Saturday, 2 June 2012

Cough up - I'm a doctor

From the outside looking in, medical diagnosis seems to be a diffuse but strongly hierarchical and mystique-ridden  process. My recent hospital stay involved a number of strands coming together to a final diagnosis, but who made the diagnosis and who gets most credit? Well no single person made the diagnosis and credit seems to be siphoned off by the most powerful as it would be in any hierarchy. 
  1. I self-diagnosed a urinary issue, which took me to my GP.
  2. My GP arranged a blood test and ultrasound scan.
  3. The sonographer scanned my bladder and advised my GP.
  4. The blood test results were returned from the lab to my GP.
  5. My GP consulted the urology department at Derby Royal.
  6. I given an urgent hospital admission.
  7. A hospital registrar assessed my prostate as small.
  8. The consultant came up with a final diagnosis and treatment plan.
Steps 1 to 8 involved six doctors and one sonographer or almost one medical diagnosis professional per process step. I should add that although not doctors, sonographers do medical diagnosis.

I'm not privy to the various brief conversations, notes and views through which these seven people made their  contribution, but as far as I can see, the final diagnosis had taken shape by step 5 and confirmed by step 7, before the consultant settled on treatment in step 8.

It was the hierarchical system we are all familiar with, where those higher up extract more from the process than those lower down without necessarily making a more significant contribution. I’ve no problem with that if genuine expertise is involved, because it’s how the world works, but I wonder to what degree medical diagnosis is designed to maintain the professional mystique and thereby pad costs.

There is also another issue that niggles away at me, because I find the structure of medical diagnosis interesting, and that is the question of automation. How much of the diagnosis depended on routine tests, such as the blood tests? Also, how much depended on the skill and experience of the sonographer, the person who diagnoses but isn't a doctor? From various clues I suspect the sonographer had a major impact in terms of technical skill and experience and also in diagnostic influence.

How much padding is there in all this? A hell of a lot I suspect. I've had a very good outcome so far, but it all felt heavily gold-plated.

Doctors should tread carefully when considering strike action. Their diagnostic skills are heavily bolstered by technical input and it is not at all clear what they uniquely contribute or how costs and mystique are unduly inflated by their hierarchical approach.

I've had a very good result so far and a potentially very serious outcome seems to have been averted. So at that personal level I'm very satisfied and genuinely grateful - but not pathetically grateful. The process feels antiquated and self-serving to me.   


Sam Vega said...

Hope you are still on the mend.

Doctors are an incredibly varied bunch, so far as their expertise and usefulness is concerned. Consultants have definitely saved the lives of family members, and I would have given them anything at that time. On the other hand, most bog-standard GPs are fairly useless. (Funnily enough, my wife has just returned from casualty after cutting her finger - we think they deserve six out of ten...)

But pensions of fifty-odd thousand...and job security most could only dream of...and the status....Strewth!

I saw "telemedicine" in action in Malaysia. Local health centres staffed by nurses who use big "NHS Direct"-style databases to make diagnoses and treat patients. If things get tricky, they are on-line via skype to a world expert. The service seemed to be good, and it certainly saves millions. If I were a doctor, I would ask myself a few serious questions before striking.

A K Haart said...

Sam - thanks, I am on the mend although there are more stages to go through yet.

GPs can be fairly useless as you say. Their role seem to be mostly divided between handing out pills or sending you off to a specialist if pills won't do.

Your experience of telemedicine sounds interesting and an obvious way to go.

Anonymous said...

GPs can be fairly useless as you say. Their role seem to be mostly divided between handing out pills or sending you off to a specialist if pills won't do.

The clue is in the name - what do you expect from a General practitioner? GPs are experts in nothing and good at everything (well some are good for nothing, but that's because they set up shop 20 years ago and have been left unchecked since then).

Because we have the NHS, the GP's job is to stop everyone from clogging up the hospital specialists. When people can access secondary care on their own, the insurers do this instead of the GP, so people would only go to the family doctor for regular stuff and when they don't know who to go to.

Also, the NHS gives GPs targets, such as >70% of the population needs to have blood pressures under 140/90 and rewards the GP if successful. In a user-pays system, the government doesn't care as much about whether everyone is healthy.

The reason telemedicine works in Malaysia is that if you die, you can't sue anybody. Recently NHS direct failed to diagnose a heart attack (as the lady in question had been calling about indigestion for years) and the nurses did not inform a doctor about the patient. Your taxes contributed about 10p in compensation to this family.

A K Haart said...

Jorge - yet GPs are paid as if they were specialists even though I suspect the job could be substantially deskilled.

James Higham said...

Yes, hope you are on the mend too. What you describe about routine tests - evidence based medicine, which Bruce Charlton has been railing against for so long?

A K Haart said...

James - I've just looked up Bruce Charlton:-

"A doctor. Dying species, salesman for Big Pharma."

Not bad!