Doctor Disillusion, Primary Care, Retail Medicine, and the Future of Hospitals

A member of the old guard of physicians believes that hospitals don’t care about patient safety, medical education, or nurses, and that CPOE won’t prevent adverse drug and wrong-patient events. His “real job,” he wrote last September in the Cleveland Clinic Journal of Medicine, “is not to diagnose, treat, and teach about diseases anymore [but] to do everything in my power to keep my patients out of the medical center. I’m not a hospital guy anymore.”

Also conspiring to keep patients out of the hospital are the dwindling ranks of primary care doctors. “In 1949,” wrote Joe Flower in Hospital & Health Networks Online, “59 percent of all physicians were in primary care. By 1970, that had dropped to 43 percent, by 1995 to 37 percent. And the slide is continuing: In 2000, only 14 percent of all med school grads were headed for family practice. By 2005 it was down to 8 percent, and more than half of all family practice residencies were going unfilled.” And it will get even worse as baby-boomer primary care doctors retire.

He cites credible sources as saying that the combination of these retirements and population aging will mean a need for 40 percent more primary care physicians by 2020, yet they are demonstrably in decline. This, according to Flower, is a problem for hospitals because hospitals depend on primary caregivers to send patients to them. Furthermore, doctors “are increasingly seeing less need to admit and little need to visit their patients in the hospital, much less take call and serve as staff.” A hospital must have patients (though we know of one amusing exception). For most hospitals, the patient supply chain is tenuous at best.

The solution according to Flower is for hospitals to take control of primary care—to buy practices, hire primary care doctors, and establish clinics, “spreading the economic risk across their whole catch basin.” They should establish competing retail and urgent practices or provide backup, IT, lab and imaging services to those that exist, and make it easy for them to refer patients.

Otherwise, he predicts, the explosive growth of retail clinics will exacerbate the problem of dwindling referrals, massively substituting nurses and nurse practitioners (themselves already in short supply) for physicians, in a structure that is isolated from the traditional healthcare system. In metro Detroit alone, the Detroit Free Press reported in January that 16 MinuteClinics and a Little Clinic had opened since 2006. MinuteClinics are JCAHO-accredited, and Little Clinic is applying for accreditation. (However, the Free Press noted without comment that three companies trying to operate clinics inside Meijer stores had closed.)

Some physicians are fighting back. In metro Detroit, for example, several physician-owned and –operated clinic chains have sprung up. They charge flat rates of between $49.95 and $80. One offers unlimited visits for $49 a month. They target the swelling number of underserved uninsured patients, and compete with the retail clinics being established by Wal-Mart, CVS, and other major retail and pharmacy chains, wrote Christina Rogers in the Detroit News. But unlike the nurse-practitioner-staffed retail clinic chains, physician-owned clinics offer in-house X-rays ($25 at one clinic), blood tests, and prescriptions and refills.The uninsured get to see a doctor conveniently and inexpensively, while the doctors get “a steady source of income that doesn’t come with the hassles of filing for insurance reimbursement,” she claims. However, “Flat-rates can only survive if they are complemented with a mix of insured patients,” said a partner in one physician-owned chain whose clinics see almost twice the volume of patients as a traditional doctor’s office — about 30 to 60 visits a day.

Convenience is clearly the critical factor. A comparative analysis of visits to retail clinics and visits to primary care physician offices and hospital emergency departments concluded that retail clinics appear to attract patients who seldom go to a primary care doctor and for whom convenience is more important than a relationship with a doctor.

Short of establishing new clinics, one way doctors can provide convenience and compete with retail clinics is simply by extending their office hours and working weekends. And technology can help: Ruth Baum Bigus in the Kansas City Star reports that one practice has installed an ATM-style dispenser of prescription medications called InstyMeds. Patients enter a prescription code, pay with cash or a credit card, and receive one of 100 medications stored in the machine—24/7.

One medical school dean told Bigus that extended hours were a necessity “for any practice to survive and thrive,” yet, Bigus noted, that school’s own physician-run multispecialty clinic had itself not yet adopted extended hours.

An American Academy of Family Physicians official opined that family practice groups will turn to technology— telephone, e-mail, videoconferencing and interactive computer programs—to “facilitate access,” which we take to mean “provide convenience.”

Simply obstructing the spread of retail clinics might not work. Massachusetts saw its first two retail clinics (MinuteClinics) last October despite a protracted fight by the Massachusetts Medical Society to prevent the granting of a license by the state health department. MinuteClinic won in part by agreeing to send patient visit records to the patients’ primary care doctors and giving a list of doctors to customers who don’t have one.

Medical Tourism

As we are often at pains to point out (most recently, here) medical tourism is another major development that is going to contribute to the demise of hospitals not paying attention. In January, some employers offering WellPoint (the largest US health insurer) coverage to their employees began offering them substantial discounts if they choose to have surgery at Joint Commission International-accredited hospitals in India.

Medical tourism has been uncontroversial so far because it has occupied a “limited niche” of un- or under-insured people making private arrangements, sometimes with the help of middlemen, wrote Robert Wachter in the Health Care Blog. But with “every healthcare insurer and large employer … now actively scrutinizing the concept,” that could change.

Issues that could arise as medical tourism grows are:

• Coercion. No-one will be forced to go abroad, but the financial incentives to go—or the disincentives to stay—may amount to coercion.

• Union dilemma. Unions may have to choose between preserving jobs and enhancing benefits versus solidarity with their brothers and sister in the medical, nursing, and allied trades unions.

• Professional hit. US providers, particularly cardiac, plastic, and orthopedic surgeons, may lose their livelihoods, or at least much of their very high incomes.

• Fixing mistakes. US doctors may be reluctant, for all sorts of reasons, some better than others, to treat patients who return from surgery abroad with complications.

• Enrolment in med school. Students eyeing a career in medicine will not be happy at the prospect of their decade or so of education and training and debt becoming devalued by foreign competition.

Wachter believes, as do we, that medical tourism and controversy surrounding it will continue to grow. But that  might be no bad thing if “flattening our world improves value …, either through the new internationalized care or by goosing our own system into action.” US automakers, he notes, answered their wake-up call “too late to save their hides.”

US providers, and hospitals in particular: Take heed.

Though you wouldn’t know it by looking at current spending, hospitals are actually fading away, according to consulting firm Sg2, as healthcare shifts to the ambulatory setting (and/or, we would add, abroad.) To succeed in the new environment, Sg2 says hospitals must align with physicians, improve their performance, and build IT infrastructure in order to become “part of a dynamic system of care with multiple patient touch points.” And they should start preparing now.

We agree, though we still see a continuing role for hospitals in trauma, critical care, and major bionic and regenerative surgical restorative and cosmetic procedures.

Scientific Standard of Practice

Accidents, errors, and other mishaps in UK hospitals affect as many as one in 10 inpatients, yet the National Health Service along with physician culture and training conspire against known solutions such as pre-/post-surgical OR team briefings and debriefings, according to a BBC report. One doctor at a hospital where such briefings were tried reported a reduction of between 30-50 percent in incidents during the trial period. Unfortunately, the report says, their training instills into physicians the belief that they are in charge and know better than anyone else in the OR.

The conceit of infallible physician judgment has been taken to task also by Lincoln and Lawrence L. Weed in the Health Care Blog. They contend (as Dr. Shanley and I have done elsewhere) that despite its obvious basis in science, medicine is still practiced as an art. Evidence-based medicine and the effective application of health information technology are crippled as a result.

Scientific standards and tools for patient care have been developed and are used by a few practitioners, but are largely absent from mainstream medical practice and medical education. “Indeed, their absence is not even recognized, because they are incompatible with behaviors and beliefs instilled by medical education.” A scientific approach would (1) ascertain what data medical science has determined will best lead to a diagnosis, (2) collect that data, and (3) match the data objectively with all available relevant medical science. In contrast, the “clinical judgment” approach amounts to a best guess based on the physician’s limited personal knowledge of medical science.

Because of the volume and complexity of scientific information, the scientific approach is possible only with software tools. Such tools have been available to, but ignored by, mainstream medicine for half a century.

Among the more thoughtful reader responses to the Weeds’ article were these:

• Con: I toyed a little with Dxplain [a decade-old decision-support system], and I am highly skeptical that it comes close to the maligned “clinical judgment” of a trained specialty physician.

• Pro: Anti-scientific attitudes prevent medicine from taking advantage of scientific knowledge and information technology. We will not make any progress until these attitudes change and I fear that it will literally not take place until the current generation of practitioners retires. Unfortunately, their replacements are not being trained in the scientific practice of medicine either.

• Pro: [A] recent report by the National Research Council of the National Academies … concluded that a serious gap in health information technology (HIT) today is patient-centered cognitive support. According to the report, we need: “computer-based tools [that] examine raw data relevant to a specific patient and suggest their clinical implications given the context of the models and abstractions. Computers can then provide decision support—that is, tools that help clinicians decide on a course of action in response to an understanding of the patient’s status. At any time, clinicians have the ability to access the raw data as needed if they wish to explore the presented interpretations and abstractions in greater depth…The decision support systems would explicitly incorporate patient utilities, values, and resource constraints…They would support holistic plans and would allow users to simulate interventions on the virtual patient before doing them for real.

• Pro: I don’t think the mainstream of the medical and surgical professions is listening. It’s going to take a significant shock to the system to put these reforms into place.

• Con: What spectacular arrogance.

Weed and Weed are not alone: Some external heavyweights have joined the debate, too. In a New York Times article last October, former US House speaker Newt Gingrich, senator John Kerry, and baseball big-wig Billy Beane wrote that most care is based on a doctor’s informed opinion, personal observation, or tradition; i.e., on clinical judgment. They called for a data-driven information revolution in healthcare. “Remarkably,” they wrote, “a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures.”

The use of data would complement rather than replace clinical judgment and result in “the best quality care at the lowest possible cost.” They recommended creation of a joint public-private sector institute for evidence-based medicine to conduct studies and systematically review the existing medical literature, and financial incentives for doctors who follow the recommended clinical best practices.

There is nothing new or revolutionary in their analysis or their proposals, but it will certainly amount to a revolution when medicine becomes truly data-driven. They fail to mention perhaps the key change agent: Medical school, which must undergo a revolution of its own first.

Other News

Simulators vs. Animals

In January, the University of Michigan came under fire from the Physicians Committee for Responsible Medicine (PCRM) for using healthy, anesthetized dogs purchased from animal shelters for surgical practice. “The procedures so badly damage the animals that they must be euthanized,” reported Megha Satyanarayana in the Detroit Free Press.

Most schools use human cadavers or mannequins, but the University of Michigan is among a handful that still uses dogs, goats, or pigs, perhaps because, as an American College of Surgeons official put it: “The experiences are not the same. It’s living versus dead tissue [and] A mannequin doesn’t respond to distress or show a favorable outcome like living tissue.” But other experts disagree, on the ground that mannequins are more realistically human than an animal, whose shape, angles, and other important surgical criteria can be quite different. Detroit Receiving Hospital* dropped animals in favor of TraumaMan simulators for its trauma course, and PCRM’s senior medical and research adviser quotes research suggesting that trainees prefer mannequins and that there is a high rate of error in transferring skills from animal models to humans in practice.

Surgical students at the University of Washington Institute for Simulation and Interprofessional Studies have access to state of the art simulation technologies including virtual reality, lifelike mannequins and artificial body parts, and a full-scale operating room. “UW,” writes Tom Paulson in the Seattle Post-Intelligencer, is increasingly moving toward requiring all medical, nursing, pharmacology students and others to master such simulated realities before ever touching a live human being.” Simulation, he adds, is no longer just about practicing surgical procedures. It’s also about practicing teamwork in the OR. The institute has received grants totaling over US$5 million toward the goal of using simulation to teach teamwork.

“This is going to change the way medical education is done,” said the institute’s head.

We think so too.

*[Disclosure: Detroit Receiving is a hospital of the Detroit Medical Center, which sponsors Health Futures Digest.]

Turf Wars: Cardiology on the Brain

Last year the Society for Cardiovascular Angiography and Interventions (SCAI) launched a training program to teach endovascular stroke procedures to interventional cardiologists who have previously mastered coronary and carotid stenting (Advisory Board Horizon Scan Monthly, July 9, 2008. Subscription required.) At the time, only neurointerventionalists in the US could perform mechanical clot removal from the brain, and there are only about 700 of them.

Critics note that endovascular therapy is only one component of acute stroke care. Also needed for a stroke unit are a staff neurosurgeon, stroke-trained nurses, advanced imaging services (including CT, MRI and biplane angiography), and coordination with EMS, discharge planners for inpatient rehabilitation, ED physicians, neurologists, interventionalists, and radiology staff.

Interventional cardiologists now perform work once considered the preserve of cardiac, vascular, and neurology specialists. SCAI envisions interventional stroke training across multiple specialties including interventional radiologists, and seeks to move away from the arbitrary designation of specialties and toward a more general, multi-disciplinary category of stroke care.

Home Medical Monitoring

University of Missouri researchers are using technology plus nursing support services from the Sinclair School of Nursing to monitor the health of older adults living at home. The technologies include motion sensor networks that detect changes in behavior and physical activity, including walking and sleeping patterns. Early identification of these changes can prompt interventions to delay or prevent falls and other serious health events and thereby avoid hospitalization and relocation.

So far, more than two years’-worth of continuous data collected from motion and bed sensors has helped identify predictive patterns not detected by traditional healthcare assessments. The end goal is a system that will automatically notify caregivers of changes in residents’ conditions and thereby enable early intervention.

Cellphones in Healthcare

The most modern cellphones and PDAs such as the Apple iPod Touch are becoming “as handy as stethoscopes,” according to an article in the Sacramento Bee. Some enable clinicians to view x-rays, images of wounds, and scan pharmaceutical libraries. Increasingly, students entering med school already own them, and medical schools are starting to require that students have them. One even distributes free iPod Touches to all students.

However, one commentator felt the healthcare industry had “not even scratched the surface” of uses for the technology, such as remote monitoring of a patient’s pulse and heart rhythms or even pregnancy contractions. Over 170 iPhone/iPod Touch professional medical applications were available as of end 2008, yet only 54 percent of physicians owned such modern devices.

HMSA Covers Televisits

Hawaii Medical Service Association, the state’s Blue Cross-Blue Shield licensee, has launched a Web-based televisit service developed by American Well. The service provides an immediate 10-minute online videoconference or text chat with a doctor, who can file prescriptions and view the patient’s medical history via Microsoft’s HealthVault and Aetna’s ActiveHealth Management (which scans patients’ medical history for gaps in their care and alerts doctors during the televisit.)

HMSA members pay $10 to use the service. Uninsured patients pay $45. The New York Times article that reported this development was unclear as to whether those are annual or monthly fees.

Laser Suturing

Surgical lasers and a light-activated dye can get a surgical or other wound to, in effect, “nanosuture” itself, eliminating one of the most challenging surgical skills—mastery of the needle and thread. The method entails painting two sides of the wound with a particular dye, then shining a laser on it. The molecules (hence “nano”suture) of dye and collagen at the edges of the wound then just knit themselves together.

The benefits include faster procedures, less scarring, and possibly fewer infections since wounds are completely sealed, leaving no openings for bacteria to penetrate. The downsides are the high cost of the dye and laser relative to needle and thread, and the fact that the method works only where light will penetrate, so it “could never replace subcutaneous sutures or be effective on dark or opaque tissue like liver and bone,” according to a Technology Review article.

In a clinical trial, 31 patients with skin cancers and suspicious moles “had their three-to-five-centimeter excisions closed with sutures on one side and photo­chemical tissue bonding on the other,” the article says, somewhat unclearly and inconclusively. Animal experiments have already shown the technique to be useful in nerve, eye, and blood vessel surgeries, among others.

A startup firm will commercialize the technology once it receives FDA approval.