Tuesday, November 09, 2010

I'm sorry, Doctor Famous is busy

What happens when a referring doctor insists that "Doctor Famous" see his or her patient, even when other physicians on the staff can do the job just as well? In Lean terms, waste is introduced into the system. As diagnosed below: The minute an additional seemingly unnecessary step is added to the flow it adds a huge delay. Here's an example:

A patient needed a certain kind of ultrasound. The hospital-based surgeon helpfully made the appointment call for the patient, telling the scheduling attendant that the procedure had to be done by one of two specific radiologists. Those radiologists only schedule those particular scans for a few hours a week, so the attendant quite properly replied that the next available times would be a few weeks hence.

The patient later wrote me to complain: Why would this all take so long to get scheduled?

I passed along the complaint to our chief of service, Jonathan Kruskal, who wrote:

I just wanted to get back to you about the patient complaint about scheduling an anal fistulogram. You may be interested to know that we have reviewed the actual telephone discussions that took place during the scheduling. (I am enclosing the tapes - How's that for an analytical tool!)

We developed this technique here at BIDMC and are the recognized authorities in the US. All of our ultrasound faculty can do this procedure, which takes less than 5 minutes to complete. The process issue here is that this physician only wanted Bob Kane or me to do this.

Obviously, Bob and I are not scheduled to work in ultrasound every day. To rectify this I trained all our staff to do this so that the studies can be scheduled every day.
If the doc had simply scheduled the study it could have been done on any day the patient chose, and Bob or I would happily have reviewed the study even if we had not actually done it. As we all know from work flow analyses, the minute an additional seemingly unnecessary step is added to the flow it adds a huge delay, which is what happened here. We have spoken to [the surgeon] about this, but s/he still prefers to have Bob or me do these.

We do these studies from 1-2:30pm because they can only be done on a single machine (no other local hospitals have these dedicated anal imaging machines) that requires time for setup and probe cleansing. It is this same ultrasound unit that we use for guiding liver biospies (by hepatologists) in day care each morning and for intraoperative ultrasound, so we need to keep it available during mornings when these typically take place.

We've been doing this for over 15 years. Patients are usually thrilled that we offer this unique high quality service. I've never had anybody complain about access before, especially since these are never urgent studies.


Anonymous said...

Of course, it would have been interesting to ask the surgeon why s/he desired only one of these two radiologists. How many of these studies has he ordered? Has he had poor experience with the other radiologists? Is there a training issue here? Or is it just because she "knows" these two?
Sometimes clinicians are reluctant to criticize individual hospital-based physicians unless directly queried.

pesha said...

This just happened to a friend at another famous Boston hospital. She's had to wait three weeks for a diagnostic special something or other that could be breast cancer by the "top" breast ca doc (never mind that it's hard to imagine there is such a top doc in Boston)...now that it's about to happen, she's very nervous. Seems to me that she would have been far less anxious if it had all just happened immediately.

Anonymous said...

In my opinion, it does make a difference. Dr. Kruskal states that they have trained all staff. This doesn't mean that they are all radiologists. It is very likely he has trained radiology techs. Although, techs are qualified, there is a definite difference in quality when a tech vs. an MD performs testing. Clearly this surgeon wants the best for his/her patients and I appauld him/her. Perhaps in the future this surgeon can let the patient know why he/she wants a specific radiologist to perfrom the test.
If I ever need what sounds like a colonrectal surgeon, I want this one!!!

clairesmum said...

if i needed an anal fistulogram done, i don't think i'd be in hurry for it, to be honest!
did the ordering MD explain his particular preference TO THE PATIENT - we can all guess at motives here, but I guess that if the ordering MD has a particular preference, and he/she explains it to patient who can, in theory, choose to agree with the rationale for waiting OR say that he would prefer to have it done sooner with any trained radiologist, then I'd be ok with either plan.

This is probably mostly about having the illusion of control, or attempting to put some control into a process (medical testing) that is inherently 'out of control' for patients - and probably for docs, too.

e-Patient Dave said...

I just don't know what to say.

Is this a surgeon being arrogant and demamding, as many are rumored to be? (I don't know anyone involved so this is a generic question.)

Does the surgeon believe that Bob Kane in 3 weeks is better than someone else now? Is the surgeon willing to take responsibility for explaining that to the patient? (My oncologist explained what was and wasn't urgent.)

Or does the surgeon feel it's important to have Bob Kane AND have him now? i.e., does the surgeon feel the world should stop and other patients should go to hell?

Or, switching away from arrogant, is the surgeon uninformed? If so, is the surgeon open-minded?

Funny, as much as I benefitted from superb manual surgery, I'm starting to see the value of robots. :-)

(Again, the above is all generic - I don't know anyone involved and didn't hear the calls.)

p.s. I wonder how much time, administrative and expert, was consumed dealing with this complaint.

Randi said...

From Facebook:

We've been looking into this same problem but the question is, how do you change it? The patient only knows to request the specific physician or service provider the referring doc suggests and implicitly trusts that information, all else being equal. The referring physician maintains their preference and the cycle perpetuates and access decreases. I'd love to know what ideas you and your team are considering.

Anonymous said...

That's why I wrote this story, to publicize the issue.

Anonymous said...

Mr. Levy:
If it were you, wouldn't you want the best radiologist performing the test? I think this surgeon is doing what is best for her patients. The results of testing depends on the quality of those performing them. Radiology techs are not the same as radilogists.; and not all radiologists are equal.
I feel you should be praising this surgeon for caring for the patient as much as she/he does.
I hope you never need this test performed but if you did, who would want?

Anonymous said...

The lack of accountability of individual clinicians to anyone is made transparent here. This autonomy puts self before patient (and perhaps patient's health if delay has consequences), other clinican's patients, quality improvement in own and other departments, hospital management, and healthcare system improvement in general. And it happens thousands of times each day. Data should be used to compare quality of work between different practitioners to guide such decisions, not subjective individual preference.

Shouldn't this surgeon answer to you and his own Chief about this? Shouldn't policies be explicit about these decisions? As it stands, the tradeoffs are determined individually, and that is hardly the recipe for quality of care that patients deserve.

Barry Carol said...

I wonder how much variance, if any, there is among your doctors and techs trained and qualified to perform this procedure with respect to both missed diagnoses and false positives. Couldn’t that information be made easily accessible to referring doctors? If there is little or no variance and the referring doctor still wants one of the two named doctors to perform the procedure, it’s arrogance in my book.

Anonymous said...

Folks, you just heard from the Chief of Service that he is confident that the people he has trained can do the test as well as anybody, and that he and the other doctor are happy to interpret the picture. What more assurance would you need?

Anonymous said...

Paul, I'm afraid I (speaking as a doc) would not be entirely satisfied with blanket assurances from the Chief of Service, in a case where at least one ordering physician is requesting that only certain radiologists read the result. This would be a red flag to me as Chair.
We dealt with this problem in my hospital pathology practice, and it usually demands some investigation as to why this request is being made. Is surgeon X known for doing this with everything? Is there someone s/he doesn't trust in that dept and if so who and why, and is it justified?
We had a pathologist in our practice who did make more mistakes and had poorer communication skills than others, and confidential inquiry among the clinicians revealed the problem and prompted remedial action.


Anonymous said...

Note the Chief's comment: "We have spoken to [the surgeon] about this, but s/he still prefers to have Bob or me do these." This appears to be that person's preference. There is no indication of any quality problem with other folks.

Anonymous said...

are you organizationally allowing these kind of specific requests which slow down treatment and generate complaints, if there is no reason to involve the higher level of expertise? the chief could have made a decision not to honor the personalized requests, unless they were contacted and a justifiable reason was presented. if in fact, the request slows things down and interferes with efficient care for everyone else.

in answer to anonymous 8:59, i would want the person who could do things competently and promptly. i do not feel for a diagnostic test that i need to wait for a 'super-expert' if an expert will do.

leave the super-experts to the people who need them.

Anonymous said...

I'm anonymous for 8:59 and have had to have repeat studies performed because the quality was very unclear from other fokls that were just as "capable"; and not for this particular study. This also slows down the process and causes the patient to repeat the study another time...so time and money. Until one experiences issues such as this, don't judge. There are a lot of adverse errors that occur. Although some not life threatening, some also delay process of appropriate treatment.
In my opinion, this surgeon is doing best by her patient.
Of course Chief radiology is going to state all are trained equally. Poor studies slow results and compromise patient care. Surgery is only as good as the studies. I support this surgoen 100% and quite frankly think we should hear from her. I'd also be a bit upset if I were her for questioning her jugment and making this out to be bigger than it is.

Anonymous said...

I hope you agree, though, that the surgeon should have informed the patient that the reason for the delay was the surgeon's insistence on having a certain doctor perform the test.

Anonymous said...

I agree 100% that the surgeon should have informed the patient of why it would take long to have test performed. As a patient, most just want rationals. I certainly wouldn't mind waiting for specific provider if the MD I trust my care to insists.