Domingo 28 de Abril de 2002, Ip nº 13

That old-time medicine
Por Nancy Shute

There's a lot to dislike about going to the doctor these days. It starts with the phone call and plodding through the impersonal "push one, push two" of the automated answering system. Then the waiting starts ... waiting weeks for an appointment, waiting in the waiting room, waiting in the examining room, wrapped in a paper gown and reading a four-year-old magazine. All that for a typical 10 minutes of face time with the doctor, who really seems as if he's trying to listen but is so obviously anxious to get to the next patient that you decide not to mention what you're really worried about.

But medicine doesn't have to be a waiting game. Ask Nancy Hilliard, a mother of three who lives outside Rochester, N.Y. When Hilliard calls the doctor's office, her doctor–not a receptionist– answers the phone. When she needs an appointment, she gets one that day. If she needs help after hours, she calls the doctor's home or cellphone. "He is literally there for you at any hour of the day," Hilliard says. When her teenage son attempted suicide, her doctor met them at the emergency room. She is amazed–and grateful. "This is the old family practice," says Hilliard, 42, who is director of cemeteries for the city of Rochester. "He knows all of us. He knows what we think, want, need. I've never seen a physician more concerned with his patients."

And patients aren't the only beneficiaries. "It's so delightful," says Gordon Moore, Hilliard's family doctor. "I really do know these people. When you call me, I can see you today. When I say 3 o'clock, that means I see you at 3 o'clock. The office visits are as long as they need to be."

Moore is one of a growing number of physicians who are radically changing how they practice medicine. Their mission is simply stated: to bring back the empathy and personal attention epitomized by TV doctor Marcus Welby. But their strategies are not entirely retro. While some are reinstating practices like the house call, many of the innovations involve the Internet, E-mail, and other 21st-century technologies. And none too soon. Primary-care doctors, squeezed by shrinking reimbursements and a byzantine bureaucracy, find themselves working harder than ever–while spending less and less time with patients. This assembly-line approach to medicine leaves patients frustrated and doctors disillusioned.

Price of mediocrity. More troubling, the quality of care is often mediocre. The United States spends a whopping $1.3 trillion a year on healthcare, yet study after study has shown that the care received is disorganized, inconsistent, and often not up to professional standards. For example, only 19 percent of people with hypertension are getting the recommended treatment; just half of people over 65 get an annual flu shot; 21 percent of eligible heart-attack victims receive beta-blocker drugs within 90 days, although the drugs greatly reduce the risk of a second heart attack. The problem, analysts say, is not that there isn't enough money being spent on healthcare. There is. The problem, says Donald Berwick, president of the Institute for Healthcare Improvement, a Boston-based think tank that supports many experiments in improved primary care, is that the system is focused on quantity rather than quality–squeezing in more visits instead of realizing that Americans' healthcare needs have fundamentally changed.

A century ago, the average life expectancy was 47 and the most common health problems were acute illnesses– infectious diseases like influenza and tuberculosis. But now the average life expectancy is 77, and people live for decades with chronic ailments such as hypertension, diabetes, and heart disease. Our current medical system, which offers short visits and sends patients hither and yon for CT scans and consultations with specialists, is ill-equipped for helping people manage chronic disease. "The medical system we've all gotten used to over the last 100 years is really outdated," says David Lawrence, chairman and CEO of Kaiser Foundation Health Plan. "There really is a much better way to practice medicine." Last year, Lawrence and Berwick helped write a report for the Institute of Medicine calling for a total overhaul of American medicine. It calls for a system in which patients can get healthcare wherever and whenever they want, including over the Internet; in which treatment doesn't vary from doctor to doctor, as it does now; in which doctors get paid for more than just an office visit; and in which "the patient is the source of control." This, Lawrence acknowledges, is "a pretty radical point of view." It's one that, although it hasn't gotten much public attention, has become the topic of intense debate within medicine. And it's one that doctors like Moore are already putting into practice.

(...)

By the dozen. Other physicians are trying to improve access by taking a completely different tack–seeing patients a dozen at a time. The idea of a "drop-in group medical appointment," invented by clinical psychologist Edward Noffsinger in 1996, may conjure up unpleasant memories of Army physicals, but the majority of patients who try them say they prefer them to a private consultation, because instead of getting 10 minutes with the doctor, they're getting 90.

In practice, it's a bizarre–and bizarrely appealing–blend of Marcus Welby and Oprah. "I met Elsie three years ago," Paulanne Balch tells her group at 8 a.m. on a Thursday. Eight patients, strangers to one another, sit in a conference room at a Kaiser Permanente clinic in suburban Denver. "She said, 'Honey, I'm just so tired I had to cancel my tap-dancing lessons.' "

"I was 91 then," says Elsie Bobo, white-haired and radiant in a pink sweat suit. She jumps up to demonstrate a spine-swaying belly-dancing move that she says has really helped with back pain. Balch, a 50-year-old family-practice doctor, starts drawing on a big white pad. "So if you look at your spine like this," she says, sketching latissimus dorsi, erector, and paraspinous muscles, and explains why it's important to keep moving a hurting back. She turns to the next patient. "Jane, how are we doing? Do you have your blood pressures with you? How much are you smoking?"

(...)

Group wisdom. Balch says group visits are more efficient, because with common health problems–high blood pressure, diabetes, depression–she doesn't have to repeat the same message a dozen times. People find out that they're not the first in the world to have kidney failure and that the person sitting right next to them went through it and is doing OK. But what's most striking is that the patients advise one another. Says John Scott, a Kaiser internist and aging expert:"Each disease is unique. But the psychosocial ramifications are the same–the anxiety, the fear of the unknown." Preliminary data indicate that such groups save Kaiser $96 to $131 per session and significantly increase patient and doctor satisfaction.

E-Medicine. If some wants to see his patients more, others would like to see theirs less. It's not that they don't like them. But they think that sitting on a paper-topped exam table is not essential for quality healthcare. Indeed, they say, patients often get better care by not seeing the doctor face to face. This month, the two doctors opened the new office of GreenField Health System, their own experiment in better medicine, in Portland, Ore. Unlike Moore's minimalist digs, GreenField looks much like a traditional doctor's office, with a sleek suite overlooking southwest Portland–but no waiting room. Patients work with a team: Health coordinators take patient histories, expedite referrals, and renew prescriptions, and a nurse practitioner helps people manage chronic diseases like diabetes. They refuse to take insurance copays, figuring the $5 or $10 isn't worth the paperwork. "You have a lot of baby boomers and gen X-ers who are used to a very high level of service in the rest of their lives," Kilo, 40, says. "We want to take healthcare to a different level." E-mail is the key to that service, he believes. More E-mail contact with patients means fewer office visits (they have reduced office traffic by 50 percent to 75 percent), which means more time for people who really do have to come in.

Blake Patsy is a believer in E-mail medicine, regularly sending Gordon his health questions. "I don't have any personal or security reasons why I can't have my cholesterol level flying out on the Internet," says Patsy, a 39-year-old consulting engineer. Patsy says his E-mails are far more thoughtful than any question he'd blurt out in an examining room. As someone who walked around with a throbbing arm for two weeks at age 33, only to discover later that he'd had a heart attack, he figures E-mail could save his life. "The huge advantage is having access to the doctor. For the average Joe who's hesitant about the doctor's office, there's a huge value."

(...)

E-mail can also help doctors deal with the "difficult" patients who want to come in every week. "These are tough visits," says Joseph Scherger, dean of the college of medicine at Florida State University and an early proponent of medical E-mail. "You can have that person send you a weekly or biweekly message and give them a little reinforcement."

Resisting change. While for Kilo and Gordon doing business by E-mail is common sense, most physicians have avoided E-medicine like an electronic plague. Last year, 23 percent of doctors say they E-mailed with patients, compared with 52 percent who said they used the Internet to get promotional material from pharmaceutical companies. When polled, doctors said they were most concerned that E-mail lacked face-to-face contact and also that insurers don't reimburse for E-mail time. But beyond the money, medicine is a conservative craft that doesn't abandon its rituals easily. In the early 20th century, for example, there were intense debates among doctors about whether it was appropriate to use the telephone in the practice of medicine. Danny Sands believes that once his peers try E-mail, they'll never go back. An internist at Beth Israel Deaconess Medical Center in Boston, Sands hands his patients business cards with a guide to medical E-mail etiquette on the back. ("Use alternative forms of communication for emergencies. Do not assume E-mail is confidential.") "The telephone is so inefficient," Sands, 39, says. "Last night I answered E-mail at midnight. I can't call people back at midnight."

Sands is also pushing a far more audacious project–putting patients' medical records on the Web. Two years ago, Beth Israel became one of the first institutions to let patients sign on to a Web site with a password and review their prescrip- tions, lab results, and history. (An example is available at http://patientsite.bidmc.harvard.edu; click on "take a tour.") So far, 7,000 patients are online. "Just yesterday I had an MRI on my spine," says Michael Kennedy, a 55-year-old novelist in Needham, Mass. "I was able to go on the site this morning and look up the preliminary report from the radiologist." To his relief, Kennedy found that the numbness in his arm was probably the result of a bulging disk, not something more ominous. "The point is, I'm able as a patient to be on top of my medical care. I don't feel like I'm being infantilized." Kennedy's now pushing to have doctor's notes, such as blood pressure recordings, on the electronic record, too. "They're my notes as well."

Information and safety. Proponents of the new medicine say that access to technology like Beth Israel's is not a frill. Instead, they say, computers are essential to making medicine more safe, responsive, and humane. "It's almost impossible to move medical care into the 21st century without information technology," says Kaiser's Lawrence. "Yet medicine is incredibly underinvested in IT." Indeed, only 12 percent of doctors have their patients' medical records computerized. "The information management is better in veterinary offices," says Florida State's Scherger. It is hard to understand why eBay or Bank of America can manage millions of secure transactions electronically, while a medical practice cannot. But 40 percent of physicians are in solo practice and are hard pressed to put big bucks into computerizing. To help those doctors, Lawrence says, the nation should consider an "IT Superfund," as well as tax credits and other incentives. Kaiser has just started the nation's largest medical IT project, putting the records of all its 8.2 million members in a nationwide database, an effort that will cost $2 billion and take until 2006. "We see the system as a way to help doctors take better care of their patients," says Bill Gillespie, executive vice president of quality management at Kaiser, who is leading the project.


  22/04/2002. US News Magazine.


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