everything I do in the operating room right here in the office.”

I pause, looking at her expectantly. Her silence is a signal for me to jump into my spiel.

“The sinuses are empty spaces within your head. You have four on the right and four on the left…” I signal to my forehead and cheeks, “your CT scan tells me that all of your sinuses are blocked and full of mucus.”

She crinkles her nose. “Blech. That’s so gross.”

I smile and walk over to the diagram of the face and sinuses on the wall. “The sinuses have tiny drainage holes–here–and when the lining of those drainage holes swell, that blocks the ability of the sinus to drain. If we proceed with an office-based procedure, I use a special kind of balloon to dilate the blocked exits. It’s something we call balloon sinuplasty.”

“Wait, is that like a Roto-Rooter?”

“Exactly,” I respond with a chuckle. “It’s like unclogging a pipe; I’m a glorified plumber.”

Her eyes widen with amusement. “And how long does that last?”

“Ideally, forever. I’ve done almost two-hundred balloon sinuplasty procedures here in the office, and of those, eleven patients ended up in the operating room needing revision sinus surgery. Yours is a problem of blocked exits and mucus trapping, which bodes very well for success.”

“And I’m awake for it?”

“Yes.”

She looks up and sharply inhales. “Does it hurt?”

“Patients tolerate it really well,” I respond automatically, sitting down on my stool. “You’ll eat like normal the morning of the procedure. I’ll prescribe you a medication that will relax you and make you forget a lot of what’s happening. You won’t be able to drive, so someone will need to drive you…”

“My husband can take me,” she adds.

“Great.”

The patient leans back. “How do you numb me up, exactly?”

“With a nasal spray,” I reply, “Then medicated cotton balls and a series of injections.”

The patient shudders. “Injections in my nose?”

“I know it sounds bad, but it’s not,” I say with a smile, my voice calm and steady. “With all the medication and numbing, most people barely flinch. You’ll hear gross crunching when I do the procedure, but it’s pretty painless. It’s just weird.”

The patient nods in understanding. “It doesn’t sound that bad.”

“It really isn’t,” I add enthusiastically.

“And the other option is to do it in the operating room?”

“Yes,” I start, subconsciously lowering my voice, “an anesthesiologist would give you medication to put you to sleep, then they’d place a breathing tube to protect your airway, and I would do the same thing in the operating room, just with different tools. And the added risk of anesthesia, of course.”

“I did get nauseous when I had my gallbladder surgery, so…”

I chime in, “Then you’d be a great candidate for an office procedure.”

“I’m leaning toward the balloon thing,” she agrees.

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A woman in black shorts and a hot pink tank top that reads “Moms Kick Butt” saunters past me toward the back of the gym. A moment later, I hear the clatter of a locker door and the soft shuffle of clothes being pulled out. Sitting crosslegged on the bench, I take my ear buds out of their case and place them in my ears. 

I’ll find a good playlist, I think.

I unlock my phone and glance at the time. 

3:25. I don’t have to get the kids until 5:30.

My index finger moves instinctively, selecting the blue square with the white “f” before I even register the impulse. I tap groups and scroll over to “Women in Otolaryngology”. The post at the top reads: Office balloon sinuplasty… why?

“Hmmm,” I say out loud to calm myself. I feel my heart drop out of my chest, but keep reading.

I'm seeing more and more patients who were told they were getting “minimally invasive sinus surgery” only to find out they had an in-office balloon and now need actual intervention.

How is this still happening?

Does anyone here still feel good offering these?

I jump to the comments.

Ugh, brings back memories of one of my residency attendings who basically turned balloons into a business model. If a patient had a nose, he’d balloon it. It was all about reimbursement. He used his balloon money to hire some famous singer to perform at his birthday party. So gross.

A guy that works in my community is notorious for ballooning everyone with a pulse.

I get even more uncomfortable with the folks who cherry-pick patients based on insurance coverage. If you’re only offering a procedure when it pays well, it’s not evidence-based. It’s predatory.

I start biting my nails and feel sweat gathering beneath the band of my sports bra before sliding down my ribs. I continue scrolling.

We had a partner who literally sorted his schedule by insurance type and magically, the “good” plans always got balloons. 

My mind snaps back to a different patient I’d seen in clinic this morning. I’d noticed his insurance and made a mental note that reimbursement was poor for balloon sinuplasty – it was just a reflex. He needed sinus work, and I steered him straight to the OR for surgery. He scheduled without hesitation.

A wave of shame washes over me. Oh my god, I’m one of them.

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That moment was a wake-up call. I went from thinking I was “killing it” in private practice to feeling disgusted with myself. I had been practicing with a reimbursement bias, without fully grasping how profoundly it was affecting my judgment. 

Sunshine laws require companies to disclose payments to physicians. The public can look up who received what, but there is no database that reveals how higher reimbursement subtly makes one option more attractive in a surgeon’s mind. There is no report on subconscious patterns. 

Physicians are fiduciaries. We are taught that our obligation is singular: act in the patient’s best interest. But when we are incentivized—by dollars or by RVUs—we intervene in ways to maximize our compensation. The question is, how often do we admit that to ourselves? We are trained to recognize disease, not how to recognize distortion in ourselves. I knew how to identify obstruction on imaging, but I was completely unskilled at detecting the invisible pressures shaping my own judgment.

Every specialty has a gray zone: a place where intervention is reasonable, but not necessary. And the more lucrative the intervention, the harder it becomes to see where reason ends and revenue begins.

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