Curbside Consult with Dr. Jayne 1/6/20

An issue that is often cited as a cause of increased healthcare expenditures in the US is our fascination with technology. This is readily apparent as I see patients. They don’t want me to tell them that it’s highly unlikely that they have strep throat due to a well-validated clinical decision support rule. Instead, they demand an in-office strep test. They have been conditioned to expect technology to provide answers, even if it involves radiating a pair of totally clear lungs because the patient is concerned that they have pneumonia. The increased reliance on patient satisfaction scores as a marker of quality care certainly hasn’t done anything to improve this situation.

Earlier this week, I received a scathing review from a patient that triggered a phone call from the COO. She was upset that I suggested that she be sure to contact her primary care physician when she is ill. I had noticed that she is a member of a notoriously restrictive HMO and I wanted to spare her the denials and her physician the penalties. Instead, she took this as a statement that I “didn’t want her business” and that she was “not welcome at urgent care.”

Being interrogated by the COO about the patient encounter  — which was unusual enough at the time that I put several interesting details in the chart — was the last thing I needed during a busy clinic day when we literally had patients trying to die in the office. When I’ve talked to the emergency department charge nurse at the local Level 1 trauma center three times in the same day, that’s a bad sign for sure.

I would love to have bureaucrats and politicians in the room with me when I have to explain to a patient with a critical illness that they absolutely need to go to the hospital by ambulance and that no, you cannot go by private vehicle when you are actively having a heart attack. I had three different versions of this conversation during my last shift: one for the heart attack, one for a patient with multiple blood clots in the lung who was short of breath, and one for a patient with what appeared to be an evolving stroke. The fact that these patients were at an urgent care center and not the actual emergency department is a result of many factors.

In my anecdotal experience, the first reason is convenience. Patients want to be seen in their neighborhood by someone who can care for them quickly. They don’t want to deal with an office that can’t fit them in or a crowded clinic.

Second is cost. They don’t want a surprise bill from going to the hospital or a denial if their care isn’t deemed emergent after a hindsight review.

Third is a complicated health literacy issue. Patients often don’t understand what can be cared for at home, what needs to be at a retail clinic, what needs an urgent care center, and what needs to go to the emergency department or even a specialized emergency department. As an urgent care physician, I think sometimes we’re victims of our own successful marketing, but that doesn’t help your stress level when you’re urgently transferring a child with a coin in their airway or telling a patient they have advanced cancer that was blown off by their primary care physician.

Many forecasters thought that high-dollar deductible insurance plans would make patients savvier consumers and wiser spenders of their dollars. What we see in practice is that patients are paying so much for their insurance that regardless of the deductible, they want more and more services to get their money’s worth. I never thought I’d see patients coming in saying, “I think I’m OK, but I just want a CT scan to be sure.” They’re shocked when they say that we don’t have enough cause to order it, or that the insurance might not pay for it.

I try to use technology in some of those situations as a teaching aid, pulling up websites and providing information about why the patient is going to be just fine. Somehow it’s more believable when they see it on a website than when the doctor in front of them is saying it. I try not to take it personally.

There are also the times though that technology fails us. Recently, some patients who had undergone preventive mastectomies after concerning genetic testing results learned that the BRCA gene test may have been inaccurate. That was earth shaking for many patients, who have come to trust high-tech answers to their questions. I saw that article on the same day that I saw the Google blog piece about using artificial intelligence to improve breast cancer screening using digital mammography. Another win for technology after a stunning loss.

I was also heartened by the ultimate telemedicine encounter that occurred recently. Apparently one of the astronauts on the International Space Station developed a deep vein thrombosis (blood clot) in their neck, which was evaluated and treated remotely. The astronaut patient performed ultrasounds with guidance from an Earth-bound care team in order to monitor the clot. A pretty cool story, but difficult when you transpose it with the reality of many patients on the ground who can’t get an ultrasound for a suspected clot on two of every seven days, simply because they’re classified as “weekends” and facilities don’t have ultrasonographers readily available.

Being at the forefront of healthcare delivery is like being on a roller coaster. There are amazing highs (identifying the blood clot in the lung before it killed an otherwise healthy 25 year old) and devastating lows that are sometimes too horrific to put into words.

In my informatics practice, I work with people every single day who are committed to trying to solve the problems that we all are facing every time we, or those we care about, interact with the healthcare system. It’s a new year and hopefully a new opportunity for healthcare technology to really make a difference for patients around the world.

I’m excited to be a part of the future of healthcare. Who’s with me?

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