Tuesday, July 21, 2009

The Push to Medical Practice Decentralization

The pager bleeped at 06:15 AM this morning.

It was a nurse, calling me bright and early to ask a favor; her mother had an appointment in our office the following day, but my office was 20 minutes west of where she lived.

“Do you ever see patients in the office closer to me?”

I explained that I used to see patients in three offices, but found that no single office was adequately staffed and rather than spread ourselves too thin (not to mention save on costs), we consolidated our offices into one location.

The nurse capitulated and agreed to bring her mother to our more remote office.

I have been interested to see the commercialization of medical practice based on a corporate McDonalds-like philosophy of a medical office on every corner. Certainly access is key for primary care practices working to attract patients, and the competition engendered by doc-in-the-box services are real. After all, convenience and availability go a long way to improve patient satisfaction and the availability of the electronic medical record should make this possible, right?

But I wonder if such an approach is always so advantageous for specialists and their patients.

I find it funny that some well-to-do patients would travel to tertiary care centers outside of our state for the “finest” of care, yet gripe when they have to drive across town to a specialist’s office for follow-up pacemaker appointments.

The downsides of decentralizing office personnel for specialists are significant: more staff are generally required, more rent, phone lines, maintenance, etc. Highly trained technicians that are involved in performing in-office procedures (in our case, pacemaker and defibrillator follow-up) could perform procedures independently at more than one site, but the benefit of the availability of a second technician-colleague or a doctor that is always on-site to help trouble-shoot problems and speed patient management can’t be overestimated. Simply put, it's hard for one doctor to cover two clinics and far easier to supervise two technicians at one clinic. Further, there is benefit to patients if there’s “depth on the bench.” That is, if one technician goes on vacation, another technician can remain behind to assure continuity of care. To me, quality care should supersede convenience in this case.

But I find myself constantly beating back to “convenience” proponents, and so far, I'm winning. But as competition heats up between large behemoth health care organizations, I wonder how long I’ll be able to hold out.



Keith said...


I feel for you guy. In these multi-hospital systems, there will be increasing pressure for you super specialists to cover all the hospitals in the network. I would let your employer know this is fine as long as they pay you the same for the time you spend driving around as you get seeing patients or doing whatever it is you do to them (putting very expensive and mysterious metal devices implated in peoples chests?). That way, they have to think about what is the most cost efficient use of your time.

Anonymous said...

I can't believe she paged you before 7 am to ask that question. She shouldn't have paged you at all. What's wrong with calling the office to ask that question during business hours?