Sunday, March 28, 2010

Fast Food

I attended the 7th Taming of the Queue conference last week. It’s an annual meeting that brings together a wide range of provider groups, administrators and policy makers to discuss wait times in health care. One of the themes this year was appropriateness of care.

One of the conference participants pointed out the subjective nature of the term “appropriate care”. While a group of critical care specialists in the ICU may feel it is inappropriate to put a 92-year-old man on life support after he has suffered a ruptured aortic aneurysm and has no reasonable hope of recovery, the man’s family may request that all life-prolonging measures be undertaken. My intent in this post is not to debate the various facets of inappropriate care, but rather just to recognize that it does occur, and can cause harm to patients as well as wasting resources in the health care system.

It’s not infrequent that I will finish a consultation visit with a patient and think that I didn’t provide much value to him. Here’s an example:

A 52-year-old man is referred by his family doctor. The referral request reads “Swelling in scrotum. U/S attached.” The man has noticed a swelling in the right side of his scrotum, gradually increasing in size over 5 years. It is not painful and doesn’t interfere with his activities. He’s in good health.

Physical examination shows a 6 cm swelling in the right scrotum, consistent with a hydrocoele (see below). The ultrasound (U/S) of his scrotum confirms the physical findings.

I explain to him that a hydrocoele is a common, benign condition that occurs when fluid accumulates in one of the tissue spaces in the scrotum. It doesn’t become a cancer and doesn’t damage the testicle. For most men, no treatment is necessary. If a man does wish treatment – because the swelling is painful, or it interferes with activity – then the fluid can be drained using a needle (temporary relief, as the fluid will return), or he can have surgery. The surgery is a minor procedure to remove the fluid and surrounding sac in which it accumulated.

The man says that he is not bothered by the swelling, and just wanted to “be sure” that there was nothing serious going on. He doesn’t want any further treatment.

From my point of view, I didn’t provide much value for this man. He had a benign, common condition that had been definitively diagnosed on the ultrasound exam. (A urologist would probably have been confident in making the diagnosis solely on the basis of physical examination, but I don’t think I would expect every primary care practitioner to be confident without the ultrasound result.) He didn’t want any treatment, just reassurance. From my point of view, that reassurance could have been offered by his family physician.

This is my subjective impression only. Many patients are quite pleased to have come in for their consultation and received this reassuring news. They feel that it has been a very valuable encounter, as they’ve had their anxiety (about cancer or organ damage) allayed.

But, could they have received the same reassurance from their family physician? There are some possible explanations why that didn’t happen in this case:

Knowledge – FP not familiar with the differential diagnosis and management of scrotal swellings

Skill – FP not familiar with the examination techniques to diagnose scrotal swellings

Attitude – FP not confident enough of skills/knowledge in order to reassure patient.

Physician-patient relationship – Patient may not trust the advice/diagnosis of FP, or may have an expectation that a specialist referral will be offered.

Of course, each of these possibilities could be phrased differently, e.g. “Knowledge - Urologists have not adequately communicated with family physicians about the management of common scrotal swellings.” My point is that I’m not blaming anyone, just pointing out that there are deficiencies in the FP-specialist consultation process that lead to inappropriate referrals/poor patient value.

I was curious about how often these “low-value” visits happen in my practice, so I looked back over the last 2 weeks of office visits. I reviewed visits from March 10-23, looking at new consultations only. (I’ve addressed the appropriateness of recall visits/internal demand in previous posts such as “Total Recall” and “Do You Recall”.) I reviewed the consultation letter I sent out and applied a completely subjective set of criteria to determine whether or not the referral was appropriate. As noted above, my impression of appropriateness is probably different from that of the patient or of the FP. (So let them write about it in their own blog.)

Initially, I tried to capture appropriateness in categories like:

Appropriate – specialist care needed (e.g. urologic cancer, surgery, unclear diagnosis with urologic symptoms)

Appropriate – FP could manage the problem, but would require special interest/experience in urologic problems

Inappropriate – problem within the scope of general practice (e.g. man with enlarged prostate and having trouble passing his urine – could be started on medication, or man with benign condition (hydrocoele, see above) could be reassured by FP)

Inappropriate – not a urologic condition (but, how do you know that ahead of time?), or testing used inappropriately that lead to an abnormal result and urologic consultation (e.g. PSA screening in men over age 75)

That started to get unwieldy so, as this was just going to be a quick-and-dirty audit, and not a scientific paper, I settled on this principle: Was I able to offer something to this patient that was unavailable to them through a “reasonable” FP? I’m using the term “reasonable” in the vague legalese sense. (I’m not a lawyer, but I’ve watched a lot of “Law and Order”.) If not, or if there had been inappropriate testing done, then I judged the referral inappropriate.

Over the 2-week period, I saw 57 new consultation patients in my office. Of those, I felt I gave good value to 49 patients. I was quite generous with awarding “good value”. The remaining 8 referrals were:

A man referred with difficulty passing his urine. He had been given the proper medication by his doctor and it had markedly improved his symptoms. He was satisfied with the results, but hadn’t continued the medication because his one-month trial prescription had expired and he hadn’t been given another prescription. I gave him the prescription.

Hematospermia (blood in the semen) – 2 patients – this is a common reason for referral. The condition is almost always benign, and serious problems (prostate cancer) are ruled out using physical examination and a blood test, both of which are accessible to FPs.

Inappropriate testing – 3 patients – One man had his PSA blood test taken while he had an infection, thus causing a false result and needless anxiety and referral. Two men over the age of 75 had PSA blood tests done to screen for prostate cancer. This is not recommended by preventative health organizations.

Hydrocoele – see the case earlier in this post.

Peyronie’s disease – another fairly common, benign condition affecting the male genitalia. As with hydrocoeles, the diagnosis is confirmed on taking a history and with physical examination. It usually does not require intervention, and this man did not want intervention, only reassurance.

Out of these 57 new consultations, I judged that in 14% of cases, I didn’t provide much value, or that patients could have received the same value without needing to see me.

In a 2005 paper “How good is the quality of health care in the United States?” (The Milbank Quarterly, Vol. 83, No. 4, 2005, pp 843-895), Schuster et al reviewed papers that looked at care provided for conditions ranging from depression to hysterectomy. They concluded that 30% of patients received “contraindicated” acute care and 20% received “contraindicated” care for chronic conditions. They point out that their figures don’t represent the exact levels of quality, and would require more precise analysis of the reviewed studies. They list many examples of where inappropriate care (overuse, underuse and misuse of testing and other resources) may harm patients and waste money.

We’re hearing more and more about overuse of xrays such as CT and MRI. (I mentioned this in “Bang for your Buck”.) This is important to recognize because shortening wait times through increased capacity (new CT scanners, longer hours of operation) doesn’t necessarily translate to better quality care for patients. In this case, there is even the potential to harm patients by providing better access. As the tests become more easily available, more doctors are likely to request them (appropriately or not), thus subjecting patients to the risk of radiation and false-positive (benign, yet alarming) findings.

So, how do we make sure patients are getting good value for the effort and expense they invest in coming for a specialist consultation?

We tried to do this for men who were being referred for vasectomy reversal. We found that men were being referred with the intent of being booked for the reversal surgery, but that many of them didn’t actually want the surgery. They just wanted to hear about what was involved, what the cost would be, and how successful it was. Even though they may not have ended up booking the surgery, men were generally satisfied with the visit because I had answered all their questions. (You could argue that they were satisfied with the visit because they thought this was the only option available to them. Perhaps if they became aware of another solution – see below – they would be very unhappy at having driven into town just for a conversation.)

We put together an information package detailing the vasectomy reversal surgery, costs and success rates. Whenever an FP referred a man, we sent the package both to the man and the FP. We asked the man to review the information and, if he still wished to pursue things further, to call us for an appointment. In the trial period, we sent out 22 packages. Only 2 men asked for further consultation. I hope the other 20 men still received good value. (FYI – we sent out satisfaction surveys with self-addressed, stamped envelopes with the 22 packages, but received scant response.)

After hearing about appropriateness of care at Taming of the Queue, I think that it is more helpful to frame “appropriateness” as the value that patients receive or perceive. I don’t mean that the patient’s desires should necessarily trump scientific evidence or resource constraints, but I think using the term “value” helps us focus on the patient’s needs, and how we can best serve them.

As wait times for specialist consultation, diagnostic testing, and surgery decrease, we must remain aware that our primary intent is to improve the quality of care we provide. Access is only one aspect of quality in health care. If we provide timely access to poor quality care, we have harmed our patients.

Fast food is not always good for you.


  1. I understand your message. But perhaps for the 52 year old man with the scrotum issue, he got great value. Some things don't come down to dollars and cents but dollars and sensitivity. There doesn't seem to be a flood of men with this issue lining up in the corridors from St. John's to Vancouver so if a brief visit to a specialist to calm fear and anxiety is warranted, then so be it.

  2. Thanks, Anonymous.

    There's a quote attributed to Henry Ford that says "If I had asked people what they wanted, they would have said 'Faster horses'".

    Anonymous, I agree that, if patients feel they get value out of such specialist visits, then they should have that visit. As I mentioned in the post, the concept of "appropriateness" is subjective, and will be interpreted differently by patients, FPs, and specialists, to say nothing of administrators and politicians.

    What I would like us to consider is whether or not patients find the specialist visit valuable because they can't imagine any other way to get the resolution of their problem. In the case of the man with the hydrocoele, I suggest that the FP could have diagnosed and explained the condition, given the treatment options and indications for intervention, and then referred the man if he chose to have surgery performed.

    As it was, the man just wanted "faster horses", that is he wanted to see a specialist as soon as possible. What if we as health care providers used our creativity to design other options for him, in the same way that Ford designed the Model T? If this man had other choices, such as having the problem resolved by his FP within a few days, rather than waiting a few weeks to see me, would he find that valuable?

    Certainly, we would have to change the system so that there was communication between FP and specialist to address areas of uncertainty and gaps in clinical knowledge. There would also have to be some incentive built into the system to promote a more convenient way for patients to have their problems resolved.

    I agree that the man felt he got great value out of his visit with me. But, perhaps that's because it was the only solution he could imagine. Part of our job is to create
    a better solution.

  3. You have presented an interesting scenario where the value to the physician is incredibly different from the value to the patient.
    By your own review, this happens about 14% of the time, though I suspect prescription renewal and a diagnosis confounded by infection are viewed as poor value by patients as well. However, the other four patients were probably very concerned until they saw you. As I read your post, I was concerned out of fear that your low-value assessment meant there was no cure for his ailment. That said, I fully agree his family physician - with the right knowledge - could have provided the same service.

    British Columbia is hoping to address this challenge by compensating physicians for communicating with one another. We are hoping family physician's will seek advice from consultants and avoid referring the patient unless necessary. Based on pilot projects and taking into account the time needed to make the phone call, we are hoping Specialist can increase their capacity by 5% to 7%. Patients should receive more timely care, whether from the family physician or the specialist. We are also hoping for improvment in the relationships between physicians, and the relationship between patient and family physician.

  4. Thank you for responding to my entry. The Ford analogy is an interesting one. Ford indeed developed the Model T and made it available to the masses is any colour they liked, as long as it was black. It was GM who introduced different colour and styling to the automobile industry in the 1920's and by the end of that decade captured huge market share from Ford. They offered the consumer choice. In the scenario you portray, the man could have been served by his GP...or a nurse practitioner...or some other professional, thus offering some choice in the system. But he wasn't. It was you. And for that man, thank God you were there. As a man myself, I am very sensitive to that man's feelings. Sensitive in a way that only another man can be and in a way that a woman is not capable of so I am glad that a professional man was there for him. As a taxpayer, I have no problem with this resolution, but would absolutely agree with you that his GP should have been able to address the matter. This assumes of course that the GP had the knowledge. There is great waste in the health care system. The scenario you describe is worthy of consideration but is not a leading culprit. Perhaps we need to look more closely at the over-management of hospitals... executive perks... useless, or even worse, dangerous bureaucracy, ie Ontario's creation of LHIN's...and that's just to start. Again, I am glad you were there for that man. If a GP is not fully confident to address a similar concern for some other man, I hope that you will be there for him too.