July 27th, 2009 by Dr. Val Jones in True Stories
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Regular readers of Better Health will recall my personal frustration that my mother-in-law received 2 months of physical therapy, a head CT, and extensive blood testing in response to a shingles outbreak that I was able to diagnose easily over the phone.
The misdiagnosis that resulted in chronic post-herpetic neuralgia and a $10,000 waste of resources, has continued to vex me. After Mrs. Zlotkus and I realized what was going on, I outlined for her the usual treatment regimen for shingles pain – explaining that most people needed a fairly high dose of the nerve pain medicine before they experience any relief at all, and to make sure her doctor gave her an adequate dose before deciding whether or not it worked.
And you can guess what happened next.
Mrs. Zlotkus was seen by a young and inexperienced neurologist who insisted on giving her a very tiny dose of the nerve medicine (it has an excellent safety profile even at very high doses). Of course, it didn’t help. She was given 100mg twice a day (where shingles sufferers often need as much as 1800mg/day) with instructions to return in a few weeks. The doctor also told her that she “couldn’t be sure the pain was due to shingles since she hadn’t seen the original rash.”
That’s like an ER physician saying to a trauma victim that they can’t be sure of the cause of the injuries because they didn’t witness the car accident.
At that point I instructed her to find an experienced pain management specialist who’d know how to titrate her medication appropriately – and who might even be able to do a nerve block to get her some immediate pain relief.
Luckily, Mrs. Zlotkus “knew somebody who knew somebody” and was able to make an appointment the next day with a senior anesthesiologist experienced in nerve blocks. The pain management physician knew just what to do, administered the nerve block, increased her medication dose, and sent her on her way. She experienced immediate relief of her symptoms and felt like a new woman.
If Mrs. Zlotkus had gone directly to the anesthesiologist in the first place, she might have saved herself months of agony and a $10,000+ bill to Medicare. (Better yet she would have gone to her PCP when she first noticed scabs on her scalp and he would have prescribed an anti-viral medicine that could have aborted the entire pain syndrome.) But how was she to know which provider was right for her? How could she know that her neurologist was prescribing her the wrong dose of pain medication, and that a nerve block might solve all of this nicely. Without the correct diagnosis, a cascade of wasted resources and personal suffering ensued. Without me nudging her in the right treatment direction – perhaps she’d still be doing neck stretching exercises in physical therapy?
I am a fan of the “medical home” concept as described by the AAFP and wonder if it could have made a difference in Mrs. Zlotkus’ care:
“In this new model, the traditional doctor’s office is transformed into the central point for Americans to organize and coordinate their health care, based on their needs and priorities. At its core is an ongoing partnership between each person and a specially trained primary care physician. This new model provides modern conveniences, like e-mail communication and same-day appointments; quality ratings and pricing information; and secure online tools to help consumers manage their health information, review the latest medical findings and make informed decisions.
Consumers receive reminders about necessary appointments and screenings, as well as other support to help them and their families manage chronic conditions such as diabetes or heart disease. The primary care physician helps each person assemble a team when he or she needs specialists and other health care providers such as nutritionists and physical trainers. The consumer decides who is on his or her team, and the primary care physician makes sure they are working together to meet all of the patient’s needs in an integrated, ‘whole person’ fashion.”
In summary, there’s a lot of waste in our medical system caused by a lack of coordination of care, hasty diagnoses, and defensive medicine. Even the most common diagnoses (like shingles) can end up setting off a chain reaction of over testing, incorrect treatment and personal suffering. We need an “OnStar” system for healthcare – a way to help patients navigate their way to the right care at the right time. The medical home model is as good a GPS system as any… so long as the primary care physician at the center of the coordination of care is not so rushed that she can’t do her job properly. And that’s the secret to making the medical home work – giving the doctor enough time to unravel the problems at hand and figure out the best next steps in care. If we get this right, we can probably say goodbye to CT scans for shingles.
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.
May 11th, 2009 by EvanFalchukJD in Better Health Network
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The New York Times interviews President Obama about health care:
I’m a pretty well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately he is the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.
It’s shockingly bad advice.
Numerous studies show that patients get the wrong diagnosis as much as 20% of the time, and get the wrong treatment half of the time. Thirty-five percent of doctors and 42% of patients report errors in their own care or that of a family member. Studies show that most errors happen because of a failure to analyze the patient’s problem correctly. Experts, like Dr. Jerome Groopman from Harvard, say that doctors, strapped for time and dealing with complicated problems, easily fall prey to cognitive pitfalls that create poor quality.
Ask questions, be skeptical, disrupt your doctor’s thought process. Make sure the decisions about your care are right.
Above all, remember it is you, the patient, that are in charge, not the “guy with the medical degree.”
(h/t @epatientDave via twitter)
*This blog post was originally published at See First Blog*
