Category: Physicians

Wanting more

published date
January 23rd, 2007 by

USA Today reports on a survey presented at the 2007 Gastrointestinal Cancers Symposium in Orlando, indicating that colorectal cancer patients are more willing to undergo repeat chemo than their doctors think. (Study: Doctors out of sync with cancer patients’ wishes)
Thirty-five percent of patients who’d had surgery and drugs already said they would have chemo again –with all its side effects and dangers– for a 1 percent reduction in the chance of relapse.  Less than 20 percent of physicians thought patients would agree to that deal. Drugmaker Sanofi-Aventis sponsored the survey, which is pretty a clear attempt to boost the use of drugs in hopeless situations, but it doesn’t mean the conclusions are wrong.

What could be the reason for the disconnect? Here are some possibilities:

  • The physicians interpreted the question literally while patients treated the 1 percent as “a low chance”
  • Patients who in healthier times would have been enthusiastic about “death with dignity” and foregoing excessive end-of-life care feel differently when doing nothing means inviting death. Meanwhile, oncologists, unfortunately, become used to seeing patients die and mentally write off patients who reach a certain stage
  • Oncologists are making judgments about what should happen rather than what patients want. This is based partly on a concern about expending huge resources when the outcomes are likely to be poor

A co-author notes another possibility: by definition the respondents already lived through chemo, so may be more positive about it than they otherwise would. I don’t really buy that explanation as the physicians should have adjusted their answers to reflect that fact.

The upside of dermatology delays

published date
January 15th, 2007 by

I posted last week on the delays Boston-area patients face in obtaining an appointment with a dermatologist. A superficial analysis suggests waits may be shorter in England.

A couple new points came up over the weekend:

The Globe published a response by Dr. Kathryn Bowers, President of the MA Academy of Dermatology. Her assessment wasn’t especially encouraging.

Most dermatologists train their office staff to identify patients with an urgent problem and attempt to fit them into the schedule as soon as possible. With doctors fully booked and, frequently, overbooked, this is often not feasible.

That’s a pretty sad admission. She also laments the “brain drain” of dermatologists who train in MA but then move elsewhere because of the difficult practice environment. I’m sympathetic to the challenges of practicing in MA, however the original article reported that Boston had the highest concentration of dermatologists of any city surveyed and the longest wait for an appointment. There must be other factors at work.
Meanwhile, a friend who is a dermatology resident in Boston confirmed the long waiting lists for an appointment at his institution, then told me:

It’s just as well that there’s a long wait. Someone who comes in with a rash is likely to be biopsied and end up with a scar. If they wait until an appointment is available the rash will probably have cleared up.

I told him that tolerating long waiting times was an awfully blunt approach to reducing unnecessary biopsies!

Commoditizing medicine

published date
January 11th, 2007 by

About five years ago I heard a fascinating talk by Harvard Business School Professor Clay Christensen that applied his well-know “innovator’s dilemma” reasoning to health care. In a nutshell the idea was that tertiary care centers should keep pushing the envelope on complex diagnoses and treatments and that over time diagnoses (though maybe not treatments) that had initially been considered complex and challenging should be systematized and therefore able to be carried out in less expensive settings by less expensive staff. The progression would go from academic medical center to community hospital to doctor’s office to retail clinic.

Clay was interviewed recently by the New York Times where he covered this ground again –lamenting the lack of progress- and also gave a clue as to why there is a shortage of convenient, low-cost diagnostic settings in Massachusetts.

We haven’t moved the health care profession into a world where nurses can provide diagnosis and care. Regulation is keeping the treatment in expensive hospitals when in fact much lower cost-delivery models are available…

In Massachusetts, nurses cannot write prescriptions. But in Minnesota, nurse practitioners can. So there has emerged in Minnesota a clinic called the MinuteClinic. These clinics operate in Target stores and CVS drugstores. They are staffed only by nurse practitioners. There’s a big sign on the door that says, “We treat these 16 rules-based disorders.” They include strep throat, pink eye, urinary tract infection, earaches and sinus infections.

These are things for which very unambiguous, “go, no-go” tests exist. You’re in and out in 15 minutes or it’s free, and it’s a $39 flat fee. These things are just booming because high-quality health care at that level is defined by convenience and accessibility. That’s a commoditization of the expertise. To have those same disorders treated in Massachusetts, you’ve got to go to a regular doctor, go through a long wait in their office, you go in and see the doctor for two minutes. He says, “You have an earache,” which you knew already, and then they charge you $150.

The whole interview is worth a read if you have the time.

What would Mickey do?

published date
January 10th, 2007 by

I’m taking a lot of flak –some deserved, most not– for yesterday’s post about my recent ER experience. When I have a moment I’ll address some of the comments. Meanwhile I asked Mickey (who’s a pediatrician) for his perspective. Here it is:

If you suspect a fracture outside of regular office hours and a doctor can’t rule it out over the phone you should go to an ER.  The solution is to make the ER faster.
When I was a resident our chief of service told us that families should not be kept up after 10 PM for scheduled admissions.  This is reasonable, but often 5 families come in for scheduled admissions after 6 PM and one resident can’t admit them all and take care of other priorities (such as the ER) without some people waiting a long time.  We decided amongst ourselves to create an overflow system in which we’d ask other residents on the team to stay late to do some of the admissions.  We needed to invoke this backup system only about 10% of the time, but it made things run more smoothly, and everyone got more sleep.  One of my most memorable nights on call began with my diagnosing a tumor that I noticed incidentally on a skull X-ray of a kid hit by a car while bicycling.  After that, one after another fascinating patient showed up, and each got great care because I got two other residents involved, people who are today among the top clinicians in the field.  We did a great job and no one waited around for 5 hours.
Hospitals should use similar backup systems to cope with peak load problems.  Ironically, measures taken to reduce doctors’ working hours have limited this flexibility by banning the others on the team from staying around.  Yet, using such a flexible system, everyone got more sleep.
Two of us from that memorable night wrote a letter to the NYT that appeared on June  8, 1987 arguing for such a backup system instead of heavy-handed regulation of doctors’ work hours.  The WSJ got me to expand this as an Op-Ed, run on 18 June.

This could have been done in 5 seconds but instead it took 5 hours

published date
January 9th, 2007 by

In case you don’t want to read this whole story, the moral is to try to get Dr. Robert Lindeman of Natick Pediatrics as your pediatrician if you live anywhere close to Natick, MA.

On December 23rd my preschooler came home from a play date with an aching, swollen foot. No one knew exactly what had happened except that he’d fallen. The next day he was still complaining about it and limping badly. (He’s not a big complainer or limper.) Normally I dread any interaction with the health care system so I would have ignored the injury and hoped it got better. But it was the day before Christmas and two days before we were leaving the country for a week.

We went to a family social function on the 24th. There were plenty of doctors there, including pediatricians. We asked one pediatrician (whom we don’t know well, but who practices pediatrics in the ER) to have a look. She took off my son’s shoe, had a look, and said she wasn’t sure. Her dad happened to be there, too. Turns out he is a pediatric orthopod! He had a look and said he couldn’t see through skin (since he lacks X-ray vision) and that he didn’t know if it was broken. Both told us that if it was a Jones fracture it could be serious and require treatment.

Then my wife saw our friend Dr. Lindeman, and asked him. He didn’t take off my son’s shoe or talk to him but said:

“It’s not broken. I can tell by the way he’s putting weight on it. Don’t worry about it.”

When we got home we called our pediatrician’s office. Our excellent pediatrician, Dr. Patricio Vives (old school, no website to link to), wasn’t around on Christmas Eve. The person covering for him said she couldn’t tell what was wrong and suggested we might want to go to the ER for an X-ray for “peace of mind.”

Oh no!

I took my son to Children’s Hospital and prepared for the worst. Good thing I did. Rather than complain about all the details I’ll just say it was a 5-hour experience, which included 4 hours and 45 minutes of waiting, 10 minutes in radiology, and 5 minutes with the doctor.

At one point (3 hours or so in) I was told –when I went to the desk and asked nicely– that we were next on our “track. ” (They have different tracks depending on whether orthopedic/surgical, medical, etc.). Around the 4 hour point, a staffer came out with a clipboard and after seeing our name toward the bottom of the list said, “you must have just come in.” I have to admit I almost lost my cool at that point. A few minutes later she came back and more or less admitted they’d lost track of us.

Who knows how long we would have waited after that. Luckily one of the physicians recognized our name and had us called in. It turned out to be another friend of ours. She saw my son, told us the radiology report was negative, and then had my son stand on his toes. As soon as he did that she concluded he was fine.

This experience was kind of embarrassing for me (and of course a big time waster). What I take away from it is to listen to advice from people you trust and don’t ask the opinion of people you don’t know well. If we hadn’t asked the first pediatrician and pediatric orthopod I just would have listened to Dr. Lindeman and not bothered to call the person covering for our pediatrician. (I’m pretty sure that if Dr. Vives had been around he would have steered us properly.) It also would have been nice to have a consumer-friendly decision support site, which could have taught me the tiptoes trick and saved my time and my health plan’s money.
So let me at least put in a proper plug for Dr. Lindeman (since I didn’t pay him for his quick assessment). He’s a first-rate office-based pediatrician with MD and PhD degrees from Columbia University. He’s board certified in pediatrics and pediatric pulmonology. He uses secure messaging with patients and families (though sadly he’s not using RelayHealth). He also handles call himself, rather than farming it out to someone else.
I don’t live anywhere near Natick, but anyone with kids who does should check his website or call his office at (508) 655-9699.

——

May 31, 2007

Yes, folks, I’m referring to the now-famous Flea blogger, so this post is getting a lot of hits today. I stand by my endorsement of Dr. Lindeman, which is based on ever-so-much-more than this particular anecdote. You’ll see a bunch of critical comments below from people who don’t have firsthand knowledge of this case and don’t know Dr. Lindeman. They’re off the mark IMHO.
David Williams