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The Cost-Effectiveness of Family Physicians – The Limits of Early Detection

July 21, 2013

Continuing my discussion of the findings in a recently published study on the ways family physicians deliver better care at a lower cost than a multi-ologist model, today I will talk about how family physicians often believe early detection of a disease does not improve the ultimate outcome.

This statement will no doubt come as a surprise to many family physicians who believe that catching diseases early, or even preventing them in the first place, are the foundations of their value to society. Some FPs might even vehemently disagree with this statement. Let me give you two examples of what we found FPs often believe.

Suppose an 18-month old infant with a fever and URI (cold) symptoms sees her family physician. The child looks like she doesn’t feel too good, but otherwise cries vigorously, plays with her toys, and is easily consoled by her mother. The physical exam only includes findings consistent with a cold. The FP reassures mom, does not prescribe antibiotics, but educates mom on the warning signs of worsening disease.

The next day mom calls and reports one of the worsening signs. The toddler is seen later that morning in clinic and looks worse to the FP. Blood cultures are drawn, antibiotics are started, and the cultures later grow out Strep. pneumoniae.

Has the child been harmed by the fact that the FP diagnosed the bacteremia (bacteria in the blood) a day later than possible? Most family physicians would say no. The accessibility of the FP combined with a good relationship with the mother drives the good outcome. A nice study by a pediatric research network shows that a delayed diagnosis in this situation results in children who recover without harm.

Next, imagine a 45-year-old man who reports to his FP a cough for two weeks with sharp pain felt over his right ribs every time he coughs. He hasn’t really tried anything for the pain, and the history and exam were unremarkable except for some tenderness when pushing on the right outer ribs. The FP recommends taking over-the-counter anti-inflammatory medicines on a regular basis until the pain is better. He believes the patient must have pulled a muscle between the ribs, or something like that.

Three weeks later, the man reports that the cough is gone, but the pain is still there. The FP discovers nothing else unusual in the history or exam. He orders a chest x-ray, which is normal. He prescribes a small bottle of hydrocodone.

Two weeks later, the patient calls the office asking for a refill of the pain medicine.

Three weeks later, the patient calls the office again, and the FP insists the man come back to the office for another chat. The man states that the hydrocodone had controlled the pain a month earlier, but now he could take 3 at once, which would only decrease the pain from a 10 to a 6. The FP determines that this situation has gone way beyond the expected recovery period for a pulled muscle, so he orders a CAT scan of the chest. The scan shows metastatic cancerous lesions eating away at the right ribs and a softball-sized mass in the kidney.

Does the fact that the FP discovered the metastatic kidney cancer two months after the first opportunity to catch it have any bearing on this patient’s ultimate outcome? I believe most family physicians would say no. The original rib pain was caused by an aggressive cancer. The aggressiveness of the cancer determines whether or not the patient will be cured after treatment, not when it was discovered.

Now you know that family physicians often believe early detection does not change the ultimate outcome of the patient. If only the rest of U.S. society believed the same, we would have a much more efficient healthcare system.

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