Lessons from a Family History

Given that my wife and I are highly overeducated physicians and Ashkenazi Jews that have been thinking about our family plans, we decided to go in for pre-conception Genetic Counseling.  Although neither of us have strong family histories of genetic diseases, we know enough (too much?) to know that we are at risk and would benefit from any advanced knowledge.  So far the experience has been very pleasant (because we haven't gotten any results yet) and quite instructive, teaching me a few lessons about health care.

Lesson 1: Glad it wasn't a physician
You can imagine that trying to get two doctors to a doctor's office during business hours takes just a little of scheduling wizardry.  I must compliment BIDMC's OB department for getting us in quickly and taking us back on schedule.  We were met by a genetic counselor who took both of our family histories and placed them on a pedigree.  While we do not have very large families, this is still a time-intensive detailed process. However, I felt that it proceeded very quickly and efficiently as our counselor was able to only ask necessary questions.  It was upon this realization that I was glad I was not speaking to a doctor.  Not that I have anything wrong with doctors, but I know that in order to justify certain levels of billing for a visit, they have to ask a lot of inane and useless questions.  (The family history normally falls in this category, for how is the family history of 95 year old woman going to help me figure out what is going on today).  Those useless questions are externally imposed by payment regulators, and while they seem harmless, are incredibly wasteful.  Now imagine all those useless questions for two people!  Needless to say I blocked out 2 hours for this visit and I was glad that we were out in 1 hour including blood work.  Had it been a doctor I can imagine it probably would not have gone so smoothly.

Lesson 2: What is the family history?
Now, not to knock it again, but in my field of Internal Medicine the family history often feels like an obligation, tacked on for billing purposes and not really helpful to diagnosis or management.  We satisfy the requirement by asking at least one question "No one in the family has cancer, right?" But then I got to thinking about information in an ideal medical system.  Although I have not seen this implemented, we have the ability to link medical records together for the purposes of keeping a true family history.  For example, let's say that both you and your mother see doctors who have an integrated medical record.  She could be in New Jersey and you in Boston, but information knows no geography.  Now, if our record knows that she is your mother, then could it not also import her medical history into your family history?  Could this be repeated for entire family trees, making the family history a truly useful part of the history?  I know, I know, HIPAA, privacy, etc., often unnecessary hurdles to good care and information.  We could still maintain privacy in a number of ways: having the information queried but not present (i.e. you could "ask the record if anyone had colon cancer without identifying who exactly had it").

And yes, I checked with my wife before posting this.

Missing the Point?

I guess this counts as a meta-blog as I am commenting on an article over at Kevinmd.com.  Dr. Riner, an Emergency Medicine physician, former president of the American College of Emergency Physicians, and payor consultant reports on the limited utility of trying to keep patients out of the emergency room as a form of cost containment.  He presents data that suggest that deferring emergency care is dangerous, ineffective and does not save any money.  I have no grounds to disagree with his argument as presented.  But as an internist and hospitalist on the receiving end of the Emergency Room, I think he misses the point.  The savings is not in keeping people out of the Emergency Room, it is in keeping them out of the Emergency Room as a way of keeping them out of the hospital.

Given the unique financial incentives and horrid liability that ED doctors face, they have a very strong incentive to admit patients to the hospital.  The hospital is the dangerous, expensive vortex patients enter which drives such high cost in our society.  The Emergency Room is merely the largest portal into that vortex.  The problem, then, lies not with the Emergency Room, but rather with a primary care system ill equipped to care for complex patients outside of the hospital.

I cannot speak for others, but when I refer to keeping patients out of the Emergency Room, it is always in conjunction with keeping them out of the hospital as well.

I do agree with the Dr. Riner that trying to save money in the Emergency Room (like trying to save money in a primary care office) misses the point entirely.

PGP: Physician Group Practice or Pretty Grim Progress?

A recent Perspective in the New England Journal of Medicine by Gail Wilensky comments on the "sobering" results of the Physician Group Practice demonstration projects.  Dr. Wilensky references the full article and comments that while some disease metrics were improved, costs were rarely decreased, and patients were not kept out of the hospital/ER (which is why costs were not reduced).  At first blush, there should be at least some recognition that health outcomes were mildly improved for roughly the same cost increase as the control population.  That is to say, even if the care management programs were not the panacea that Medicare hoped, there was improvement.  That being said, I do not find it terribly shocking that these programs had such limited success.  We have seen time and time again that you cannot just wrap around a broken primary care system and except great results.