Inadequate Communication Between Hospitalist and PCP is Detrimental To Patient Care

The American health care delivery system is reaching a point of crisis.  Its costs are escalating as outcomes and quality of care are diminishing.  It focuses on crisis management and treating problems aggressively with medicines and interventions of uncertain benefit, while neglecting true health and wellness.  It is estimated that 1 trillion dollars annually is being spent on unnecessary care, much of which occurs in the hospital, and some of which leads to harm. Medicare, although concerned about rising health care costs, does little to address the real issues and actually but subtly encourages aggressive management when less could indeed be more.  Hospital acquired infections and death from medical errors are far too numerous, often occurring in patients who did not have to be hospitalized in the first place.  Patients and physicians are frustrated, while private insurers and both Medicare and Medicaid are becoming unable to fund this excessively costly care without raising premiums or exhausting trust funds.  Something certainly must be done.

We wish to focus on one glaring problem occurring in hospitals that is relatively easy to fix and whose resolution could improve outcomes.  Currently, as many hospitals close their doors to primary care physicians (PCPs) and instead rely on hospitalists, there often is a lack of communication between these doctors that can lead directly to costly mistreatment.  A true and common story will set the stage.

Mrs. P suffers from dementia and lives in a nursing home.   One day she became unresponsive.  The nurse on duty could find no obvious reason and so immediately called 911 and sent her to the hospital.  While she quickly woke up, the emergency medicine physician admitted her for further evaluation.  Her assigned hospitalist found bacteria in the urine and treated her for a urinary tract infection, calling in an infectious disease consultation and starting her on a potent intravenous antibiotic.  He also requested consultations from a cardiologist and a neurologist to determine the cause of her unresponsiveness, and they ordered further tests including an MRI and an echocardiogram.  Mrs. P became more confused, was exposed to aggressive evaluation and treatment, and was losing her strength as a result of bed confinement.  She was ultimately sent back to her facility after tens of thousands of dollars of medical care, worse off than when she arrived.  She was fortunate to have not suffered further harm from her hospital-induced delirium and the potent medicines she received.

Let’s dissect what happened, and why.

The emergency medicine physician was faced with a lethargic person who could not give a coherent history, hence she was subjected to an extensive work-up and then admitted to the hospital. The hospitalist, likewise, was faced with a patient he had never met before, with only the emergency room records as guidance. He detected neurologic, infectious, and cardiac problems and so called for specialist consultations and extensive testing. 

It is unfortunate that the nursing home nurse did not call the patient’s primary care physician (PCP) upon transfer, but it was even more unfortunate that her PCP was not contacted at any time during her emergency room stay or subsequent hospitalization by any of the doctors who saw her.  Had they called Mrs. P’s PCP they would have learned that she had a long history of progressive dementia and similar unresponsive episodes in the past that had been fully evaluated. Further, they would have learned that she always carried bacteria in her urine without tissue invasion and that she could have received any of her treatments in the nursing home where she would have been safer and more comfortable, at a far lower cost.  A recent study showed that 20% of hospitalized patients who receive antibiotics develop an adverse event so avoiding unnecessary antibiotics must be a top priority.

The growth of the hospitalist movement over the past twenty years has been truly phenomenal – at 50,000 physicians it is the largest medical sub specialty, surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000. Studies suggested that quality was improved and costs reduced with hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something increasingly difficult for the community based PCP to achieve.

The hospitalist is experienced in managing the types of medical issues that lead to hospitalization and works full time in the hospital. As a result they come to know how to “get things done” and potentially can give more efficient care. But they are far too often burdened with large numbers of patients, and often know very little about the patients they are treating. With too many patients to care for and too little information they tend to request consultations for problems that, given adequate time, they could have managed. This is especially problematic if the patient has multiple medical issues and is elderly. Other reasonable concerns are the diminishment of the patient-physician relationship and miscommunication and discoordination at both admission and discharge.  Communication with the patient’s PCP however could alleviate many of these issues.

PCPs have been – generally – content to allow the hospitalist to manage their patients, indeed it has been a major advantage for many. PCPs have seen their overhead costs rise dramatically, necessitating seeing more and more patients per day for less and less time each in order to cover those overhead costs. The multitude of rules, regulations and requirements foisted upon them by the insurers has further consumed extensive time, time that previously could be used to care for their hospitalized patients. Today, many PCPs do not have time to see patients in the hospital, while others are barred from doing so by hospital rules. 

In this situation, both PCPs and hospitalists could have improved Mrs. P’s care substantially, and reduced the cost of unnecessary care, simply by communicating.  A call or text by the hospitalist to the PCP upon admission and at various decision points might have enabled Mrs. P to leave the hospital before any consults were called, before extraneous tests were ordered, before antibiotics were initiated, and before she became more confused and weaker.  More than half of elderly patients leave the hospital worse off than when they came in, and involvement of a PCP in a patient’s care could potentially facilitate more rapid discharge and less aggressive treatment. 

A recent survey indicated that 95% of hospital leaders are concerned that discharge communication is “inefficient” and 80% have concerns about communication among care team members.  PCPs complain that they are never called. Hospitalists often state that they just don’t have time to call the PCP but when they do, the PCP is not available. Each is culpable. Each must remember that the issue at hand is the patient’s care and welfare, not their convenience or preferences. It is a matter of professional responsibility. What could help? The electronic medical record was supposed to solve these sorts of problems but it has not and probably will not in the foreseeable future. There are some HIPPA compliant texting systems which could be utilized and there are HIPPA compliant smart phone apps that can coordinate among all involved physicians, nurses, hospitals, other facilities and even the patient him or herself. One of these types of systems could potentially negate the issue of non-availability although it will not top the value of nuanced conversation among physicians. 

In the end, there is nothing that trumps good physician to physician communication. It must be incumbent on hospitalists to involve PCPs during in-patient stays and it must be incumbent on PCPs to respond to hospitalists and provide crucial insight and information when asked to do so.   Not only can outcomes be improved, but costs can drop and patients and their families can feel more comfortable knowing that their own doctor is involved in their care.  If necessary, hospitals should set policy that makes hospitalist to PCP communication mandatory; everyone will benefit.  Very basic solutions can frequently lead to profound improvement. 

 

This post was co-authored by 

Andy Lazris, MD, CMD  a primary care physician whose private practice focuses on geriatric patients especially those residing in long term care and assisted living facilities. He is the author of Curing Medicare and co-author of Interpreting Health Risks and Benefits and was first published on Medical Economics on July 29, 2017

Solving the Crisis in Healthcare Requires Solving the Crisis in Primary Care

There is a crisis in the provision of primary care in the United States. If you are a patient, a primary care doctor, an insurer, an employer or a policy maker, this crisis is exceptionally important to you. The crisis means that Americans do not get the level or quality of healthcare that they deserve and need. This crisis is the major reason that healthcare in total is so expensive and why costs keep rising. This crisis needs to be fixed and fixed as quickly as possible. Fortunately, a solution exists that is within reach. It will be a disruptive and transformative change so it will not come easily to a profession that is “conservative” by nature. My new book Fixing The Primary Care Crisis, addresses all of these issues in easy to read language.

Contrary to what many assume, PCPs are much more than providers of “simple” stuff. They are more correctly specialists that deal with the very complex. Comprehensive primary care includes wellness and health maintenance, prevention and risk management strategies, attending to the episodic events that occur in life, and especially the care of those with complex chronic illnesses including coordination of care when a specialist is needed. It also includes developing a strong relationship between doctor and patient, building trust along the way and offering true healing. This means that the PCP can competently handle the vast majority of our health needs. To appreciate this is to begin to understand why the current system just does not and cannot work and why it needs to change.

The fundamental problem is that primary care doctors (PCPs) care for too many patients with too many short visits per day, and as a result do not have the time they need to provide high level care. They need time to listen, time to think, time to give quality preventive care and time to offer care of complex chronic illnesses and to coordinate care for those actually do need a specialist referral. They also need to be able to build a trusting relationship with the patient and to offer true healing, something that also takes time. In other words, they need time to practice their profession, something they currently are unable to do fully or effectively.

This crisis has led to a culture of highly frustrated doctors who feel they are on a never ending treadmill, and are leaving private practice or retiring early. It means that patients are equally frustrated at the long waits, short visits, high costs and no sense of being listened to, of not receiving empathy, of not being actually cared for. The crisis means that there are currently not enough primary care doctors, and it will only get worse because students in medical school see the impact of this crisis and choose not to enter primary care as a result.  It’s a downward spiral that needs to be reversed.

The crisis began a few decades ago when insurers, beginning with Medicare, held reimbursement rates low (cost control through price fixing). At the same time, doctors’ office costs were rising. In order to meet basic overhead expenses while maintaining their incomes, PCPs began to see more and more patients per day. The average PCP’s income in 1970 was slightly more than today (in inflated dollars) but the PCP was seeing only one half the number of patients as today. Now, with about 25 or more patients per day, a visit is often only 15 to 20 minutes: actual “face time” with the doctor is just 8-12 minutes. If you’ve been a patient recently, I’m sure you’ve experienced this. While this amount of time is long enough for a simple problem, it is much too short for someone with a complex issue, or someone with multiple chronic diseases and taking multiple prescriptions. And it is not nearly long enough for an elderly person with impaired vision, hearing or cognition. There is no time for compassion, to build trust or to be a healer. Since there is too little time, the tendency is to send a patient off for tests or to a specialist when a bit more time with their history would provide the answer. There is not enough time to discuss lifestyle changes, meaning it is easier to just write a prescription and hope for the best. It is these steps that are the major cause of higher and higher medical care costs in the United States: unnecessary referrals, unnecessary tests, unnecessary X-rays and unnecessary prescriptions. And with it has come the loss of the close and trusting doctor-patient relationship and the lack of true healing.

When PCPs do have time, they can develop a trusting relationship and then give superb preventive care. This type of care will reduce serious chronic illnesses in the future, the diseases that today account for 75-85% of all medical costs. When they do have time, PCPs can treat the vast majority of issues brought to them by their patients without the need for specialist referrals or excessive testing. When PCPs do have time, they can coordinate the care of those patients that truly do need to be referred, ensuring high levels of quality at a reasonable cost. When PCPs do have the time, they can appreciate the underlying stress and anxieties that propel so many illnesses and trips to the doctor. When PCPs do have time, they can give truly proactive preventive care – population health - by reaching out now rather than waiting for the patient to arrive with a problem.

To address this crisis, both patients and PCPs will need to take charge and change the paradigm of primary care. Government will not do it. Insurers will be slow at best to do it although there are some examples to the contrary that we’ll explore in this book. A few enlightened employers are beginning step up as we shall also explore. But if there is to be real change—change that works—it will take PCPs and patients to force the issue. Patients need to demand the time they deserve. PCPs need to be able to give them the necessary time. This means fewer patients per PCP. Patients will need to migrate toward doctors that have 800 or less patients (compared to today’s standard of 2500 or more) and can therefore give them more time as needed.  The actual number per doctor should depend on the demographics of the doctor’s patient panel (the doctor’s patient load)—for example, a panel of mostly older individuals with chronic illnesses means fewer patients. Fewer patients means more time for each patient and much better access to the PCP. We’ll take a look at what some innovative physicians, insurers, and employers are doing—separately—to transform primary care and bring it back to being “relationship medicine” with a heavy emphasis on health and wellness and the care of complex chronic illnesses in addition to typical episodic primary care: true comprehensive primary care. One of many innovations is to not accept insurance and charge a reasonable amount per visit according to a posted price list. Another is using some form of “direct primary care” (DPC).  DPC comes in many variations and is known as membership, retainer or concierge medicine, but in essence it means charging a flat rate by the month or year for all primary care services, reducing the number of patients under care to about 500 and offering same or next day appointments for as long as necessary and access to the PCP via his or her cell phone twenty four hours per day and via email. It means comprehensive primary care not just episodic care: attention to health and wellness, reduction of risk factors, preventive actions, intense management of chronic illness and coordination of specialist care when needed and a return to relationship medicine with trust and healing. The latter is essential if we want to move from a reactive to proactive approach to healthcare. That means much improved care quality and satisfaction, and lessened frustrations for patients and doctors alike. Often it means generic medications at wholesale prices and laboratory and radiology at deeply discounted rates. Despite a widespread belief to the contrary, DPC is not just for the elite, the rich or the 1%. In fact, it can be quite reasonable – “blue collar” –  and, when DPC is combined with a high deductible health insurance policy (which is much less expensive than typical policies,) the savings for patients are substantial and the total costs of all care decline quite dramatically.

Among other options is capitation, as in some Medicare Advantage plans, but where the payment to the PCP is sufficient per patient that he or she can afford to have a reasonable total number of patients. Another is for insurers to create incentives for reducing patient numbers. Yet another is for employers to create their own primary care clinics with a low employee to physician ratio or to offer a payment into a health savings account (HSA) to purchase the membership in a direct primary care practice. One additional example is to place extensive primary care resources for the management of the “sickest of the sick,” often the socioeconomically disadvantaged with insurance via Medicaid – a team of PCP, nurse practitioner, nutritionist, mental health therapist, etc. We will explore each of these and other options.      

In all of the examples cited in the last two paragraphs where the PCP to patient ratio is reduced to a manageable level, the care quality goes up and the total costs of care come down very substantially. Throughout Fixing The Primary Care Crisis, we’ll look at the details of how that can be.

Fixing The Primary Care Crisis explains the crisis and its origins. It details what outstanding primary care can be for patients and society as a whole. It explains how and why illness has changed from the acute infectious diseases of the past (e.g., typhoid, pneumonia) to complex chronic illnesses (e.g., heart failure, diabetes with complications, kidney and lung disease) of today and why chronic illnesses now constitute 75-85% of all healthcare costs. It reviews how healthcare insurance went from covering unexpected expensive medical care (“major medical” and the catastrophic) to now include primary care; how employers have adjusted their assistance by expecting employees to pay a larger and larger portion of premium plus co-pays and deductibles. It then delves into some of the approaches referenced above that are being taken to return primary care to true relationship-based medicine.

Finally the book ends with a chapter that gives explicit recommendations to patients, doctors, insurers, employers and academic medical center leaders to effectively transform primary care to achieve the outcome of the very best care in a cost effective manner that improves quality yet reduces the total costs of care.

Together, this crisis can be solved with much better care, much improved satisfaction, much less frustration by patient and doctor alike, much less total money spent and with many more students selecting to become primary care physicians thus resolving the PCP shortage. It will be a win for everyone. But the change will only occur if and when patients become educated and then advocate for the new paradigm.  Fixing The Primary Care Crisis provides the information needed to make that transformation happen.

Aging Gracefully Part 4 Comprehensive Primary Care For The Elderly

Comprehensive primary care is essential to good health, wellness and needed medical care during our elder years. It is critical to Aging Gracefully.

In the last few posts I wrote that Aging Gracefully physically requires attention to lifestyle/behaviors to assure good nutrition, plenty of exercise, reduced stress, no tobacco and – for preserving cognitive function – intellectual challenge and social engagement. That is what each of us needs to attend to but we also need a good primary care physician (PCP) to assist us on our journey. That PCP needs to have adequate time to listen and listen fully.

The Erickson Living retirement communities have developed an approach that appears to work well for its residents. Let me use it as an example. The fundamental concept is to assure that everyone has comprehensive primary care. The Erickson leadership learned that healthcare was of paramount importance to their residents. A strong program would be good unto itself but also a strong marketing attraction. After substantial study and trial and error they set the resident/patient number per doctor at a remarkably low 400 for their in-house salaried PCPs. They found that this 400:1 ratio was the ideal number of elderly geriatric residents per doctor in order to assure the quality, humanistic and integrative approach to care desired. (For comparison, the usual patient to PCP ratio is about 3000:1.) They have clearly demonstrated that this approach to primary care with a low number of patients per doctor (and a team that functions akin to a medical home) not only gives superior care but that it results in much reduced total costs of health care overall. 

According to the medical director, Matthew Narrett, MD, residents can have same or next day appointments for as long as needed, they are offered extensive preventive care (“It is never too late to prevent,”)    the PCPs are well versed in gerontology issues  and there is a strong commitment to listening. Some of the results of this approach: Chronic illnesses can be managed usually quite successfully without the need for referral to specialists but, when needed, specialists are readily available (many conduct office hours on site on a rotating basis eliminating the need to travel to a distant office). Hospital admissions are down absolutely and markedly so in comparison to equivalent groups of elderly individuals. The length of stay in the hospital for those who must be admitted is lower and the 30 day unanticipated readmission rate has consistently been below 11% (the national rate is about 20%plus) despite the average age of their residents being about 82, i.e., one would expect their average rate to be higher than the national rate for Medicare-covered individuals overall. Dr Narrett reported that resident satisfaction was very high. I confirmed that when I was at the Charlestown community to give a talk organized by residents. With no staff present, I asked the 90 or so attendees their impression of the healthcare program. I received only positive accolades.

At the Charlestown and Riderwood communities where I have toured (and other locations) the onsite clinic includes not only the PCPs, but one or more nurse practitioners, a podiatrist, and a suite for a visiting dentist, for an optometrist and for an audiologist. The podiatrist is full time (at the larger communities) but the others are there commensurate with the need. Various outside medical and surgical specialists (e.g., cardiology, gastroenterology, dermatology, orthopedics, etc.) offer office hours on site on a scheduled basis. The clinic has an on-site nurse to coordinate special needs such as preparing for surgery, returning to the community from the hospital, transferring to assisted living, arranging in-home special needs care, etc.

A Medicare Advantage Plan is also offered by Erickson Living to residents of their group of 18 continuing care retirement communities. In the Erickson plans (administered through United Healthcare) one can choose the on-site PCPs or continue with one’s own PCP, can access a wide range of specialists when necessary, can use most any hospital, can be driven to most off-site doctors’ offices at no cost, etc. Unlike Traditional Medicare where one must spend three days in the hospital in order to be eligible for Medicare to pay for the first 100 days of residential skilled nursing care,  this Advantage plan waives the required three day stay. In other words, if the resident would benefit, the doctor can make the decision and can arrange immediate referral to their on campus site. This of course eliminates a very costly and potentially hazardous hospitalization. There is also an on-site benefits specialist to assist residents with their questions. The most common plan costs substantially less than one might pay for both Medigap and Part D policies yet it includes greater benefits (e.g., basic dental) with few co-pays and no deductibles. 

Older individuals perhaps even more than others need comprehensive primary care. It is a critical aspect of Aging Gracefully. Unfortunately, most older people do not have the benefit of a PCP who can spend the time they need.

My takeaway from the Erickson model is that when the PCPs are allotted the needed time and can listen and think, the care is excellent, satisfaction is strong and the total costs come down substantially. It also means that the PCP can get back to relationship medicine where trust builds and healing is possible.

I am not advocating for Erickson Living or that you move to a retirement community but my recommendation is definitely that you seek out a PCP who can and will offer the time you need to assure good healthcare so that you can Age Gracefully.

Disclaimer – I have no financial relationship with Erickson Living. It is used solely as an example to demonstrate the utility and value of a PCP (along with a well-functioning team) who can offer each patient the time necessary for comprehensive primary care.

Lack of Listening is the Core Problem in American Health Care

The Crisis in Primary Care – Part 4

There is and will be a need for many more primary care physicians (PCPs).Why? There is a shortage now and it will be exacerbated in the coming years for at least four reasons. The population is growing, the population is aging and there will be more individuals with health care coverage as a result of the Affordable Care Act (“Obamacare”). I believe that the need will be much greater than the estimate of 52,000 in 2025 as proposed recently in the Annals of Family Medicine. The authors did not address this fourth and particularly important reason driving a need for more PCPs.  If PCPs actually cared for only a reasonable number of patients, perhaps 500 to 1000 (depending on demographics) rather than today’s common 2500+,  such that they no longer were seeing 24-25 or more patients per day in their offices, then the need for more PCPs would be much greater. With fewer patients seen per day, the PCP can then spend the time needed to listen, to prevent, to coordinate and to think – four key activities that they often are not able to do effectively today. This drives a need for substantially more PCPs.

The need is not to graduate more total medical students but to make primary care desirable as a medical professional career. This means overcoming the current non-sustainable business model so that graduates once again will select primary care.

Here is an example of the value of a primary care physician being able to take the time needed to thoroughly listen to a patient and assess the situation. The PCP saw a lady one day that he had known for many years. She was always very enthusiastic and very articulate. One day she came in for a routine visit. The PCP noticed that her speech patterns were slightly different than he remembered from the past. No one who did not know her well nor anyone who had only a brief conversation would have recognized her speech as changed. She was unaware and felt fine. The changes were subtle but they were clearly changed in his mind. The rest of the history was unremarkable. He did a neurologic exam which was also unremarkable. But he was certain that something was amiss. So he ordered an MRI of her brain. Her insurer refused because she had no specific indications with an otherwise normal history and examination. He had to call multiple times and explain his rationale; finally the insurer relented. The MRI showed a primary brain lymphoma – treatable, probably curable. 

 

The message is simple. The PCP knew his patient well and because he had the benefit of an extended visit time he was able to notice the subtle changes in her speech pattern. His skill combined with a long history with his patient and adequate time made all the difference and probably saved her life. 

Compare that experience to the following story sent me recently.  

“My mother's "real world" story is mostly about a cardiologist but touches on the very problem you describe about PCPs in a brief but pointed way.  

“I took my mother to the cardiologist this week. He spent a good amount of time with her, mostly listening, trying to figure out her medical issue. Once he thought he'd hit upon what was causing the problem and the solution (which happily, did not involve a drug or surgery but behavior modification), he said he'd call her internist who she has been seeing for many many years to tell him about the discussion. My mother waved her hand dismissively and said, "He doesn't know me." The cardiologist looked surprised and a little confused but I understood. My mother was saying that her internist had not spent time listening to her and getting to know her unique situation like this cardiologist had done. 

“My usually non-compliant and defiant mother called me the morning after her appointment to report she had done what he recommended and would continue to do so. His unhurried gentle questioning, sympathetic listening and obvious desire to figure out how to help her is what made my mother trust him. I felt that my mother had actually consulted with a physician - a healer.” 

There is both a good and a not so good side to this story. The good is obviously that the cardiologist listened to her and then developed a plan of action – with her and her daughter - that she could accept and follow. The not so good or even most unfortunate is that she felt her PCP that she had visited for many years didn’t really know her – because he did not listen.  

When doctors do not have enough time to really listen the result is that they do not listen. A study from 1984 of primary care physicians observed throughout patient visits revealed that the doctor interrupted the patient within 18 seconds on average. Relating to this article, Koven commented on KevinMD “In only 17 (23%) of the 74 visits was the patient provided the opportunity to complete his or her opening statement of concerns. In 51 (69%) of the visits the physician interrupted the patient's statement and directed questions toward a specific concern; in only 1 of these 51 visits was the patient afforded the opportunity to complete the opening statement.”  This is not only remarkable but a sad commentary on the short visit and the lack of attention by physicians to actually listening to the patient.

This lack of listening is the core care problem in American healthcare today. It is prevalent, pervasive and getting worse, not better. It is the inadequate income per patient (by whatever payment system – fee for service, capitation, etc. -- is used) that is driving the lack of listening. Today the PCP sees too many patients for too little time each. Until the payment system is corrected and, in return, doctors get back to listening, healthcare will not be true care and certainly not healing. Call this a future combination of shared rights and responsibilities – the doctor earns a decent income in return for offering superior care to a reasonable number of patients. This would be a good balance all around. And although primary care would cost more, the total cost of care would come way down. 

My next post in this series will address the “paradox” inherent in today’s American medicine.

 

 

Improving Cancer Patient Care While Markedly Reducing Costs

It is often difficult to appreciate that improving the care of patients can actually reduce the costs of care. Last year Dr H Brody wrote in the New England Journal of Medicine (vol 362, p283-5) about “Medicine’s ethical responsibility for health care reform – the top five list.” In essence he challenged physicians to be first to find ways to rationally reduce health care costs by identifying the top five tests or treatments in any given specialty or subspecialty that could be markedly reduced or even eliminated without harm to the patient. He made some specific suggestions to get things started.

Now Drs.Thomas Smith and Bruce Hillner, two oncologists from the Massey Cancer Center in Virginia, have accepted the challenge and published in the same journal (vol 364, p21, May 26, 2011) a proposed list of five suggested changes in medical oncologist’s behaviors and five changes in attitudes and practices. Their proposal is noteworthy because it directly addresses some of the most important issues that affect cancer patient care yet inordinately increases the cost of that care.

I will not repeat each of their suggestions but will comment on a few. One change in behavior is to limit chemotherapy to patients with a good performance status (with an exception for those with highly responsive disease.) It is well known that a person’s performance status is a very strong predictor of whether a patient will respond to a treatment or have any meaningful extension of survival. The authors point out that their proposal is in line with current guidelines by national oncology organizations. They make the simple recommendation that a patient should not be given chemotherapy if he or she cannot walk into the clinic unaided. Unfortunately, many oncologists today push ahead with further treatment despite their patient’s performance status.
Another suggestion is to “replace the routine use of white blood cell stimulating factors with a reduction in chemotherapy dose in metastatic solid tumors.” The hematopoietic colony stimulating factors (CSFs) are very valuable in pushing the bone marrow to recover white blood cell numbers after aggressive treatments. The concept is that infection is common when the white blood cell count drops below 500 per ul. This is a common occurrence in the treatment of acute leukemia and some other situations where very aggressive chemotherapy is used and the CSFs can be lifesaving in those patients. But they are not needed for modest reductions in WBC counts. In truth, drops below 500/ul rarely happen in the treatment of patients with most solid tumors such as breast, prostate, lung or colon cancer. Yet these very expensive stimulants are used routinely but at high cost. Smith and Hillner suggest that at about $3500 per injection, the sales by oncologists to their patients’ amount to some $1.25 billion per year.
And there is the rub – to change these two practice patterns would be to substantially reduce the oncologist’s income. Oncologists earn a decent but not high income from basic care of their patients. But fully another one half comes from the administration of chemotherapy and support medications such as drugs for nausea and vomiting and drugs to boost the bone marrow to produce red blood cells (erythropoietin) and white blood cells ( pegfilgrastim, Neulasta). In effect they serve as a pharmacy for these drugs, buying them wholesale from distributors, preparing them and administering them while collecting a markup for their effort. This brings their incomes to among the highest among internists. To cut back on chemotherapy or Neulasta administration would have a telling financial impact.
Another suggestion, this one a change in attitude, is to address the importance of end-of-life discussions. The authors point out the truism that such discussions are a critical perquisite to good care planning by both doctor and patient and family. But they point out that far too often, oncologists wait until new symptoms appear or until they feel there is nothing else that can be done before entering this type of discussion. But when such discussions are held at an appropriate time, there is greater use of hospice and “less depression or anxiety, less aggressive end-of-life care and [patients] rarely die in an intensive care unit or on a ventilator.” Further “it allows the surviving caregiver to have a better quality of life and would save our society millions of dollars.” And yet, such discussions are all too infrequent or come too late. It is the physicians’ obligation to their patients and patients’ families to be honest and direct, albeit caring and compassionate at the same time.

With these changes (and some of the others that Smith and Hillner recommend) in behaviors and attitudes, the care of cancer patients would be greatly improved yet the costs would be very greatly reduced. That is a good exchange. Let’s hope these suggestions become the norm of care and that physicians in other specialties take up Brody’s challenge as effectively.