S is for Specialist

---

An expert is someone who has succeeded in making decisions and judgments simpler through knowing what to pay attention to and what to ignore.
(Edward de Bono)

---

There are about 50 common types of  medical and surgical specialists.  The list runs from allergists to vascular surgeons.  So, in the big picture of health care where do they fit?  Do they add to health care quality?  Are their services cost-effective (as you might evaluate a drug or device)?  When should a patient see a specialist (or not)?  Why are specialists happier than primary care doctors?

Many years ago there were no specialists.  Doctors delivered babies, set broken bones and used leaches.  Treatment of war wounds with amputation heralded surgery as a specialty in the latter part of the 19th century.  As time went by other specialties came into being mostly because specialists were the conduit from research to clinical practice.  As medical information was more widely available specialists simply had more experience with uncommon or difficult problems.  Specialists led the way for new treatments .  Pulmonary doctors treated consumption (TB).  Cardiologists studied EKGs.  Obstetric specialists invented forceps for difficult births.  Now there are at least 50 varieties of specialists.

The specialist world is divided between procedural (surgical) and medical (expert advice) specialists.  A cardiac surgeon is a good example of a surgical specialist.  An endocrinologist is a good example of a medical specialist.  Some specialists do a little of both like cardiologists who do heart catheterization procedures and provide expert advice for treatment of heart disease.  Medical research has exploded to such an extent specialists still maintain an edge by focusing on smaller and smaller areas of expertise.

One might be led to believe every condition should be evaluated by a specialist.  But, there is good evidence to the contrary.  Based on Medicare data:  Areas with more specialists spend more on health care for Medicare beneficiaries but see no improvement in the quality of care, mortality, or patient satisfaction.  The foundation of modern American medical care is being questioned.  What went wrong?  Is it Kryptonite?  How can this be?

 

There are two answers to what went wrong.  First, knowledge about a disease does not always lead to cure but always runs up the bill for tests.  Second, medication and surgery do have complications that can be serious to the point of shortening a person’s life.  In aggregate the specialty world “hit the wall”.  The positives could not offset the negatives.

The foregoing indictment of specialists really put the wind to the sails of primary care.  In fact, treatment of most common ailments is well established with what are called “evidence based guidelines”.   Quality, safety, cost-effectiveness, and patient satisfaction thus depend on a good process to implement the known guidelines rather than special knowledge.  Until recently primary care providers had the lowest job satisfaction of any provider group.  Now, with a new sense of importance and purpose they seem to be personally happier.

The specialty world is fighting back by addressing cost-effectiveness.  Cardiologists have devised cost-effective strategies for treatment of heart attacks (evidence based guidelines) with dramatic improvement in survival.  Oncologists are following guidelines for treating many cancers and engaging hospice at a more appropriate time.  Gastroenterologists have found they can prevent colon cancers by following evidence based  guidelines for doing colonoscopy.   The world’s specialists are not all on board with the idea of being  cost-effective.  Those who do procedures are still criticized for doing them too often (if you have a hammer everything looks like a nail).

THE BOTTOM LINE:

1. If you have health problems then have regular visits with a primary care provider.  They usually do have good advice about going to specialists.
2. Do your homework.  Search the Internet about your problem.  If there are ideas you find then discuss them with your primary care provider.
3. There is still some “ego” challenge for a primary care provider to ask for help in difficult situations.  The simple question: “Do you think a specialist could help us with this problem?” is usually well received.
4. If you have a life altering problem or are hospitalized more than once for  the same disease a visit to a specialist is certainly reasonable.
5. If you do go to a specialist make it clear you want your primary care provider kept informed.  Likewise, make sure the primary care provider communicates with the specialist (sends periodic updates) and follows the recommendations primary care actually  requested.

Rate Your Health Care Provider

The following rating system is intended for adult primary care office visits, but could also apply to some specialty visits.  There are no extra points for famous doctors, university clinics or the only provider in town.  Add up the points to see how your provider’s office is doing.

Performance	Points
When I call the office, who answers?
A real person	2
A computer answering system that connects to a real person	1
I know the office will provide appointments:
New patient appointments within 3 weeks or Follow-up appointment for new problem in 3 days	2
Urgent problem (during office hours) on same day	3
The office designates time for walk-in visits	2
The office has some evening and weekend hours	2
Moving through the office (assuming you were on time)
Checked-in within 5 minutes	2
Checked-in within 5 to 10 minutes	1
Face to face with the provider within 5 minutes of appointment time or within 30 minutes for a walk-in visit	3
Face to face with the provider within 10 minutes of appointment time or within 45 minutes for a walk-in visit	2
Checked-out within 5 minutes of leaving provider	2
Checked-out within 5 to 10 minutes of leaving provider	1
Provider visit
I do not have to take off clothes before seeing provider	2
I can sit in a chair at eye level with the provider	2
Provider seems to care about me	5
I am not interrupted while I say the reasons for the visit	4
The part of my body with problems is examined	3
The paper chart or the computer is just used by the provider to find information to help me	2
The diagnosis of my problem is made clear	4
I am directed to handouts or Internet sites about my problems	1
Before I leave, the provider asks if I have any other questions	3
It is clear when I need to return for recheck	3
Medication Management:
The reasons I need to take all medications are explained	3
My provider sends prescriptions by computer	2
Possible side effects of medications are discussed	1
At each visit I receive a list of my active medications	3
Tests (x-rays, blood tests, EKG, biopsies etc.)
If I need tests I am told why	2
The office always lets me know test results within a week	2
I always get copies of test results	2
Practice environment
My provider has associates who substitute when needed	2
Hospital care is done by hospitalists	2
My provider is part of a system including specialists	2
Physician assistants or nurse practitioners work at the office	2
TOTAL POINTS  =

—

Score	Rating
60 and over	5 star
50 to 59	4 star
40 to 49	3 star
30 to 39	2 star
below 30	1 star

–

Hotels have struggled to get the coveted 5 star rating for decades.  It is not just whether the hotel chef can make a souffle but whether the whole experience of staying in the hotel is superior.   The items in the above score are considered elements of quality for health care delivery.  It’s not easy to get 5 stars.

Medical and surgical care has focused on diagnosis and treatment for hundreds of years.  To that end individual providers spend years, if not decades, honing diagnosis and treatment (some say, to a fault).   The vast majority of problems in primary care are fairly easy to diagnose (like diaper rash, acne and diabetes).  Treatment is harder because it spans time, is a process and requires patient engagement.  So, as it turns out, the wrapper may be as important as the package.  Providers are well trained and licensed but the wrapper of delivering care is where quality, safety, cost-effectiveness and satisfaction reside.

Routine Check-ups — expensive and worthless

The Cochraine Colaboration is a highly regarded organization which focuses on medical evidence for better health care.  They reviewed the available medical research on the common practice of medical check-ups and came to the following conclusion:

“With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.”

General health checks in adults for reducing morbidity and mortality from disease (Review).  Krogsbøll LT et al.  Published Online: 17 OCT 2012.  The Cochrane Library.

This review indicates that you will not live longer or be healthy just as a result of getting a routine check-up.  This should not come as a surprise.  It is actually hard to find good screening tests.  Checking blood pressure, checking weight, and checking cholesterol are about the only proven screening tests.  Those tests and not the “check-up” are what has value.   But, going to a health care provider for pregnancy, vaccinations, symptoms or follow-up of a known condition has tremendous value.  So it is important to make this clear:  if you have a health problem see your health care provider, if you don’t have a problem then get your cholesterol checked, your blood pressure checked, get help if you are over weight, don’t smoke, and don’t drink alcohol.  Outside those guidelines don’t waste your money or time on the routine “check-up”.

Analysis of the Affordable Care Act

The New England Journal of Medicine published an editorial about the Affordable Care Act (ACA) by former Health and Human Services Secretary Gail R. Wilensky, Ph.D. on October 18, 2012.  Dr. Wilensky is a knowledgeable source for comments but she is clearly a political player.  Her description of problems for the ACA is reasonable although her conclusion a voucher system solves the problems does not follow logically (fully understandable in this political season).  But it is worth summarizing her findings and adding a less political conclusion.

She states that US health care suffers from

1. Millions of people go without insurance.
2. Health care costs are rising at unaffordable rates.
3. Quality of care is not what it should be.

Her criticism of the ACA (in summary form by this blogs author):

1. The penalty for not purchasing insurance is too small
   (she suggests a penalty like medicare that builds up every year if a person does not comply)
2. A lack of organization to ensure effective, high quality and affordable care.
3. No attack on the system of reimbursement of providers, based on number of services, rather than quality and cohesive delivery.
4. Not enough resources are put into value-based purchasing and accountable care organizations (ACO).  And, too little money is at risk for providers who fail to meet quality targets.
5. Not enough regulatory framework to force physicians into large multispecialty groups and patients into primary care systems.
6. No sense of urgency to make meaningful reforms take effect.
7. Lack of clarity  on how market forces will be harnessed.
8. Allow a 2-tier system so those who can afford more health care coverage can purchase it.
9. Reduce the cost of health care by government action (presumably health care vouchers as proposed by congressman Ryan)

Vouchers are one way to put a maximum on how much government will pay.  But, without simultaneously attacking the other problems we just end up with low cost awful health care — not a happy outcome.

 

 

Patient Satisfaction (the CMS view)

The chart above is extracted from CMS data.  All US hospitals are now required to collect data on patient satisfaction.  This data is used by Medicare to adjust hospital payments upward for good satisfaction scores or downward for poor satisfaction scores.  This new payment adjustment certainly has the attention of hospitals since the adjustment amounts to a significant amount of money.

If one looks at the actual questions they really are pointed toward the quality of communication.   The questions are not about whether the treatment was satisfactory but whether there was good communication between the patient and the doctors, nurses and other staff.  The focus on communication tends to get around the criticism that sick people are never satisfied because they have some disease.   Even a sick patient can be quite satisfied (or not) with the communication received during a hospitalization.

The above table is the summary for the entire US.  The data is subject to a selection bias because the patient selects the hospital with some intent to select a good one.  But given that bias the results are not all that great — about 20% of patients did not feel they always had good communication with nurses and doctors.

Satisfaction is not the same thing as quality health care.  You might have been given the wrong medication or had unnecessary surgery but you went away happy (and ignorant of the problems).  Doing the right thing and getting a good outcome is what hospitals need to focus on.  Patient satisfaction is a small step in the right direction.