Tuesday, May 26, 2015
Cancer
I recently finished reading The Emperor of All Maladies by
Siddhartha Mukherjee. It is the story
of the study and treatment of cancer – one of the most stubborn scientific
puzzles ever faced.
A part of the story that I found interesting was the
intensive competition among the treatment modalities – surgery, radiation and
chemotherapy – each controlled and represented by a different medical
specialty.
I remember being told at one point that a study conducted in
a major cancer hospital found that the treatment chosen was determined
primarily by the specialty of the physician who first saw the patient. If it was a surgeon, the patient would be
operated on, if a radiation therapist, radiation would be used and chemotherapy
in the case of a medical oncologist.
That seems to be changing.
The May issue of Modern Healthcare had an article about the cancer
program at the University of Tennessee Medical Center, which claims that 60% of
its cancer cases are treated according to an evidence-based protocol. The article also said that “New cases are
presented at weekly cancer conferences….and a multidisciplinary team develops
patient treatment plans.” I noted that
it did not say “all new cases” and that there was no discussion of how disagreements
were resolved.
I asked a medical oncologist friend about that. He said that there are also weekly interdisciplinary
conferences at his institution, at which new cases are presented. Individual physicians decide which cases to
bring and after a case is discussed, the physician who brings it makes the
final decision on the course of treatment.
He remarked that while there are well established treatments for some
types of cancer and that those treatments are almost universally applied, there
are other types for which the best treatment is not yet scientifically agreed
upon and that in those cases, the specialty of the patient’s physician still
influences the selection of treatment.
I suspect it works somewhat the same way at the University
of Tennessee.
So patients still cannot be assured that they will be
treated according to institutionally adopted, evidence-based protocols, but the
situation is better than it used to be.
Thursday, May 07, 2015
Non-profit vs For-profit
There is concern in Massachusetts about a reported decline
in the quality of care following the purchase of ten nursing homes in the state
by Synergy Health Centers, a for-profit nursing home chain (Woes follow nursing home chain’s arrival,
The Boston Globe, May 5, 2015). The
article discusses similarly reported declines in nursing homes recently purchased
by Genesis Health Care and Zenith Health Care Group, two other for-profit
chains.
It all poses the issue of what role for-profit enterprise
should play in the provision of health care services.
Professionalism is a very important component of our health
care culture. We believe that those who
provide diagnosis, treatment and care should put the patient’s interest over their
own. They should not behave in ways that
are of financial or other benefit to them but are of no value or damaging to
their patients. The reason we don’t let
doctors sell medicine is because we don’t want them to be tempted to make money
by prescribing a drug the patient doesn’t need or might find harmful.
As our health care system moves towards financial mechanisms
that incentivize providers to do less rather than more, we will see whether the
for-profits can discipline themselves to resist the temptation to withhold
needed services in order to increase profits for investors.
To some extent that will also be an issue for non-profit
providers but the absence of private investors looking for a return will reduce
the intensity of the temptation and public ownership will provide a more
effective means of redress if they succumb.
