A New Paradigm for Care: Readers Respond to the Challenge

A New Paradigm for Care: Readers Respond to the Challenge

Editor’s note: In a recent issue (CONSULTANT, August 2012, page 547), Dr Gregory Rutecki described a telemedicine program at the University of New Mexico, the Extension for Community Healthcare Outcomes (ECHO), in which subspecialists and primary care practitioners in underserved areas use a video interface to discuss cases and share relevant information. Initially, the program focused on hepatitis C, but it has since been expanded. Dr Rutecki asked, “If ECHO becomes a new paradigm for additional locations and diseases, do you feel up to the challenge of becoming a combination primary care provider and subspecialist?” Here readers respond.

I am a National Health Service Corps scholar who has worked in a rural community health center and in prisons, and I have been both the telemed provider and the recipient of telemed assistance. I had a chance to review the ECHO database, and it looks like they have a great system. Especially exciting is the possibility to work with a chronic pain specialist, because addiction, overdose, and death related to opioids were a huge challenge in my rural community. I think “force multiplier” is an apt analogy, because I took the information I learned from the notes written by our University of California, Davis, colleagues, and applied it broadly to appropriate patients.

One thing that seems very exciting about ECHO is the potential for real collaboration. I have had no end of difficulty in interacting with specialists, not due to maliciousness on their part, but because their support systems are built to keep us apart. Secretaries, medical assistants, office managers, and hospital
telephone operators are generally trained to act as a filter, limiting access to the physician. This is incredibly important: as a primary care physician, I have been paged many, many times at 3 AM with patient requests for medication refills and other non-urgent issues. However, at some point the filtering system lost the ability to distinguish a physician requesting assistance with a case from a patient who wants to make sure their prescription for acetaminophen is filled before the pharmacy opens. A system like ECHO can allow us to work face-to-face in a way that promotes collaboration, but will still allow the specialist to manage the interactions and stay efficient.

To answer your question, you bet I’m up to the challenge!

——Mike Noonan, DO

Thanks for such a positive response. You have experience in advancing collaboration comparable to ECHO, so I am excited to hear and learn from you!

——Gregory W. Rutecki, MD
Professor of Medicine
University of South Alabama College of Medicine
Mobile

Regarding Dr Rutecki’s commentary on the Extension for Community Healthcare Outcomes, the video interface format for the management of hepatitis C is valid but does not address the real reason that primary care physicians are challenged in the management of this and other complex disorders. It is not a lack of knowledge or interest; it is a lack of adequate reimbursement for such time-consuming activities. Reimbursement schemes almost mandate a rapid through-put of patients. Time-consuming problems get sent to specialists in order to “keep the numbers up.” Sad but true.

——Keith Nichols, MD

I wholeheartedly agree. This is another example of something that is great for patients, requires primary care time and effort, but does not resonate enough with payers to warrant reimbursement.

——Gregory W. Rutecki, MD

Pitfalls in Practicing Medicine by the Numbers

I read Dr Gregory Rutecki’s editorial “Is the History and Physical Worth Doing Anymore?” with interest (CONSULTANT, January 2012, page 16). The fascination with new methods goes beyond expensive imaging techniques.

Reliance on biochemical laboratory analyses and comparison of results with reference ranges (sometimes called “normal” ranges) as a virtually exclusive input to diagnosis and treatment decisions runs roughshod over individual patient differences. Reference ranges are statistically derived and thus apply to any one individual patient only by the laws of probability.

Here’s an example: a “normal” individual has a greater chance (1/20) of being outside the 95% reference range than of rolling snake eyes on a pair of dice (1/36). These odds are not all that long. But comparing two lists of numbers just seems more scientific than discussing signs and symptoms. And more patients can get cranked through a numerical algorithm that takes less office time and effort.

Jerome Groopman, MD, put it wonderfully: “But today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers. Statistics cannot substitute for the human being before you.”¹

—— P. Hill, MSN, NP

REFERENCE:

1. Groopman J. How Doctors Think. Boston: Houghton Mifflin Company; 2007.

A Leafhopper by Any Other Name

Regarding the article “Acute Otitis Media: 6 Steps to Improve Diagnostic Accuracy” (CONSULTANT, December 2011, page 917), I want to offer one minor correction.

Figure 4 (shown here) depicts a “grasshopper” in a child’s ear canal. Having enjoyed various aspects of entomology as a hobby, the mislabeling of a leafhopper as a grasshopper is much like watching TV with my medical background and seeing a chest x-ray hung up incorrectly in the background. More amusingly from a biologic view, it is like calling bat a rhino. The insects are that unrelated.

True, there may exist very tiny grasshoppers, but most are much too large to fit in a child’s ear when mature. The insect depicted is a mature insect, since it possesses wings. It will not grow any larger.

Leafhoppers, sharing similar habitats and behaviors as grasshoppers, are common insects. Most people ignore them as they walk through grassy areas. The insects are those little critters that leap out from the person’s footstep just before being crushed.

—— Mark D. Schmidt, MD