Category: Physicians

Just imagine what HDTV could bring

published date
February 2nd, 2007 by

It’s a good thing doctors in Ireland have time to watch television:

An Irish doctor, however, has [performed a diagnosis] while watching television by spotting that a government minister had a tumor in his cheek.

The… surgeon…was at home with his doctor wife before Christmas. They were following a current affairs program…in which… the overseas aid minister… was being interviewed.

“If you look very carefully,” the surgeon reportedly told his wife, “his face moves when he talks but the lump doesn’t.”

The next day he called the minister’s office and left a message. [The minister]… phoned back and the surgeon told him about his fears, advising him to see a head and neck specialist at a Dublin hospital immediately.

Doctors… carried out tests and quickly found a tumor on his salivary glands. It was removed during an operation last month…

[The minister] told the Irish Independent newspaper: “I’m a very lucky man. The consultant wouldn’t have seen the left side of my face but for the fact that I was sitting at the left of the group in the television studio.

Thanks to Mickey for spotting this one.

Another reason to avoid the ER if you possibly can

published date
January 31st, 2007 by

Here’s one more reason to stay away from the emergency room: there might not find an experienced specialist when you get there:

Specialists such as neurosurgeons and orthopedists more often are saying no to a rising number of calls from emergency rooms and there doesn’t seem to be a simple way to get them to answer again, reports Josh Fischman. With ER visits up sharply over the past decade, the specialists say they are expected to do too much while on call and the risk of being sued has increased. At the same time, free-standing surgical clinics mean specialists can increasingly do without the operating rooms that hospitals have typically offered in exchange for going on call. Three-quarters of ERs reported a shortage of specialists, according to a 2006 survey by the American College of Emergency Physicians.

Contrast the madness of trying to get off-hours care in the US with the common sense approach of the UK’s National Health Service. While on a visit to a business in Milton Keynes in the UK, I picked up a brief brochure in a business’s reception area. It laid out the services provided by the local “Walk-in Centre,” describing the minor ailments (such as coughs, colds, stomach ache, vomiting, rashes) and minor injuries (such as minor head injuries, sprains and strains to limbs, recent eye injury) that are handled there with no appointment.

The brochure also specifies services not provided, which include x-ray’s, Rx renewals, and immunizations.

The facility is open 7 am to 10 pm every day, including weekends and holidays. I’m sure it’s not perfect but it sounds a lot better than a trip to the ER in the US. Its existence must also help the ERs run smoother.

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.