Perhaps doctors should be more like the President.
After all, we also carry the ultimate responsibility for our constituents, even though we, too, have team members who do part of that work.
The way I understand things to work at the White House, those other team members collect, review and prioritize the information the President needs in order to manage his, and all our, business.
That is how things used to work in medicine, too, before computerization revolutionized our workflows: Nurses, medical assistants or secretaries would open the mail, gather the faxes, look over the lab and X-ray reports and put them on physicians’ desks in a certain order. Highly abnormal or time-sensitive information would be prioritized over routine “signature-needed” forms, and in my case, essentially normal reports on patients already scheduled to be seen within a few days wouldn’t even reach my eyes until the patient appointment.
Computers changed all that.
Now, most of the information goes straight to the doctors’ inboxes, unseen by other human eyes in the office. This is said to be faster. It is, to a degree, in the sense that the information leaves the laboratory or the X-ray department faster via their Internet connected computers. But in the typical medical office, we have now turned decision making doctors into frontline mail sorters and de facto bottlenecks of routine information.
Dr. Melos is a gastroenterologist in solo practice in a medium-sized Midwestern city. One day she hears a knock on her door. When she answers, she finds two representatives of Athenian Health System, who request a few minutes of her time. She invites them to take a seat in her office.
After exchanging pleasantries, the visitors get down to business. They extend Dr. Melos an offer to join the ranks of Athenian’s employed physicians. If she declines, they say, they will hire their own gastroenterologist, whose practice will grow rapidly on referrals from their large network.
The representatives of the health system are remarkably candid. “We will not take up your time with arguments about the appropriateness of what we are doing. What we have here is a large imbalance of power, and as a business matter, you really have no choice.”
Dr. Melos replies that she has always worked amicably with Athenian Health, using many of its diagnostic testing services and admitting her patients to its facilities, so the health system has no need to deliver such an ultimatum.
The representatives respond that, if they allowed Dr. Melos to maintain her practice in the form she is accustomed to, it would make Athenian Health, which is seeking to consolidate its market position in the area, look weak.
Although you may not realize it, your doctor is a monopoly. Yes, you can see someone else, but not without difficulty. And if you wanted a second opinion, how far would you go? In part, through insurance coverage, in part based on a desire for convenience, healthcare is generally a local monopoly. However, that may be about to change.
I’m a radiologist, an expert in medical imaging. When I started my career in 1997, I’d show up for work and it was just me and my films. The exams presented to me were a mix of imaging- CT, MRI, ultrasound, plain X-Rays- all captured, presented and stored on film. By 2000, the film was gone. Just about everything I did was done on a computer.
I was an early proponent for this technology (also know as PACS for Picture Archiving and Communications Systems). It allowed my group to work faster and smarter. However through a series of steps (consolidation, specialization and finally commoditization/globalization) technology broke up the local monopoly many radiology groups enjoyed. Similar to Instagram, PACS allowed medical images to be seen instantly by anyone anywhere. And now, based on improvements in technology, I’m expecting similar changes for the rest of healthcare.
Tele-radiology first emerged in hospitals when computers began to be used to optimize the daily workload. At the beginning of my career, several doctors divided work for the day into piles. Each person did his or her allotment with no real help from peers. With the transition to digital, work became a common pile that was shared among physicians in the same hospital. Faster doctors filled downtime gaps reading more cases, resulting in improved overall efficiency.
A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.
Treating the Well:
In my early career in Sweden, well child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.
These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.
With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.
Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.
Americans tend to like fast things: instant coffee, sports cars, and speed dating. Many share a fascination with record holders, such as the world’s fastest runner or texter. And increasingly, the same goes for medicine. The number of minute clinics is exploding. Some emergency rooms now post their current wait times on roadside billboards. And increasingly, physicians and other health professionals are under pressure to increase the speed at which they see patients.
A friend of mine, a family physician, was recently advised by the new manager of his practice that he will be penalized if he doesn’t increase the number of patients he sees each day in clinic. A thorough and compassionate physician who is known for the quality of the relationships he builds, he asked the man, “How am I supposed to work faster and still provide good care?” The practice manager thought for a moment and responded, “Why don’t you stop asking open-ended questions?”Continue reading…