Thursday, August 12, 2010

Guest Blog: What primary care can learn from oncology - Part 2 of 2

This is the second of two guest posts by Shantanu Nundy, MD. You can find the first part of this piece here.


Perhaps the best evidence in support of the care we provided our leukemia patients came from my most startling observation: nearing the end of my 4-week rotation, I have yet to admit a single patient from the emergency room. In general medicine, by contrast, well over 90% of admissions come from the ER.

ER admissions are undesirable for a number of reasons. For one, everything in the ER costs more. Though I have never verified this myself, it is rumored that ERs routinely charge $200 for a single dose of aspirin. Furthermore, because ER doctors are trained to address the worst-case scenario and often know little about the patients besides what is written in the medical record, patients often get unnecessary and expensive tests and procedures in the emergency room. Finally, because leukemia is so super-specialized, leukemic patients are also at risk for substandard care from ER physicians who are generalists by nature.

How are inconvenient, costly, and potentially suboptimal ER stays avoided in leukemia? At diagnosis and frequently thereafter, patients with leukemia are educated about the signs and symptoms of serious complications such as infection. When fever or another acute issue arises, they have a clear care plan. They know who to call and can often reach their primary oncologist directly. Physicians that receive the call triage patients over the phone. If the patient needs to be admitted, he or she will be told to come into the hospital directly, where an inpatient bed will have already been arranged and where the resident on call (e.g., me) will have already been made aware of the oncologist’s concerns and given an initial plan and workup. Patients who need to be seen urgently but not necessarily admitted will be scheduled for a same day or next day appointment. Because every doctor in the group knows each patient (thanks to the weekly leukemia conference), even if the patient’s provider does not have a clinic spot available, the patient can be seen by another provider.

So why do my primary care patients not get as good care as my patients on leukemia? It’s not that primary care doctors are bad and leukemia doctors are good. Clearly it’s not that simple. Reimbursement in oncology is higher than in primary care, and in general oncology has a higher proportion of commercially insured rather than publicly insured patients. This gives oncologists resources primary care physicians can only dream of – outpatient laboratory services, IV infusion suites, advanced practice nurses, and dedicated case managers. Oncology also receives greater NIH funding, which supports research of new and existing treatments, and funding from philanthropic institutions and charities (think “Live Strong” and breast cancer awareness). It is also a more narrow field that requires fellowship training, compared to primary care which spans three different specialities (internal medicine, pediatrics, and family medicine) and includes general and subspecialty trainees.

But some of it is cultural as well. When I asked one of my leukemia attendings to explain why there were so few ER admissions, his answer was that leukemia specialists viewed inpatient and outpatient care as part of the same continuum of care and took responsibility for patients over the full cycle of care. Comparatively, in general medicine, outpatient and inpatient care are treated quite separately, a reality that has been formalized by the growing hospitalist movement, in which patients admitted to the hospital are taken care of by a group of physicians wholly separate from their outpatient providers.

Primary care doctors often argue that we need more resources, better compensation, and greater reimbursement. I agree on all fronts, and in fact many of my observations above only support this notion. But I think even with the resources at hand, there is much we can improve upon. We must become more scientific in our methods, more integrated in our care, and more patient-centric in our approach. We need not wait for change in Washington, DC to get started. We can begin by taking a closer look at our peers and learning from their successes, starting (at least at my institution) with leukemia. This will provide useful answers to the important question of why the care of oncology patients seems to be better than that of general medicine patients.

As I leave the world of oncology and return to general medicine, I can’t help but ask myself another question: what would happen if my primary care patients benefited from the same systems of care as my patients in oncology? How much better off would they be? I’m not sure of the answer, but given what I observed this past month, I would love to find out.

- Shantanu Nundy, MD

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