Sunday, April 06, 2014

Walk-in Health Care: Growing Popularity (and Concerns)

From The Washington Post, April 6, 2014
Not a lot of time for a long blog post today, but I came across this article in this morning's Post and have been thinking about its implications for health care ever since.

The basic arguments in the article are as follows:

1. Between the growth of eligible patients (something that will continue to grow with expanded coverage facilitated by the Affordable Care Act) and the continued decline of doctors graduating from medical schools with specialities in primary care or family practice, gaining access to primary care has become increasingly difficult.

2. Consequently, retail chains, such as CVS's Minute Clinic, have expanded pharmacy offerings in their stores to include basic care for things like infections, vaccinations, and sports physicals. Some offer testing for basic preventative measures, like blood sugar testing, according to the article.

3. The services provided by these retail chains are more convenient, faster, and cheaper than other available options.

In a sense, the clinics solve a few problems. In an environment where people lack easy, quick access to medical services that physicians offices are too pressed to provide, the clinics can dispense antibiotics before infections (and discomfort) become severe, offer timely vaccinations (a critical need during flu season at the very least), and alleviate some of the burdens placed on the existing primary care system.

But, there are problems with this, too, some of which the article addresses but doesn't really offer a clear solution for:

1. The impact this might have on the care of children, in particular, is unknown and troubling. As the article quotes from an American Academy of Pediatrics (AAP) representative: "There is no such thing as a ‘minor illness’ when it comes to children. Pediatricians use these ‘minor illness’ visits to identify other, potentially more serious issues." What seems like a series of acute illnesses may be masking a chronic condition that goes unnoticed because there isn't a consistent physician caring for a child. Pediatricians and primary care doctors also watch for other issues children may be experiencing, such as nutrition issues, developmental problems, or even signs of abuse. All of these may be missed under such a disjointed system of care.

2. A lot hinges on preventative care, from our own long-term health to many health policies (not least of which, the Affordable Care Act). Increasingly, disease is not conceptualized as a single, isolated incident, but as a stress point that occurs at the end of a steady progression of illness, which has been exacerbated by individual circumstances and lifestyle choices. Properly caring for the little things that happen to us over time may be more essential to our long-term health than we realize, and reliance on acute or emergency care may exacerbate the negative affects of short-term thinking.

The problem of the dwindling primary care provider is a really serious issue. It strikes me that, on one end of the spectrum, the issue is addressed by concierge medicine--a specialized, expensive system where access to a physician is restricted by how much one is willing to pay. In this case, a select few can get same-day appointments, a doctor's email address, and, if needed, a quick diagnosis and prescription to treat an ear infection or an in-hospital consultation and coordination of care after a heart attack.

On the other, we have the CVS Minute Clinic. Here, you may not have a doctor's email address (or even see an actual doctor), but the service performs the same functions, providing quick, convenient access to medical information within the time constraints of otherwise busy people. Here, access is almost universal, but it's not as complete or complex and lacks the relationship-building and health maintenance objectives of the concierge option. While this system may solve acute problems, again, we're addressing acute measures to the possible detriment of chronic conditions that go unnoticed.

All of this might not be a problem. But we at least need to acknowledge how it is at complete odds with our larger objectives of preventative medicine that shape expectations for medical care and outcomes today and ask what the impact will be if this is the system that is takes up residence where the doctor's office once stood.

Sunday, February 02, 2014

The Rhetoric of Feline Oncology: Or, What Happens When Your Cat Never Had Cancer (But the Doctor Said He Did)

Milton during his follow-up oncology
appointment, 6 months after his
initial cancer diagnosis. 
The title kind of tells it all.

In 2008, after a long bout of excruciating gastrointestinal troubles, my cat Milton—then 8—was diagnosed with intestinal cancer. Specifically, carcinoma of the jejunum and colon.

The pathology report described “multiple intestinal masses that are mucinous in appearance.” The cells retrieved through a fine needle aspirate of the masses revealed a “severe degree of nuclear variation and variation in cell size.” All possible treatment options were either too invasive for him to endure (sick as he was at the time) or unlikely to impact the particular kind of cancer he had. They didn’t even try to book us a follow-up appointment—the letter simply concludes, “I do expect him to decline over the next 2-8 weeks.”

At the time, these words were terrifying, final, the source of hours of tears and lots of Googling for alternative interventions and treatments. In the years since, they have meant afternoons spent at various veterinarian offices investigating mysterious symptoms that may have indicated that the cancer had spread (always turning out to be absolutely nothing), countless ultra-sounds and further small biopsies of his intestines to see how the tumors were doing (fine, by all of our best estimates), so many elaborate diets and supplements that Milton oftentimes ate better than I did, and a lot of fear and anxiety and worry for all of us that any mis-step in his care might bring dire consequences.

But, this week, at an appointment with the very same oncology unit that gave Milton a 2-8 week death sentence 5 ½ years ago, I learned what those words really meant:

There’s actually very little accuracy associated with these tests, surgical biopsy being the gold standard for this type of diagnosis, so although the conclusion at the time was that he likely did have cancer, the fact that it hasn’t killed him yet indicates that he actually never had cancer at all.


Wait, what?

This was my response. Very eloquent.

So, what is wrong with him, then? I asked, still knowing that my dear cat experiences, well, for the sake of protecting his privacy, I’ll say “frequent gastrointestinal distress.”

Hmm. Not sure, the doctor says. IBS? Combined with old age?

So, 5 ½ years of doctors, medicines, alternative treatments, expensive tests, and constant worry all because he has, basically, been an aging cat with an upset stomach?

This experience has been interesting for a wide range of reasons (and infuriating as well), and I’ve had a wide range of reactions to it. But, for right now, I’ll put on my rhetorician hat, and analyze the situation through that lens. Because, looking at this case through its discourse is incredibly revealing.

Looking back through the original pathology reports, you can actually see the spaces where the discourse makes itself available to both offer a devastating diagnosis and explain away a mistake at the same time. As terrifying as the words on the report were, they were still couched in contingencies that I was too saddened to see when I originally read them: “the radiologist suggests carcinoma,” “a carcinoma is suspected but cannot be proven with this cytology,” “surgical biopsy would be required to make a definitive diagnosis.” None of those contingencies ever mattered at the time, and I never revisited them. Once the word “carcinoma” entered my world, my focus was on identifying, addressing, and defeating that, not on questioning its presence.

Yet, the contingent words were the words the oncologist relied upon this week as she delivered the news.

When I said, “But, I thought you took cells out of tumors. I thought those cells were cancerous, and that meant he had cancer.” She said, “Well, all we can see are irregular cell patterns, and irregularity can exist along a spectrum of pathology, from healthy, to sickened, to fully diseased cells. So, we may have seen cells that were cancerous and were later resolved by the immune system or cells that just looked abnormal because of inflammation.”
Milton, sitting on papers (of course).
Also, if you look carefully, you can see his belly is
pink after being shaved for an ultrasound.
And, naturally, “this is why surgery is the gold standard for diagnosis,” because without a chunk of diseased tissue, there’s no way to know for certain that what’s really in his body is really cancer and what kind of cancer it is. So, the combination of the ultrasound showing a mass and the extracted cells are the least-invasive best guess. That’s all they really have—a best guess that you can hope isn’t as bad as it seems.

The problem is, of course, that a lot of decisions are made based on that best guess. Most gravely, I could have chosen to have him put to sleep. This wouldn’t have been an inhumane option, given a cat that was pretty sick and going to die at the time. It wasn’t an option that I considered, but it is something that some people absolutely would.

On the other side of things, I could have chosen one of the more invasive options they provided, and that subsequent doctors have recommended since, like chemotherapy and radiation. This is the only point at which the oncologist did express some acknowledgement of the consequences of this error: “Well, in retrospect, it’s really good that you didn’t move forward with any more aggressive treatments, like radiation or chemotherapy treatment for a cancer that wasn’t there.”

“Humph, you think?” was my knee-jerk retort.

Overall, the experience reified everything I’ve read and suspected and analyzed about communication and medicine over the past few years. That, in that examination room, objective truths are hard to find (try as we might to find and rely upon them), conversations are rarely the same for doctor and patient, and the documents produced and the words those pages simply are different for the person who types the words versus the person about whom they are typed.

A similar sentiment is reflected in one of my favorite quotations from Kathryn Montgomery:

“The lump is there. It is a sign, caught in medias res, a clue to a natural history that is unfolding. Science describes and explains it and determines what can be done about it. But the importance of that lump, the acts its discovery entails, and what those acts will mean are social and cultural matters.” How Doctors Think, page 15

There may be cancer—except when there’s not—but cancer isn’t the same thing for the doctor as it is for the patient. Cancer, for this veterinarian, was a series of pieces of paper, test results, and a subsequent medical history that seemed to disprove original observations made by another veterinarian years ago. Cancer, for Milton, had meant that he had lived an entirely different life for the past 5 years than he would have without that diagnosis.

To put it in Montgomery’s terms, the veterinarian offered a scientific ending to the story of the lump, in the form of a conclusion: the lump was never there, and that was a good thing. But, it’s not as simple as that. The lump was never just the lump for Milton and for me. It was a series of treatments that were doing very little or nothing to treat the (still to be determined) disease he actually had; side effects of those treatments that were endured in vain; and a lot of time, energy, and fear funneled into a disease that wasn’t there. The narrative of that experience works very differently with such a scientific twist—gotcha! He didn’t have cancer at all!—at the end.

I share all of this with a rhetorician’s lens and a certain level of seriousness because, well, I can. As much as we love our pets, feline cancer isn’t as important as human cancer—pathology can get a cat’s cancer wrong; oncology can afford the educated guess that turns out to be a mistake. Owners can set the boundaries and refuse treatment without being called—at least openly—negligent. All of it happens without consequence; the consequences for the owner or the vet if one makes the wrong interpretation or the wrong choice aren’t as dire as they are if this were to happen to a human. So, in many ways, the rhetoric of the science here is a bit more raw, closer to the surface, open about its reliance on its own discursiveness. Well, we never knew, for sure, that he had cancer, and we never really said so either.

Regardless, as I say, this is good news. The best news I have ever received in an oncologist’s office, that’s for sure. But that’s only part of the point. Every part of the end of this part of the story is fraught, shaped by discursive contingencies, marred by rhetorical mis-steps, and shaped by the fact that the facts were never as certain as I thought they were. A lesson I still don’t know what to do with but that I should probably figure out before I arrive at the next vet appointment.