Tuesday, August 10, 2010

Guest Blog: What primary care can learn from oncology - Part 1 of 2

Shantanu Nundy, MD is an internal medicine physician at the University of Chicago and the author of Stay Healthy at Every Age: What Your Doctor Wants You to Know. The following piece was originally posted on his blog, BeyondApples.org.


Why do my patients with cancer get better care than my patients in primary care?

As the senior resident on my hospital’s inpatient leukemia service this past month, this question troubled and intrigued me daily. Despite the sheer complexity of treating leukemia (administration of chemotherapy, bone marrow biopsies, stem cell transplantation), the resources required (transplantation routinely costs $1 million), and the severity of the illness (patients with little to no functional immune system), I couldn’t help but marvel at how coordinated, integrated, and patient-centric the care was.

From the first day I saw that things in leukemia worked differently. Most inpatient ward teams consist of an attending, a senior medical resident, one or two interns, and medical students. Each member of the team is “on service” for 2-4 weeks after which they rotate to different parts of the hospital or to the outpatient or research setting. As a result, a patient admitted to general medicine today is taken care of by a completely different team than took care of her 3 months earlier when she came in for the same problem.

On leukemia, our medical team included an advanced practice nurse (APN) who did not rotate off and on service. Being on the inpatient leukemia team was her primary responsibility 365 days a year. When I wondered if a patient admitted for chemotherapy needed an interval CT scan, she would remind me that the patient had just received one a month earlier. When the patient later developed a rash that I considered getting a biopsy of, she reassured me that the rash looked no different than the one the patient had developed the last time she received chemotherapy. And when I was trying to determine which prophylactic antibiotics to discharge the patient on, she contacted the primary oncologist to get his opinion and, if necessary, arranged prior authorization for medications that her insurance company might otherwise deny coverage for. Perhaps most importantly, our APN was a constant presence for patients fighting a disease that wrecked havoc on their bodies and their lives.

Often when the medical team finished examining a patient, the patient would ask to speak to our APN privately, no doubt to receive additional emotional and psychosocial support, something that is terribly lacking in many patients with chronic disease, yet serves to reduce treatment breaks and improve adherence and identify co morbid conditions such as depression that are common but often go unnoticed.

Then there was the weekly leukemia conference I was reminded to attend. Thinking I was walking into another research lecture, I was surprised to learn that this meeting was really a “tumor board” in which new and active patients were discussed. Sitting around the expansive conference table were leukemia attendings and fellows, advanced practice nurses, social workers, case managers, and the inpatient leukemia team. We began by discussing the admitted patients with my team providing the updates and the outpatient oncologist providing context and overall direction. ... We then discussed the new patients — while multiple leukemia specialists went back and forth formulating the diagnostic plan and initial chemotherapy, the case managers and social workers figured out how to best coordinate the dozens of steps required to place a central line, draw routine blood tests at home, and schedule chemotherapy and follow up visits. Finally, everyone was encouraged to bring up concerns about any patient on the roster.

In general medicine, doctors are often left to deal with complex medical and social issues with little input from others. Though I’m in a large group practice of over 100 primary care physicians, we have no clear and formal mechanisms for asking and receiving advice from each other on individual patients. In addition, despite the fact that many of the day-to-day challenges of primary care center around not the medical but rather the socioeconomic determinants of health, I do not have access to dedicated social work and case management services.

At the conference we each received a roster of all the patients the group was actively managing. Each line of the roster included the patient’s name, date of birth, type of leukemia, and treatment plan – nothing surprising. But in addition, it included the name of any clinical trial or research protocol the patient was on. Flipping through the roster, I was stunned to see that virtually every patient was enrolled in a research study of one sort or another. Those who were not in a study of a new experimental chemotherapy or drug (Phase I or Phase II trial) were instead on a study to collect and track patient responses to an established leukemia treatment.

General medicine is no less cutting-edge than leukemia; many of our treatments have no good data supporting their use and new drugs come out each year. And yet, to my knowledge, I don’t have a single patient in my practice on a research protocol. Worse still, we don’t even analyze our own data. If you asked me what the average HbA1c is for my patients with diabetes, I couldn’t tell you. In comparison, the oncologists at my hospital can report their institutional survival rates for specific types of leukemia by age of diagnosis, gender, and ethnicity.

This dedication to building evidence was matched by a commitment to use the available evidence. At times it almost seemed as if they were speaking another language. Sentences often were punctuated by phrases such as “per the CALBG 10580 protocol” and frequently, recommendations were accompanied by specific citations from the oncology literature. In primary care, most of our recommendations are based on experience or habit; seldomly we may refer to a consensus guideline. It’s no wonder, then, that studies show it takes 7-10 years after a new guideline or seminal study is released for practice patterns to change. It’s not that such data doesn’t exist — it’s that often we just aren’t using it.

(to be continued later this week)

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