July 8th, 2009 by Dr. Val Jones in Health Policy, True Stories
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My mother-in-law just had a CT scan of her head in the Emergency Department of her local hospital. My husband called me to ask if I could “talk to her about her headache.”
Severe headaches in the elderly are indeed worrisome, and I wondered if she had fallen recently – if she might have a bleed in her brain requiring immediate surgery. Of course, she’d need a CT scan to rule that out… I was prepared for the worst. But what I learned by simply talking to Mrs. Zlotkus was unexpectedly revealing – not only about her diagnosis but about our healthcare system in general.
As it turns out, Mrs. Zlotkus had been having severe headaches for about 3 months. She was taking Vicodin daily to “take the edge off.” When I asked her about the location of the pain, she said that it was “just on one side of my head, from the top of my neck to the top of my head.” I asked her if the pain sometimes traveled to the other side, or if it involved her eye. “Never,” was her quick response. She also told me that she’d been seeing a physical therapist for 2.5 months for neck stretching exercises.
Mrs. Zlotkus told me her CT scan was negative, and that her blood tests didn’t show any “temporary arthritis.” (That’s temporal arteritis, I presume.)
“Well,” I said, “There’s only one thing left that I can think of that will give you a headache in the exact area you’re describing – and that’s shingles. Did you notice any scabs or painful bumps on your scalp when the headaches first started?”
“Why, yes!” Said Mrs. Zlotkus. “About 3 months ago I noticed some very painful, crusty scabs on my scalp. I thought for sure it was because my hairdresser used extra strong chemicals on my hair. I scolded her for it. She told me to put tea tree oil on it.”
Oh, boy. There it was – a diagnosis as plain as the nose on her face.
“Um… Well did you tell the ER docs about the scabs?”
“No. They never asked me about it and I didn’t see what my hairdresser’s chemical burn had to do with my severe headaches.”
My mother-in-law’s work up (ER visit, CT scan, several doctor visits, pain medicines), misdiagnosis (neck muscle stiffness), and mistreatment (physical therapy) for shingles probably cost upwards of $10,000. Worse than that, she did not get anti-viral treatment early enough in her outbreak to prevent a long-lasting pain syndrome (called post-herpetic neuralgia). Now that she has this shingles-related headache, it’s very hard to treat. And taking lots of acetaminophen-rich medications (Vicodin) is the last thing her liver needs right now.
So how did the healthcare system fail Mrs. Zlotkus? In my opinion, this is a great example of the “failure of synthesis” that Evan Falchuk discusses on his See First blog. Somehow, the physicians involved in Mrs. Zlotkus’ care didn’t take the time to think about her symptoms, to ask the right questions, and to put all the puzzle pieces together. Instead, they just ruled out the potential emergency issues (a stroke/hemorrhage, or temporal arteritis) and gave her a follow up appointment with a neurologist (who couldn’t fit her in their schedule for 2 months). They didn’t take a full history – they just dumped her in the most likely diagnostic category (neck stiffness) and let some other specialist follow up. Shameful.
I’ve described more egregious examples of hasty medical care on this blog – consider the case of an elderly woman (the mother of a friend of mine) who was misdiagnosed with “end stage dementia” when she really had acute delirium from an overdose of diuretics… Or the case of my girlfriend who was mistaken in the ER for a drug seeker when she was suffering from a kidney stone.
Sometimes I feel as if I have to keep an eye on all my friends and family before they set foot in a hospital, ER, or doctor’s office. I’m afraid that those providing their care will be so rushed and thoughtless that my loved ones will wind up with a huge bill, the wrong diagnosis, and perhaps even a near-death experience. I am seriously afraid for them.
The bottom line is that we have to stop rewarding providers for volume over quality. We have to value the history and physical exam beyond the CT scan and lab tests. We have to give doctors the chance to think about their patients – rather than turn up the speed dial on the clinical treadmills as a means to reduce costs.
My mother-in-law just spent $10,000 of our tax dollars on a diagnosis that could be made in 5 minutes of thoughtful questioning over the telephone. Multiply that cost by the number of other Medicare beneficiaries who are suffering similar misdiagnoses in this country and we’re talking serious money.
Under-thinking leads to over-testing. Has the CBO taken that into consideration in its scoring of various reform plans? I don’t think so. To me, this is yet another reason why we need physicians at the table in healthcare reform – we see the real cost drivers that others might not think of – even if some of us are too busy to diagnose shingles correctly!
June 22nd, 2009 by Dr. Val Jones in Expert Interviews
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Evan Falchuk is the President and COO of Best Doctors – a company designed to solve the “failure of information synthesis” that occurs in a convoluted healthcare system that rewards speed over accuracy. I met Evan for a breakfast in Boston last month – and found him to be a highly perceptive, passionate, and affable individual. He’s the kind of guy who asks the right questions, and has a firm grasp of what ails us – both at a personal and systemic level. I like what he’s up to – and invited him to be a regular contributor to Better Health. So for your reading enjoyment, I’ve prepared a transcript of our recent interview:
Dr. Val: What is Best Doctors?
Falchuk: Best Doctors exists for a simple reason: as many as one in five patients get the wrong diagnosis. It usually happens because of a failure to put together the information in a patient’s case in a way that leads to the right answer. Best Doctors offers an in-depth analysis of a patient’s medical information to make sure they have the right diagnosis – and that they are on the right treatment path given their condition and preferences.
Doctors receive the information from Best Doctors well, because it’s pertinent, useful, and from recognized experts in the important questions in the case. We have a very high regard for doctors, and so we do our best to make sure the information we deliver helps the doctor and their patient make good decisions together.
Best Doctors makes money by selling its service to companies, who give Best Doctors as a free benefit to their employees and their families. We do a lot of work with these companies to encourage their employees to call us when they’re facing a medical situation. All our cases are voluntary, confidential and independent of health coverage.
Our customers say they buy Best Doctors for a couple of reasons. First, they want to help their employees deal with the uncertainty they face when they or a family member are sick. And second, they find that if they can help their employees avoid incorrect diagnosis and treatment, they can save a lot of money on health expenses. Since we find that about 20% of cases have something wrong with the diagnosis, and about half have something wrong with the treatment, you can see where the improvement in quality and cost happens.
Dr. Val: Is Best Doctors a family business?
Falchuk: It started out that way.
My father, who is an internist and Professor at Harvard Medical School, started the company about 20 years ago, along with another doctor. They are both from overseas, and regularly saw patients who traveled to Boston for answers to their medical problems. Usually, they were able to tell their patients that their doctors had done the right things, but often they found serious problems. In those cases they worked closely with the patients and their doctors to fix them.
My father taught me that if you spend time thinking about the right questions, often the answers become obvious. This has always been the philosophy he teaches his medical students, and it is the vision we try to implement every day at Best Doctors.
So much of how our health care system is organized today seriously undervalues thinking. We can’t really change the health care system but we can change what happens to each person we help. It’s an important and inspiring mission.
As far as the business is concerned, what started out as an idea 20 years ago is now in 20 countries around the world and covers millions of people. It’s come a very long way, but there is still so much more to do.
Dr. Val: Why did you leave your law practice in DC to work with your dad in the medical world (or – why didn’t YOU become a doctor?)
Falchuk: After studying history in college, I became an attorney. For the next five years, I worked in a big law firm in Washington, DC– although if you count up the hours I worked, it was probably more like 50 years. I learned a lot and had the privilege of working with some extraordinarily gifted people. I liked being a lawyer. The trouble was, I didn’t love it. So I am very fortunate to have a father who not only created such a great business, but who also was thrilled to have the chance to have his son work in it with him.
Some people tell me I was destined to do something in health care. My mother is a nurse, and is now the President of Hadassah, perhaps most well-known for its terrific global health programs and its world-renowned hospital in Israel. My sister works for a big pharmaceutical company. Among my uncles and cousins on both sides of my family I count no fewer than a dozen doctors. Even my brother is in on it – he is an executive producer and director of the TV show Nip/Tuck.
Dr. Val: Tell me about your brother’s brush with a misdiagnosis.
Falchuk: His story is really a classic example of what Best Doctors is all about. He was working on his new TV show, Glee, and woke up one day with numbness on one side of his body.
His doctor first told him to wait it out, then sent him to a chiropractor, then some physical therapy. Nothing worked. He was thinking about getting a steroid injection, but his doctor first ordered an MRI. It found bad news: a malignant tumor in his spinal cord, high up in his neck. He was referred to a neurosurgeon.
The neurosurgeon told my brother he would first have radiation on the tumor. Then he would have surgery in which his spinal cord would be carefully cut open to remove the tumor. He was told he could end up paralyzed, or dead. That was when he called me, and we started a case at Best Doctors.
One of our nurses took a history, and we collected his records. Two internists spent hours reviewing them. The records noted our family history of a kind of malformed blood vessel called a cavernous hemangioma. Our grandfather had hundreds of them in his brain when he died at 101, and our father has dozens of them in his. I’ve got one in my brain, too. This was in my brother’s charts, but none of his doctors had mentioned it.
We asked an expert in these malformations if this was something that ought to be ruled out. The expert said an MRA should be done to see if that was what was going on. We gave that information to my brother and his doctors, and they agreed. The test showed that this was exactly what my brother had in his spinal cord.
Quickly, the plan changed. Although he still needed surgery, there would be no radiation. That might have caused the malformation to bleed, which would have caused the terrible complications we were worried about. Even if that didn’t happen, the surgeons were prepared to operate on a malignant tumor. They would have been surprised to find a delicate malformation there instead.
He had his surgery at the end of November and it went well. He is having a good recovery and is very busy with his new TV show. But his case is a sobering example of the kinds of things we see all the time.
Dr. Val: Who should use Best Doctors services?
Falchuk: If your company has Best Doctors, I always say that if you feel unsure about your medical care you ought to call us. From what I have seen, patients are the first ones to know that something isn’t right and have the most at stake in the outcome. The worst that happens is that we will confirm you are on the right path. But everyone is entitled to feel confident that they are making the right decisions for themselves and we want to do whatever we can to help provide that.
Dr. Val: How can people gain access to Best Doctors services?
Falchuk: Your employer signs up for Best Doctors and then makes it available to you and your family for free. We don’t have an individual consumer program – we prefer to provide this for free to members and their families.
Dr. Val: What do you make of the “Health 2.0” movement – and how is it impacting your business?
Falchuk: I see Health 2.0 as being about consumers being active participants in their care. There are a couple of trends intersecting. Yes, there is a ton of information available on the internet, some good, some not so good. But there is also this growing sense that you have to advocate for yourself so you don’t fall through the many cracks in our health care system. This idea of an “activist” patient is going to be an increasingly important part of the landscape. As a business, we play an important role helping people be good, smart, helpful advocates for their own cause.
Dr. Val: Do you have any words of wisdom for patients out there who are trying to get good care?
Falchuk: My best advice is: don’t get sick. If you must get sick, make sure that you ask as many questions as you can, and learn as much as you can about what is going on. If you’re not satisfied with the answers you are getting, don’t be afraid to ask for a second opinion. Remember, you are entitled to feel confident that you are making the right decision for yourself.
