On March 21, 2006, in Practice
A New York Times analysis of factors driving a trend toward complementary or alternative medicine neglects to mention the one factor we would have thought to be obvious: Lack of affordable access to conventional medicine; not to mention access to “concierge” or “boutique” medicine, about which the ethical debate seems as intractable as the debate over embryonic stem cells.

On the other hand, the trend to retail “mini-clinics,” some staffed by doctors, others by nurses, has the potential to redress the access balance, up to a point. In one sense, they show that the free market can indeed fix things, though in the meantime a lot of people (who tend not to be wealthy free marketeers) will suffer, and even those with access to a mini-clinic will not find a Gamma Knife there to excise their brain tumor.

In this context it is encouraging that Harvard Medical School is making major changes to its curriculum in part to improve students’ understanding of the effects of social and economic conditions on disease, medical ethics and professionalism, and health policy.

Technological advances have eroded the fortunes of cardiac surgery and could well do the same for neurosurgery and orthopedic surgery. The problem for hospital CEOs is figuring out when the changes will happen to them, given not just changes in technology but also regional variations in markets and competition.

Another implication of the ongoing revolution in surgery is that eventually — say, In 15-20 years — we may have no surgeons left capable of performing open procedures.

Patient-Doctor Relationship

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US$27 billion spent annually on complementary or alternative medicine (CAM) is “The most telling evidence of Americans’ dissatisfaction with traditional health care,” writes Benedict carey in the New York Times . He points out that CAM users “do not appear to care” about the absence of scientific evidence behind it, the minimal training of CAM practitioners, or the profiteering of CAM potion peddlers. On the other hand, they do care about conventional medicine’s inadequacies “– a misdiagnosis, an intolerable drug, failed surgery, even a dismissive doctor… Haggles with insurance providers, conflicting findings from medical studies and news reports of drug makers’ covering up product side effects.”

In short, “Consumers generally know that quackery is widespread in alternative practices, that there is virtually no government oversight of so-called natural remedies and that some treatments, like enemas, can be dangerous.” And yet, more and more Americans turn to it.

Concierge Medicine

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“Typically,” writes Phil Galewitz in the Palm Beach Post , “a doctor switching his practice over to concierge medicine will reduce his patient load from 2,500 to about 600, which gives him the financial freedom to spend more time with each patient yet turns off some existing patients and smacks of greed to others.” One elderly Florida man who had to change family doctors after his own went concierge (a.k.a. “boutique”) and demanded an annual retainer described it as “extortion.” But happier (and probably wealthier) patients told him: “For [US]$4,500, it’s peace of mind that the care is there when you need it,” and “It’s a comfort knowing I have an internist whenever I need him.” That patient pays $1,500 a year.

A key contributor to this dilemma is Florida company MDVIP Inc., which “started the trend in 2001 with one doctor, and has now grown to 104 physicians and 32,000 patients in 17 states.” One MDVIP doctor told Galewitz he considers concierge medicine “a better way to provide preventive care,” but said he “would not have done this if I could not have other doctors willing to take the patients who chose not to join”

The US Government Accountability Office concluded last fall that the trend was not harming patients’ access to doctors, mainly on the basis that concierge medicine is not widespread. The Department of Health and Human Services, which oversees Medicare, ruled in 2002 under its then head Tommy Thompson that concierge practices can provide services under Medicare as long as they also provide services that are not covered by Medicare. Tommy Thompson started doing work last year for MDVIP, after he left the Bush administration, notes Galewitz.

The American Medical Association considers concierge practices ethical if arrangements are made for existing patients who choose not to participate.

An executive at The Commonwealth Fund, a private foundation that supports research on health and social issues, begged to differ: “The classic concierge care system of paying a premium fee to get services that I would hope should be delivered to all Americans is troublesome to me because it is only available to those who can afford it.” Added an executive of Blue Cross and Blue Shield of Florida: “Don’t believe for a minute that this is about the patient. This is about doctors wanting to make more money.”

Minute Clinics

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A LiveWell Medical Clinic opened in January in a California shopping mall. It is open 74 hours a week and takes both appointments and walk-ins. The clinic will page or call patients while they shop when a doctor brcomes available. That same month, QuickHealth opened its second outlet in a San Francisco drug store, charging a flat US$39 to see a doctor.

These are examples of a trend toward customer-convenient and price-transparent medicine which, writes Victoria Colliver of the San Francisco Chronicle , “has gained momentum during the past year.” The head of the California Medical Association told her he recognizes the trend but is concerned about the lack of continuity of care for the patrons of such clinics.

In addition to clinics staffed by physicians are the growing number of “mini-clinics” staffed by nurse-practitionersm which offer more limited service. Colliver mentions WellnessExpress Medical Clinics in several Bay Area Longs Drug Stores, and similar clinics in Target, Wal-Mart, CVS, and other retailers around the US.

A QuickHealth physician formerly in private practice who taught health policy at UCSF told Colliver: “The political situation is such that we won’t see [a national health system] in the near future. So we’re filling a need.” LiveWell’s founder, a UCSF-trained pediatrician, told her: “The concept is changing in the world as far as what a physician’s role is. We’re not this God-like creature. We’re ordinary people, and we’re here to provide a service.”

One consultant opined that clinics staffed by physicians might not be as cost efficient as those staffed by nurses, but in any event, if such clinics reduce the number of emergency room visits, they could have a significant impact on lowering health care costs. “The status quo can’t continue,” he said, “We shouldn’t be treating $45 problems in a $300 environment.”

Harvard Med School Curriculum Changes

Source: Liz Kowalczyk, “Harvard alters doctors’ training.” Boston Globe, March 20, 2006

“Harvard Medical School is embarking on the most dramatic changes to its curriculum in 20 years,” reports Liz Kowalczyk in the Boston Globe . Among the changes to be phased in over the next three years:

  • Instead of spending one- to three-month stints in various hospitals, third-year med students will stay in one hospital and follow some patients the entire year.
  • Students will be required to take one-semester classes on the effect of social and economic conditions on disease, medical ethics and professionalism, and health policy.

The goal is to enable students to build stronger relationships with their patients and teachers. The University of Pennsylvania Medical School already pairs students with a chronically ill patient for three years.

Choosing the Right Service Lines

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HealthLeaders ’ multi-author cover story for March discusses at length the changing nature and fortunes of hospital service lines. Despite the possibility that biomedical treatments may eventually replace the need for some orthopedic surgical procedures, it is posited that orthopedics will continue to be a robust service line, mainly on the basis of increasing demand by the aging Boomers. On the other hand, heart programs are feeling the pinch from advances in technology and treatment techniques, with cardiac surgery getting fewer cases to do and the interventionalists getting more. “In a few years it may take a thousand primary-care physicians to support [a cardiac surgery program],” said one expert, and “the trend [will] get more draconian.”

The opposite dynamic appears to be at work in neuro, where technological advances are enabling smaller hospitals to take a piece of a growing market, although for the moment, this does not apply to neurocranial procedures, which are still done on an inpatient basis since they require solid physician and ancillary expertise, as well as access to expensive diagnostic-imaging equipment. Deep brain stimulation also needs expensive imaging equipment and high-priced interventional radiologists to operate it in concert with neurosurgeons. But with new technologies, such as minimally invasive methods for treating brain aneurysms, the need for such invasive brain surgery will continue to decrease, and therefore (by implication — the article does not say this directly) neurosurgery could go the way of cardiac surgery.

Revolution in Surgery

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The revolution from open surgery to minimally invasive surgery that has occurred in just the last 15 years was initially regarded as just a fad. But by the mid-1990s “the floodgates opened,” a senior surgeon told Eric Berger of the Houston Chronicle . The revolution has already had major impacts — more than 60 percent of surgeries in Texas are now performed on an outpatient basis, versus 15 percent 20 years ago — and its impacts continue to unfold. Turf wars between surgeons and minimally invasive “interventionalists” are rife, and younger doctors are “more likely to gravitate toward the less invasive procedures.” The latter trend points toward a future in which there are no surgeons left who know how to perform open surgery.


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