When you go to an emergency room for any medical problem, you may or may not be aware that the treating doctor is doing as assessment of you that will eventually be fed into his or her brain's newly learned "protocol". What happens to you after the assessment is not quite as unique as the questions that were asked of you might seem. You will likely enter a "chest pain" protocol, a "head trauma protocol", an "asthma protocol" or any relevant protocol that the receiving facility has designed to maximize its efficiency and operations and minimize cost to you and the hospital. How did these treatment algorithms originate? What are their advantages and disadvantages? Why should you be wary of such approaches? What can you do about this?
Treatment algorithms or standardized approaches to care arose as a result of the need to streamline medical approaches so as to maximize efficiency and ensure that the minimum steps were being taken to address particular issues. Also, treatment algorithms are ideally based on research, so that any protocol would likely be designed to reflect this research and minimize "fluffy" approaches that do not have a basis in proven science.
While these are admirable goals and obviously serve important functions, I have also noted a trend in some domains of medical research, to justify short cuts so as to justify spending less money on medical care. A test, for example, may not be done, since the likelihood of it helping out is not very great. However, if this were my loved one, I would want the test to be done anyway, as even if there was a small chance of it being helpful. These "small chance" tests and treatments do not make it into standard algorithms, so that unless you are proactive about your own care, you are not likely to receive the test or treatment.
If you have ever tried to get yourself checked into a hospital recently, unless you are about to kill yourself or someone else, or going in for acute treatment, you are unlikely to be able to stay for more than a few days. This may be less true if you are part of a "boutique" network and pay out of pocket. While socialized medicine may limit the number of available boutiques, I would argue that boutiques exist for a good reason: that their thorough, often intensive approaches that exceed the current standardized hospital approaches could be actually necessary and helpful. They may be too expensive to be part of the norm of care, but you might notice that even the same hospitals often have two treatment centers for the same disorders: one that routinely costs much more than the other. Why then, do boutique protocols differ from regular protocols? Should you care?
I believe that you should and my focus here is on the individualized approach to diagnosis and treatment. For your next medical appointment, you might want to go in with a different set of questions than you might ordinarily do. Here are some potential questions and considerations to ask your PCP about so that you can gain more clarity about the care you are receiving:
1. Ask your PCP: How do the tests you are doing differ from test that a boutique service may offer?
2. Ask your PCP: Are the additional boutique service tests unnecessary or are they more thorough?
3. Ask your PCP: Could you recommend a boutique specialist in the area that I could talk to?
4. Then, call up a boutique specialist, and ask them specifically how their approach to dealing with your illness differs from standard care.
5. Ask for a three-way conversation between your PCP, the boutique specialist and yourself.
6. Ask your PCP: what other tests might you do if cost were not a consideration? Why?
7. Most importantly, do not leave the office until you have a plan that will help you understand the duration of your care. For example, I often meet people who are seen for back pain, and who just accept months of no change in treatment without any sense of when surgery might be necessary, or of what the potential dangers of surgery are.
The message of this column is that unless you track your own care, you will likely be part of a "standardized" approach to care. While it is extremely difficult for doctors to do anything outside of this norm, it is also important for you to be clearer about what you are getting and not getting. If you do, and if you take charge of your own health, you are likely to receive much better care than if you do not.
As we approach "health care coverage for all", we must also be more aware of an increase in standardized approaches. We must constantly be weighing the pros of "at least having care available" with the cons of suboptimal care. Boutique approaches are not necessarily better, but they potentially offer the patient an individualized treatment approach. If you are not receiving such care, it is imperative to ask: is there anything that I am missing? If so, how can this be addressed?