7 disruptive changes that will affect medicine

Generally we prefer calm seas but often they don’t get us anywhere.

We need disruptions, transformations to make the changes necessary for real progress in medicine. Sometimes it is a new technology; sometimes a cultural change. But then a refinement may occur. The refinement may not seem like a “disruption” but indeed it can be because the refinement may create a demand for change.

Here a few more disruptive changes or refinements that are leading to disruptions of the old ways.

Retainer based practices: Primary care physicians find that their incomes have been flat or reduced, their work hours increased, their time with each patient shortened and their frustrations with insurers heightened dramatically over recent years. Some are just saying “I can’t take it any longer” and switching to a different type of practice model. Some simply will not accept Medicare, telling their older patients that they must either pay out of pocket or go elsewhere.

Others are converting to “retainer-based” practices. Here the patient pays a flat fee each year, often $1500 to $2000, in return for having their PCP available by cell phone 24/7 and responsive by email. Appointments within 24 hours are guaranteed. The physician will see you in the ER, take care of you in the hospital and do home or nursing home visits as needed at no extra charge. But you still need your insurance in case you have need to see a specialist, have tests or imaging studies or are hospitalized. So the cost to you is extra. This is very disruptive of the standard approach today but I predict it will become very common in just a few years.

Smartphones: Physicians, especially younger physicians and residents, are becoming very reliant, although not dependent, on these devices. They use them as shortcuts to knowledge, to stay well informed, and to communicate, argue, and debate with one another, which is a excellent form of learning. Smart phones keep being refined and as they are, more and more physicians want them, use them, rely on them and become more effective physicians as a result.

Greater clarity with imaging: Today’s CT scanners and other devices can produce remarkable images of the body’s internal organs, better than those of a medical illustrator. And the clarity of the images increases dramatically each year with engineering refinements. Virtual colonoscopy using a CT scan, for example, can now be done in a manner such that the viewer can see a high resolution magnified image of the inside of the colon, capable of visualizing small details of a polyp, a diverticula or other anomaly. It can be projected on a large TV screen where a group can review it together and jointly consider the situation and make recommendations for care of the patient.

Surgical robotics: Today the daVinci robot is used primarily for cardiac surgery, prostate cancer surgery and some gynecologic surgery. But soon it will be used by other surgeons in diverse fields. An otolaryngologist for example, might perform surgery on the base of the tongue to remove a cancer while avoiding the critical nerves and blood vessels in the area. The visualization of the site is much better than with conventional surgical approaches, the margin of safety is improved and the patient’s outcome is bettered with more effective surgery, more salvage of critical anatomy and faster recovery. These refinements in the use of the robot will likely lead to considerable demand from both patients and physicians.

Image guidance: We tend to think of “X-rays” as being used for diagnostics and the newer technologies have dramatically improved this ability. But think of the surgeon who “wants no surprises” once inside and operating. The greatly improved ability to visualize organs makes no surprises a near reality. But the imaging can also guide the surgeon to improve on his or her technique during the procedure. Intra-operative CT scanning can be used intermittently and at low dose to assist the surgeon to know the location of critical vessels or nerves. Ultrasound can be used to give real time direction to the placement of radioactive seeds into the prostate to treat cancer. These and similar image guidance techniques improve safety and effectiveness.

Fewer general surgeons: It has been known for some years that there are too few general surgeons; fewer are entering the field and some areas, especially rural and urban poor areas, have all too few general surgeons today. The reasons for the reduced interest of graduating medical students is not completely clear but the trend is obvious.

Reduced career time as a minimally invasive surgeon: Laparoscopic or minimally invasive surgery spread across the country and the world with remarkable speed after its introduction some 20 years ago. The patient has smaller incisions, faster recovery time, less time in the hospital and the costs are lessened as well. Surgeons rapidly learned the techniques and patients demanded it. But there is a price not fully expected. Surgeons are developing a variety of occupational problems from carpel tunnel syndrome, to neck disorders, to low back pain. It is all about ergonomics – “the patient is better off but the surgeon is suffering.” Indeed it may well be that their practice lifetimes may be substantially curtailed unless these ergonomics issues are addressed and quickly.

There are many changes coming in medical practice and these are but a few. The ones noted here will have significant and ultimately disruptive effects on the way medicine is practiced today and tomorrow.

Stephen C. Schimpff is a retired CEO of the University of Maryland Medical Center in Baltimore and is the author of The Future of Medicine — Megatrends in Healthcare. He blogs at Medical Megatrends and the Future of Medicine.

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  • http://leonardof.med.br/ Leonardo Fontenelle

    I’m definetily fond of the idea of retainer based practices. That’s how primary care professionals should be paid. One may consider incentives for keeping the patient healthy, but the foundation is a capitation.

  • http://www.cymbalinteractive.com Mark Horoszowski

    Disruptive…. or in some cases, rich enhancements. Great post – thanks for sharing!

  • http://hweissmd@yahoo.com Herman Weiss

    “Disruptive” indicates changing the playing field, and in the list you describe soon to be commodities. Which physician won’t have a smartphone, generating notes and posting claims immediately etc. A practicing physician cannot exist without it.
    Robotics will no longer be something a hospital looks to, to get a competitive advantage but rather they will become ubiquitous and unable to exist without it. Advancing the imaging services is also going to become standard of care, and as such will not be considered “disruptive”.
    I agree with all you wrote in terms of these changes (some have happened already) as necessary and imminent, just I think their disruptive forces are overstated. I was hoping you were going to illuminate the world with breakthroughs that are truly disruptive.
    Although I do like you practice shift, back to personalized healthcare, but me thinks $1,500 is too little to help.

  • LynnB

    I am sure theses things are disruptive in bad or good ways to procedure based specialties. My own nomination after 20 years in practice at the same location is insurance oversight . I realize that physician ripoff artists are the ones whose antics have made life heck for the rest of us. Two examples

    1. Pre-authorization for many radiology studies requires requiring notes to be done in “real time” , while patient is in the room. The test can’t be scheduled till the pre-auth is done which can’t be done until the note is reviewed. Because I type 20 WPM this means all the other patients wait at leat 30 minutes while I click, click, click away. It took more total time but much less of my time when we had transcribed, free-text notes. For example, out of the box , our EMR has point and click notes that meet the MRI criteria only for LBP, not for C spine disease, not for cancer followups, not for adrenal masses, not for biliary obstruction, not for any CNS problem. All of that is typed into the HPI, ROS, PE portion of the exam. Over a few glasses of wine most of my colleagues either don’t order the test , have the patient come back next week just to get the note done (no talking allowed) or refer to a specialist who has longer visit times.

    2. Insurance company reviews based on claims data which are often inaccurate but publicized .Angry patients come in for their visit, saying “you didn’t order an A1c”. I show them the A1c from last month , billed to their wife’s insurance. It’s their company, the one that pays so poorly they have set it as a secondary that did the review. This could be such a wonderful, wonderful tool to find people who have not been in, to remind me I have not done something , but its just disruptive now . I don’t want to be de-selected because all our labs go to the doc with the lab license if they can’t figure out who ordered it, or because people are double insured , or because they get mammograms done in Arizona when they go there for the winter because they had one there a few years ago and the tests need to be 12 months apart at a minimum. It takes hours to copy the charts , send in the “missing ” data , and then next quarter same thing, same patients.

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