Tuesday, May 26, 2015


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. 


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