Lack of health care coordination benefits physicians

An excerpt from Potent Medicine The Collaborative Cure for Healthcare.

It was mid-summer 2010 when the full scope of everything that Nancy D’Agostino did not know hit home. Still raw from surgery and missing parts of her body, she thought that all the hard choices were behind   her.  Then  here   was  a  new  face,  a  radiation  oncologist, outlining  side  effects of treatment  and  asking her to  choose. And then a medical oncologist was offering chemotherapy and everyone was saying treatment was her choice.

“I have a BA in sociology, for heaven’s sake,” D’Agostino said. “I’m a smart person, but I was having a hard time absorbing what they were saying.”

There had not been a lot of time to study up on the subject, either. In mid-June, she went in for her annual mammogram and told the nurse about a small lump on top of her left breast that she discovered in the shower a few days earlier. D’Agostino’s mammogram was read immediately and a doctor suggested she get an ultrasound next. They could do it right away. Impressed with the office efficiency and with one eye on the clock because she had a carpool of girls to collect from the ice rink, D’Agostino agreed. There was definitely a shadow in her breast; a solid form that nobody liked.

D’Agostino’s family doctor was  part of a multispecialty clinic that did a lot of testing on  site, so they could also offer D’Agostino an ultrasound-guided needle  biopsy of  the  tumor  immediately. Across town, skating practice was winding down so D’Agostino consented to this next step so long as they promised to make it quick.

“I literally went from exam to biopsy in an hour,” D’Agostino recalled. “Then  I was  back in the car with  six girls and their  skating bags, holding an ice bag  to  my  chest  and  it  hit  me: I just had a bad mammogram. I’m 43, I’ve got two kids and a husband and a carpool and I really don’t have time for this. I cried a little.”

Two days later, while packing for a family Father’s Day trip, she got the news that it was cancer. Monday morning, accompanied by her husband, D’Agostino met her surgeon and connected with her immediately. Dr. Honnie  Bermas answered her  questions, scheduled more   tests,  and outlined D’Agostino’s choices.  Lumpectomy or mastectomy? One breast or both? D’Agostino needed to choose a plastic surgeon and a hospital.

Over the next week, overwhelmed and feeling like she had been hit by a truck, D’Agostino felt alone. Just before the July 4 holiday, she met a girlfriend for lunch at an Olive Garden restaurant who looked at D’Agostino aghast and said, “Why haven’t you ripped that thing out by now?”

“She was right,” D’Agostino said. “I wanted no part of that tumor. I wanted nothing to come back that would hurt me. I wanted nothing left behind.”

Having decided on a bilateral mastectomy with immediate reconstruction work, D’Agostino felt relieved. A month after her diagnosis, she was in Appleton Medical Center for dual surgeries and out again 24 hours later. She was prepared to focus on her recovery.

She was not prepared for the medical oncologist or the radiation oncologist and a completely new set of life-and-death decisions. “They started talking about percentages and life expectancy and they wanted a decision from me, but I was lost,” D’Agostino said. “I was two weeks post surgery. Parts of my body were missing. The easiest thing was to do nothing. That’s what I wanted.”

Nothing was what she almost got—not because it was the best thing for D’Agostino, but because of the way systems of care at Appleton Medical Center was arranged.

Without coordination, a patient can languish for weeks from one step to the next while her tumor grows and the illness progresses. Without integrated care, critical information is easily lost and treatment delayed or   misdirected.   Or, as happened to D’Agostino, specialists offer complex and sometimes contradictory information to the patient who sorts it out alone.

Lack of coordination exists, as I have said earlier, because systems have been set up to benefit physicians. Doctors are busy people. They tell themselves that they must  organize their patients  for  maximum efficiency in  order to get everything  done.  If that means visiting a hospitalized patient before dawn, when the patient is too groggy to communicate effectively so be it. If an important surgery needs to wait a week until the doctor is doing three other similar surgeries — that is business as usual.

In the world of lean thinking, this is called batch processing. The operator (doctor) lines up the work in progress (patients) that require similar activities and then performs that task on each in succession. Manufacturing and service companies that convert to lean thinking have realized that batch processing creates a focus too narrow. Waste and inventory accumulate between discrete operations; communication failures become endemic. When an operator’s job is one small piece, he or she easily loses sight of the complete product and hence, the customer’s needs. The customer, after all, is paying for a whole product, not the individual pieces.

As ThedaCare began a transformation to lean thinking in 2002, one of the  most important breakthroughs came as leaders  realized that  the core  product  was not  surgical procedures or  physician consultations or  IV  bags  and bandages. That is what most healthcare providers thought they were selling. What people wanted to buy, however, was healthcare — babies safely delivered, mended bones, tumors removed, better heart function.

John Toussaint is President and CEO of ThedaCare, Inc. and the author of Potent Medicine The Collaborative Cure for Healthcare.

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