Tuesday, September 29, 2009

Prostate teams

I had dinner tonight with a grateful prostate cancer patient who was able to take advantage of our Cyberknife to receive targeted radiation therapy. But what especially impressed him was the fact that he was able to meet with a medical oncologist, a urologist, and a radiation oncologist all at the same time to help him decide on his treatment plan.

Our approach is to help each man understand the nature of his disease and clearly present the relative value of treatment options -- open surgery, laparoscopic surgery, traditional radiation, radioactive seeds, Cyberknife, and watchful waiting -- in a direct, unbiased fashion.

Until tonight, I thought that every place did this, but apparently not. One of our urologists at the dinner told me the story of a friend of his in New York who had been diagnosed and was wondering where to go and what to do. He advised his friend that there were lots of good hospitals and doctors there, and the key was to find a place that offered an interdisciplinary team. His friends searched and searched but was unable to find a place that offered this kind of team. Well, one place offered a team, but did not offer the full range of treatment options.

Now, maybe his friend did not do a full survey or missed some program, but he was clearly an informed consumer, and he could not get what he needed. I'm curious to see if this is typical of other people's experience. Please comment here.

11 comments:

Barry Carol said...

Shared decision making is a great idea, but I wonder to what extent insurers will pay for a team consult of this type. How much does it cost? How long does it usually take and does it have a billing code?

Anonymous said...

Certainly on the community hospital level (where most people outside Boston receive their care, (:) I have not heard of such a team, ever. It's pretty reliable that the urologists will recommend surgery, the radiation therapists radiation, etc. - if the stage of the disease is not so advanced that the different options remain. This is a wonderful idea and I imagine that it would be cheaper in the long run, Barry.

nonlocal

Paul Levy said...

Barry, I'll get the answer for you from our folks. Short answer, though, is that it takes more time and effort, and I can't imagine we get paid for the differential.

Nonlocal is certainly correct that it avoids "silo" choices of therapy, aka, "when you have a hammer, everything looks like a nail." Breaking down the disciplinary mindset is exactly the idea.

adena said...

I was recently treated at BIDMC's breast clinic for breast cancer. They also offer an interdisciplinary team approach, which is so helpful (oncologist, surgeon, radiation oncologist). After meeting with the team, I had a clear treatment plan. From others, I've heard of bouncing around to different doctors trying to make a plan, and wasting valuable time...

jessica lipnack said...

Such a simple idea, bringing together the treatment team WITH the patient, rather than each specialist in isolation speed reading notes (if that), and speaking separately with the patient. I've just witnessed a patient receiving different information from different doctors, sometimes from people in the same practice with contradictory beliefs, and completely conflicting information from people in different departments. In the (NY) hospital where I've camped out for the past two months, the doctors in related fields often don't even know one another.

Boundary-crossing communication may be the most economical way to reduce the cost of patient care. It's really true: talk is cheap.

Barry Carol said...

Paul and nonlocal,

Just to clarify, I’m a big fan of shared decision making. The more empowered patients can be the better as opposed to the doctor just saying “here’s what we’re going to do” and expecting the patient and family to just passively accept his or her judgment.

The prostate cancer process described by Paul seems to lend itself, at least in part, to the development of DVD’s for the patient and family to take home and watch. In addition to reviewing the treatment options available depending on how far the disease has advanced, it might also include brief interviews with patients who have already gone through it and talk about the treatment option they chose and why as well as how they felt about it both before and after. Upon digesting that information, the patient and family could then meet with the team. The meeting may not need to be as long and could well be more productive as the patient and family will already have some familiarity with the options and will be able to more fully explore the issues important to them.

As I understand it, this process is already in place for more elective procedures like hip and knee replacement and back surgery. The challenges relate to breaking down the silos among physicians and getting paid adequately by the insurer and the patient for the time and effort required.

Anonymous said...

Barry;

Excellent idea. I have a close friend who went to the Cleveland Clinic for valve surgery. They had him and his wife view a video with all the gory details of the surgery, the day prior to the procedure. She was a nurse so she was OK with it, but he had a panic attack right on the spot and they had to call someone to calm him down! Certainly the chance to view something like that ahead of time might have been a better venue.

nonlocal

Anonymous said...

Barry - you are right, the challenge is to break down barriers between physician silos. The fee for service structure of our health care system rewards silos - and multidisciplinary teamwork gets punished, not rewarded, in current models of physician and facility reimbursement. In our BIDMC multidisciplinary clinic a new patient will typically spend 2 to 3hours speaking to 2 or 3 physicians from different specialties (urology, radiation oncology, medical oncology) but instead of having incentives for such patient-centered care, docs and hospitals are punished for having multiple specialists see a patient because payors/providers (eg Medicare) limit facility fee (component of reimbursement that is intended to cover overhead such as cost of the clinic space where a patient is see) payments to be equal to the facility fee of a single doctor visit (which would take one-third the time, and incur accordingly less overhead expense). So to provide a multidisciplinary clinic service the hospital and doctors must adopt a "long-term vision" view that what is better for the patient is ultimately also better for the hospital and doctor. This requires an outside-the-box business strategy that places value on what really matters: patient well being. A barrier to more widespread adoption of such a cancer care model is that payors (Medicare, Blue Corss, etc) have shown little more than lip-service interest in care quality measures that focus on patient-reported satisfaction with their care quality.
BIDMC Prostate Doc

Anonymous said...

Your team left out proton beam radiation. Even if your hospital doesn't offer it, it is something that your patient might have liked to consider.

Anonymous said...

I am just beginning reading Christensen's "The Innovator's Prescription" (at the suggestion of e-patient Dave.) I'm only on the first chapter, but it already addresses the stupidities in our system noted above by BIDMC Prostate Doc. I look forward to reading the "prescription" part.

nonlocal MD

Anonymous said...

in response to the fan of protoon beam: proton beam should probably not be considered a standard care option for prostate cancer, because it has no benefits over standard IMRT radiotherapy (despite marketing claims) while it costs about 5 times as much, and is only available at a handful of elitist medical centers that make obscene profits at the expense of less priveleged patients, doctors, and hospitals