Bob Buckley: Good outweighs the bad in medical advances

The Examiner

The changes in medicine in my lifetime have been exponential. As a result, the quality of care has improved in many respects. For example, cancer treatment has improved dramatically. I recall attending a seminar in the early '90s and a physician-speaker made the bold statement that most patients do not survive metastatic cancer.

Shortly after this seminar, I began representing a woman who had metastatic breast cancer. I consulted with one of the leading breast oncologists in the world and he told me that I should let my client know that she should get her affairs in order because her life expectancy was very limited.

Bob Buckley

As it turned out, he was correct as she died while our case was still pending. Another client had a similar outcome from metastatic breast cancer and so the speaker in Chicago and my breast cancer expert were correct. Yet, treatment of breast cancer has improved.

Other forms of cancer treatment have also improved. Advances in treatment of leukemia is an example of improved treatment. Acute promyelocytic leukemia is not only treatable, but can actually be cured. I have often wondered where we would be today in cancer treatment if we had spent half of the money we spent on wars in the Middle East on cancer research.

The technology of surgery has changed too. Robots are now performing many surgeries. The surgeon must still guide the robot, but surgical technique has improved as a result of the robots, provided the operator has the requisite skill and training.

Minimally invasive procedures have increased too. Yet, I have experienced firsthand the results of unskilled providers performing minimally invasive procedures. My only caution is to those undergoing such procedures is to make sure that the surgeon has extensive experience. The “practice of medicine” has additional significance in those settings.

There are three other changes that have occurred in medicine: the advent of the hospitalists, nurse practitioners and electronic medical records. I have seen the good, the bad and the ugly with each of these “advances.”

The term “hospitalist” was created in the 1990s. Dr. Robert Wachter is one of the founders of hospital medicine. It was created in large part because of Medicare. Medicare reimbursed hospitals a fixed payment based on the discharge diagnosis. Physicians were paid on a “per day” basis.

Hospitals attempted to reduce the length of stays and costs of care, but many physicians still prescribed longer inpatient recovery times, so hospitals began to look for physicians whose incentives and motives were in line with new hospital policies. The financial crunch on hospitals made change necessary.

Other factors drove the change. When primary care doctors went to the hospitals to make rounds, they were not in the office seeing patients, looking at tests and responding to patient needs so they could see one or two patients in the hospital. It became obvious that this was not an efficient way to provide patient care.

The data clearly showed that hospitalists were an economic aid to the hospitals. Since hospitalists spent all of their time at the hospital, they could help health care become smoother and more efficient. A primary care doctor who is used to treating patients in non-acute situations was not as equipped to handle acute situations, whereas the hospitalist had more experience in such cases.

The drawbacks of hospitalists also became obvious. If the primary care doctor was not involved with the patient in the hospital, the separation leads to a possible void in the care. The other problem is that there is not continuity of care as a hospitalist might be present for a day or two of the hospitalization and then is replaced by a substitute who must start from scratch learning about the patient.

Hospitalists are not able to engage in long-term care either. Hybrids have been developed in some hospitals so primary care doctors rotate into hospitalist practice so they can provide continuity. There are many challenges with hospitalist medical care.

A similar issue exists with nurse practitioners. Some advanced nursing education programs provide nurse practitioner training in gerontology, family practice, pediatrics and women’s health care, but others are only providing family practice training. This works well for nurse practitioners in primary care practice, but there is a question whether family practice training is adequate for a nurse practitioner working in acute care. I am sure the nurse practitioners will vehemently disagree with me, but I have some experiences to support my position.

We see nurse practitioners in specialized fields such as cardiology, orthopedics, neurosurgery, neurology, pulmonology, hematology and infectious diseases. Their training in these fields is clinical “on the job training” and many do a superb job, but an orthopedic doctor spends five years after medical school learning his or her craft, and a nurse practitioner handling post-operative care does not have their training or experience.

The final area of change has come with the advent of electronic medical records. I plan to address some of the issues with electronic medical records in my next column. It may seem as if I am opposed to these advances in medicine. While I have seen the bad and the ugly, I will also argue that the good far outweighs the bad and the ugly. I understand medical economics, but I also understand quality patient care. They should not be mutually exclusive.

Bob Buckley is an attorney in Independence. Email him at bbuckley@wagblaw.com.