What if doctors worked like dentists? (Note to dentists, I realize that you are doctors too)

This week there was a hilarious video If Air Travel Worked Like Healthcare that parodied the inefficiencies and frustrations many of us experience with the healthcare system.   The video reminded me of a recent visit to my dentist, he was commenting on having to wait at our local emergency room for hours with his son who had potentially broken his arm.  He commented “if I ran my office like they run that emergency room, I’d be out of business in a month”.   

It made me wonder, what would it be like if my family doctor worked like my dentist.

Every six months my dentist calls me to book a preventative care appointment for cleaning and check-up.  My dentist offers evening and weekend appointments that make routine cleanings easy and convenient to book.  Every few years my dentist ensures I have x-rays updated; his office keeps track of that screening schedule and calls me to book the appointment.  During my appointment I spend most of my time with the hygienist who does all the cleaning and routine exam before calling in the dentist for a 5 minute consultation and chat.   If I require urgent care from my dentist his office will makes sure I am seen right away (usually the same day).  The continuity of my dental care is maintained by my dentist.

My family doctor (like most GPs) doesn’t believe in annual well visits so there are no preventative care appointments.    It is my responsibility to track my own periodic screening schedule (such as pap tests) based on government approved clinical guidelines and schedules that seem to change quite frequently. When I remember to call for my screening appointment it will take six months to book a ‘non-urgent’ appointment and I will have to mark it in all my calendars because no one from my doctor’s office will call to remind me.  My work/family schedule will have to accommodate the appointment when it comes due because rescheduling will mean 6 more months of waiting.  When I visit my doctor, she takes care of 100% of the visit.  If I require urgent care I usually find myself in a walk-in clinic or emergency room.  The continuity of my medical care is scattered among many providers.

In my ideal, imaginary healthcare system my doctor would run her office like my dentist.  All my preventative appointments would be monitored by her office, they would call me when I was due and it wouldn’t be my doctor who took care of these appointments, but an RN or even LPN.  My doctor’s office would also track and schedule my screening appointments and book me in within a reasonable timeframe that would include evening and weekend appointments.  Again, my doctor doesn’t need to perform these routine screenings, a nurse or nurse practitioner can with my doctor providing a brief consultation following the screening.  If I require urgent care that is not acute, I would be able to visit my family doctor within a day or two and the continuity of my medical care would be maintained in one office.

Last week I wrote about Prognostications and Health Policy citing the OMAs decision to not provide annual physicals.  This week the Washington Post ran an article Don't Open Wide, Annual Check-Ups Are Pretty Much Useless.  We could find all kinds of holes in both the OMAs decision and the research cited by the Post, but it is infinitely more enlightening to look the Mayo Clinic’s recently published a study Why Patients Visit Their Doctors: Assessing the Most Prevalent Conditions in a Defined American Population  

Here are the top 10 reasons people visit their family doctor

1. Skin disorders
2. Osteoarthritis/joint disorders
3. Back problems
4. Cholesterol problems
5. Upper respiratory conditions (not including asthma)
6. Anxiety, depression and bipolar disorder
7. Chronic neurologic disorders (such as Parkinson’s and Alzheimer’s diseases)
8. High blood pressure
9. Headaches/migraine
10. Diabetes

It seems strange to me that while family doctors don’t see a need for preventative care, they do spend the majority of their time responding to patients dealing with chronic conditions that could be prevented. 

I believe it's time to have a chat about the future of preventative care.  Who is responsible for monitoring it, what is the best way to manage it, how do we position government policies to incent it, how can healthcare consumers and practitioners work together and where does new technology fit in to keep everyone living to their optimal health.

It’s your health.  It’s your health information.  Manage it well. 

Prognositcations and Health Policy

This week a number of interesting articles and announcements occurred.  The annual Consumer Electronics Show in Las Vegas provided lots of fodder for the quantified self-movement and prognosticators from around the world were exclaiming health innovation predictions for 2013.  Much of the exciting news centred on mobile health solutions, quantified-self tools and the emerging role of the consumer in the future of healthcare.

Mixed into all of this the Government of Ontario (Canada) and the Ontario Medical Association (OMA) announced that healthy people don't need physicals.   The agreement to eliminate the service will save millions of dollars in what the OMA claims are unnecessary tests and procedures as part of the annual physical or Periodic Health Examination (PHE).  In Canada, physicians and governments control the healthcare system and when they create a void by taking a service away such as annual physicals, one would think there would be an obligation to educate healthcare consumers on how to fill that void. 

Wow, I thought, what an incredible opportunity for the medical community to promote digital solutions for self-monitoring health status as a replacement for the annual physical.  What a great policy window for a government to offer tax rebates to consumers who purchase digital monitoring devices to self-manage their health.  But that didn’t happen.  Medical associations, while denying any value in annual physicals, continue to deny the effectiveness of digital self-monitoring. 

So, if the OMA claims that annual physicals are unnecessary, what is the role of physicians in preventative health care?  Who will benchmark an individual’s health status and who will assess and monitor an individual’s risk for chronic illness given that many factors are behavioural but many are also inherited? 

We know that chronic illnesses (diabetes, hypertension, arthritis, asthma, COPD and types of cancer) are creating a tremendous burden on healthcare systems around the world.  We know that managing chronic illnesses costs $190 Billion annually  in Canada and in the US, total direct and indirect costs from chronic disease were estimated to be $1.1 Trillion in 2003 (last time data was available).  We know that chronic illnesses are largely preventable. We know that certain behaviours increase our risk for chronic illness (smoking, being overweight, poor eating habits).

Preventing chronic illness and managing risk factors should be a collective priority for healthcare consumers, the medical community and governments. 

That said,  I don't oppose this shift away from physician-centric annual physicals but I want my primary care provider to acknowledge the role of self-monitoring and I want her to work with me to build our collective capacity in interpreting data from self-monitoring devices.  We need physicians and governments to agree on standards for self-monitoring devices that work from existing clinical practice guidelines and approved risk assessment tools.   We need them to partner with us.

Programming devices to alert individuals when their health is at risk is here now and it’s easy; however, having the medical community endorse the use of digital devices is a battle we will see played out for years to come.  The Fainting Goat optimistically predicts that annual physicals will be replaced by digital monitoring by 2015!!!  Well, maybe 2017 ... anyone for 2020? 

It's your health.  It's your health information. Manage it well. 

Connecting the Dots: Reflections on 2012

In 2012 a man with prosthetics ran in the Olympics, we landed a vehicle on Mars and someone jumped from the edge of space.  It was a year of truly amazing scientific advances.  

Steve Jobs once said, “You can’t connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future.”  As I look back on some of the ‘dots’ I can see a pattern of evolution and discovery surrounding personal controlled health information percolating among health technology innovators.   I see momentum growing and I believe we are on the verge of meaningful access to our personal health information.  This movement will empower us to measurably improve our health and provide evidence of the benefits of collaboration between healthcare systems and healthcare consumers.

Here are my top 7 DOTS from 2012. 

1. Dave deBronkart (US) @ePatientDave is the original epatient passionately promoting the most underutilized resource in healthcare, the patient and he should know, he beat the odds and is alive today to tell his story.  Dave deBronkart: Meet e-Patient Dave Dave did it, you can do it too, just say Gimme my Dam Data.
2. Salvatore Iaconesi (Italy) @xdxd_vs_xdxd  - 39 year old Salvatore Iaconesi lives with with terminal brain cancer (an “unwanted passenger” in his body) and wants to transform the meaning of the word "cure” and the role of knowledge. He cracked the codes to his clinical records on September 10^th and posted them online inviting the world to respond to his CT scans, MRIs, lab notes and glioma diagnosis in whatever way they want.  Salvatore also spoke at TEDx in Rome The Cure where he explained how he took the hundreds of thousands of responses to build his personal strategy to combat his brain cancer. 
3. Richard Van As and Ivan Owen (South Africa & US)  – a year ago Richard lost 4 fingers from his right hand, around the same time, Ivan created a mechanical hand that could be worn and operated by a person’s actual hand.  Richard lives in South Africa and was searching the internet for a solution to his health issue and Ivan lives in the US and posted a video of his mechanical hand on YouTube.  The internet brought them together and for almost a year, the two have been engaged in an online collaboration to equip Richard with a prosthetic hand.  You can read about their story here Coming up Shorthanded.  
4. John Wilbanks (US)@23andme - John is a genome adventurer, his work on Pooling our Medical Data includes accessing his genome through 23 and Me and publishing it online to learn even more through international genome researchers and analysts.
5. Brian Goldman, MD (Canada) @cbcwhitecoat – ER doctor and host of CBC Radios White Coat Black Art.  His weekly show provides an important perspective of the healthcare system in Canada.
6. Berci Meski, MD (Hungary) @Berci – Medical doctor with PhD in genomics, his tweets are always informative and forward thinking with an eye on how technology can advance medicine.
7. Andrew Spong (UK) @andrewspong – with a focus on health communications Andrew circulates a wealth of information on patient-centred care.

There are many more inspirational people out there working to improve access to personal health information.  The movement is growing in strength, what will 2013 bring? 

All the best for a happy, healthy year. 

Fainting Goat