Most people today have never had a house call from their doctor. I confess that I’ve never had one myself. But I have made a few house calls in my time. There’s no doubt, however, that this practice is a dying art.

Bob Greene, writing in The Wall Street Journal, interviewed Dr. Charles Kemper of northern Wisconsin who practiced for forty years in the town of Chippew Falls, population 14,000. Dr. Kemper, now retired, is 98 years old and recalls a different era in medicine.

“The relief in their eyes,” said Dr. Kemper. “That’s what I saw when they opened the front door. There was often deep worry in their eyes, too, but the main thing I saw was relief; relief that I had come to their home, that I had arrived. That’s a look that a man never forgets.”

Dr. Kemper practiced from the 1940s to the 1980s. I began my career in 1975 when I entered medical school. Even then we were being discouraged from making too many house calls because of the limitations of such visits compared to the vast array of technology and resources available in modern hospitals. But something was being lost in the doctor-patient relationship.

Dr. Kemper still exhibits the “old school” attitudes of so many of the doctors I trained with and practiced among in the last forty years. “It was never a nuisance,” Dr. Kemper said. “If someone was calling at 3 a.m., I didn’t have to ask them if it was an emergency. They wouldn’t be calling me if it wasn’t. I was out of bed and out of the house within 10 minutes. I didn’t waste time asking if they thought it could wait until morning, Of course it couldn’t. They needed me there, and they needed me now.”

Unfortunately, there are fewer doctors today with his attitude. Even in my career I’ve seen a declining interest among younger physicians to see patients in the hospital emergency room, let alone make house calls. Doctor-patient relationships are taken for granted.

When I started my practice in the 1980s, it was routine for me to see every patient who needed an orthopedic consultation in the hospital ER. It was the rare case indeed when the ER physician handled the problem and simply referred the patient to my office. Today, it is just the opposite. It is rare when the orthopedic doctor-on-call actually goes to see the patient.

I know this because many people wind up in my office seeking treatment when they didn’t get it in the ER by the orthopedist-on-call. Even worse, many who show up in that doctor’s office a few days later are turned away because the doctor doesn’t accept their insurance. This is called “abandonment” by the legal profession and by the ethical standards of medicine of my generation.

This problem is not limited to orthopedics. Most primary care physicians today don’t even go to the hospital. They rely on “hospitalists”, physicians employed by the hospitals, to care for their patients when they are hospitalized. My “old school” primary care physician just retired and I’m having difficulty finding a new one who is willing to make hospital rounds.

Sadly, this trend is continuing from the era of Dr. Kemper, to my era, to the present generation of physicians. Doctors are forgetting that they have a sacred oath to care for the sick and injured whenever it is necessary; not just when it is convenient. The culture of medicine is changing, and not for the better.

This is why I oppose any system of healthcare that removes all incentives from doctors to provide the best quality care for all patients. Fee-for-service and an open market where patients can choose their doctors incentivizes doctors to do their best for everyone. They establish relationships and by doing so they build a reputation in the community that will last throughout their career.

On the other hand, single-payer systems, like Canada and the VA, remove all incentives for such quality care since patients have no choices in selecting their doctors. Doctors need not concern themselves with building a quality reputation when their income is standardized and the flow of patients is guaranteed. The result is sub-standard care, inefficiency and delays in treatment.

America has always enjoyed the best quality healthcare in the world. But changes in our culture and our healthcare system now threaten the future of that care. Only a return to a system that gives patients maximum flexibility in choosing their doctors and doctors maximum incentives to provide the best care possible can alter that future.

 

The pendulum is swinging back. Years ago chemotherapy for breast cancer was rare. Later, it seemed everyone received it. Now some are questioning that routine.

When I was a young surgeon in training I did mastectomies for women with breast cancer. Those who had no evidence of metastasis (spread of the cancer) received no other treatment. Those with metastasis received radiation therapy and sometimes chemotherapy.

As experience with chemotherapy increased and new drugs were developed, more chemotherapy was given. Many women with no evidence of metastasis still received chemotherapy after surgery. Today that practice is being re-evaluated.

Lucette Lagnado, writing in The Wall Street Journal, says the shift to less chemotherapy is being called “de-escalation.” Proponents of this shift believe many women have been overtreated with drugs that may have harmed more than helped. They believe chemotherapy should be reserved for those women who have a high risk of the cancer spreading.

Oncologists Differ

This de-escalation has created a rift between those oncologists who support this trend and those who do not. Cancer mortality rates have improved since the late 1980s and some researchers credit chemotherapy for this improvement. Although chemotherapy agents have been in use since the 1940s, current drugs are less toxic than the early days when nitrogen mustard was used. Side effects are less and ways to diminish their impacts on the patients have improved.

Dr. Steven Katz, a professor medicine at the University of Michigan, is a supporter of de-escalation. He says, “Tens of thousands of women were overtreated; they got surgery they didn’t need, they got radiation they didn’t need, and they got chemotherapy they didn’t need.”

Today patients are routinely given genomic testing to determine the behavior of their tumors. A low score means a woman has a good prognosis and won’t benefit from chemotherapy. A high score means a greater risk of recurrence and a need for chemotherapy. A middle score presents the greatest treatment decision challenge.

Katz and Stanford oncologist Allison Kurian published a study in the Journal of the National Cancer Institute. The study was composed of about 3,000 women with early-stage breast cancer treated by some 500 doctors from 2013 to 2015. The study revealed that the use of chemotherapy declined overall during that time from 34.5% of cases to 21.3%.

Other doctors are more skeptical. At New York’s Memorial Sloan Kettering Cancer Center, Dr. Jose Baselga says that while there is data to support forgoing chemotherapy on certain women with early-stage disease – and he had personally been prescribing less – these represent only a small fraction of patients. He believes others will die if chemotherapy isn’t given.

Another study published in The New England Journal of Medicine in 2015 looked at the treatment of over 10,000 women. Of these, 1,626 had early-stage breast cancer with no lymph node involvement. They were given hormonal treatment alone, without chemotherapy. Those with a low genomic test score had “very low rates of recurrence at five years with endocrine therapy alone.”

But others warn of their experience in the past. Dr. Gabriel Hortobagyi, has practiced oncology for over four decades at MD Anderson Cancer Center in Houston. He recalls the years when high percentages of women died from breast cancer. He credits chemotherapy for helping achieve the turnaround we enjoy today. He believes chemotherapy has saved “tens of thousands, maybe hundreds of thousands of lives.” But he stresses, “We have to do it responsibly and on the basis of the highest level of evidence. The worst toxicity is death.”

 

 

Technology is changing our world. Healthcare is no exception.

Andrew Arnold writes in Forbes of four technological innovations that are having an impact on our healthcare. He makes the following statements:

• Cloud electronic records improve access to health information
• Telemedicine is becoming more accessible
• Big data and artificial intelligence usage is going mainstream
• IoT devices and robots will improve the care quality

 

Cloud electronic records

Electronic medical records have largely taken over most hospitals and many physician offices after strong arm-twisting by the Obama administration. Those hospitals and physicians who refused to make the switch are paying now in the form of deductions of their Medicare payments.

While most of these institutions maintain their own records in house, a growing number are relying on cloud technology to provide storage. Arnold says the use of cloud technology for storage has two benefits:

• Patients can access their own records – by using passwords or key codes
• Multiple providers can access individual patient records – by sharing the passwords or key codes. He believes a national database of medical records is the next logical step.

 

Telemedicine

Arnold says millenials want much more control over their health and the care they receive. Furthermore, he says they are impatient by nature and don’t want to be bothered with ancient concepts like “making doctors’ appointments and getting treatment for what are non-serious conditions/illnesses. They prefer internet-based visits on their own time.”

He believes the solution is more telemedicine. Furthermore, this will improve healthcare in rural areas where fewer specialists are available. The use of video monitors may make it easier to have a conference with other physicians at the patient’s bedside. This may save lives in poorly served areas.

Bid Data and Artificial Intelligence

Pooling of data from sources all over the world will lead to improved diagnostic accuracy and treatment. He says:

• Providers can use data to develop better patient profiles and risk factors.
• Computers can predict the future effectiveness of treatment by analyzing data of past successes and failures.
• Reduction in provider costs – by predicting re-admission rates of patients and times of months and year of high and low demand. This will lead to lowered provider costs and presumed lower healthcare spending.

 

IoT Devices and Robots

This refers to devices worn by patients that monitor heart rates, blood pressure and blood sugar levels. Electronic stethoscopes and goniometers are now available in educational institutions. Arnold says this will lead to savings by reducing costly office visits that will no longer be necessary or alert providers to conditions that warrant immediate care and treatment.

Robotics such as the DaVinci surgical tool are currently in use for those procedures that demand greater precision through smaller incisions – such as brain and prostate surgery. Arnold sees robots providing many of the activities of nurse’s aids.

Count Me Skeptical

All of the above sounds great from the perspective of the outside world (those not providing healthcare). But as one who has been a physician providing care for the last 43 years (including training), I have a few concerns:

• Electronic medical records – These were supposed to revolutionize medicine and eliminate medical errors, reduce employee staffing, improve efficiency, promote communication across distance barriers, and reduce costs. None of these expectations have been fully realized. (For more on this see Electronic Health Records – Another Obama Train Wreck.)
  • Cloud storage may be a method of improved storage and facilitated recovery of information from remote locations. However, security has not lived up to the promises given and increased access by more people will only increase this problem.
• Telemedicine – This is no substitute for a “hands on” examination and “face to face” conference with your doctor. Millenials may be impatient but they will pay a price in lowered quality healthcare if they try to get their healthcare online without establishing a proper patient-doctor relationship. (For more on this see Beware Online Medical Treatment.)
  • Telemedicine does make sense for remote areas of the world where there is no other alternative.
• Big Data and AI – Certainly we should use increased data analysis to improve our understanding of disease processes and treatment outcomes. Orthopedics has been leading the way in this area for years with registries for outcomes in total joint replacement worldwide.
  • Reduction in Provider Costs – Don’t expect any savings by the hospitals to be passed on to consumers. They are not building bigger and fancier buildings by returning savings to those who pay the bills.
• IoT Devices and Robots – These devices may improve our ability to monitor our health (or our disease) better and may lead to improvements in treatment and recognition of emerging health crises. However, don’t count me excited to think that a robot will replace the human touch when it comes to nursing, even for nurse’s aides.

 

Arnold is certainly correct when he warns there is a risk with all this new technology. He says, “But with all of this promise comes a huge risk – security. And technology has had a hard time keeping up with the cybercriminals who are quite adept – just ask Experian or the IRS. A potential solution lies in blockchain technology, and some healthcare providers are already experimenting with it.”

I’m sure the cybercriminals will find a way to figure that one out, too.