I have always felt that every family needs a doctor to help its members navigate what is becoming an increasingly complex and challenging medical landscape. There are so many choices that patients need to make with very limited knowledge and understanding. In addition, there are economic and other forces acting that do not always work in a patient’s favor. For example, the overhead involved in providing state of the art medical care has become so expensive that much pressure is placed on health care providers to see more patients and do more tests and procedures. If a physician has a very expensive hammer, then there are great pressures to make a patient a nail that can be treated. There are also so many layers between patients and physicians such as the people who take the initial call and schedule appointments, nursing assistants, nurse practitioners and physician assistants, interns, residents, and fellows to mention a few. These two conditions, high overhead and many layers, conspire to reduce the quality of care while increasing its costs; not a good combination.
There is hope though. As a physician, I am often asked for advice by family, friends, and colleagues in an informal manner that is called a “curbside consult.” In a few minutes, I can often get a pretty good idea of what the problem is most likely to be and can give advice that at the very least will set the patient on a good course. And if I do not know what is going on, I can usually refer them to another physician specialist or other type of health care provider who can help. This curbside vindictive can save the patient a lot of time, effort, and expense as well as provide emotional support and reduce stress. It is also very satisfying and rewarding for me.
All of these conditions and circumstances lead me to believe that one of the few ways we can provide better care at reduced cost is to provide patients with what I call a Medical Navigator using the internet. It is a GPS like system that allows patients to diagnose certain common conditions easily and rapidly, in some cases, initiate treatment that involves safe and readily available remedies; provides patients with useful information that at the very least will allow them to interact with their family doctor, general practitioner, or internist in a more effective and proactive manner by alerting patients to what potential diagnostic and treatment options are available so that they can take greater agency over their care; potentially reduce the number of clinical visits needed and thereby initiate care sooner and possibly more appropriately, effectively, and SR reduced cost. Another way to look at it – it is taking an Amazon approach, by making greater use of the internet, combined with a Khan Academy approach in disseminating knowledge widely, concisely, and in as simple and understandable a manner as possible. Seems to good to be true? We’ll see the following clinical example applied to a very common medical condition called Carpal Tunnel Symptom (CTS) that often produces unpleasant and debilitating hand symptoms (pain and numbness) and findings (weakness and reduced dexterity).
CTS: what if…
Current treatment pathway:
For months you have been waking up at night with increasing dominant right hand numbness and pain. You also have begun to notice difficulty opening jars. You search the internet and think you may have Carpal Tunnel Syndrome. You call your family doctor and get his nurse practitioner (NP). She says you may have CTS and need to come in for a clinic visit. She fits you into a cancellation spot in 2 weeks. You arrive sleepy and are seen by both your physician and his NP who diagnose you with CTS and recommend you try using a right wrist-hand splint at night fir several weeks. After 3 weeks of persistent right hand discomfort, you call your doctor’s office. They recommend you see a neurologist to undergo an EMG/NCV diagnostic study. They tell you to use the wrist-hand splint during the day when possible. An appointment is made and you see the neurologist 3 weeks later. She agrees that your history and exam indicate a diagnosis of CTS. Your EMG/NCV study is borderline abnormal with mild slowing of right median nerve sensory conduction and a normal EMG. You are told that your options are to continue with medical therapy with the addition of hand therapy on a weekly basis by a hand therapist or undergo a surgical release of the carpal tunnel. Your symptoms have stabilized and you decide to undergo a trial of hand therapy for 4 weeks. After 4 weeks of hand therapy on a weekly basis by a trained therapist and daily on your own, you decide to explore the surgical option. You are referred to a hand surgeon whom you see in 4 weeks who recommends you undergo an endoscopic carpal tunnel release which you undergo 4 weeks later. Your right hand symptoms improve significantly after the surgery. Summary: 3 clinic visits followed by surgery if indicated over 17 weeks (4 months and 1 week).
Possible treatment pathway:
For months you have been waking up at night with increasing dominant right hand numbness and pain. You also have begun to notice difficulty opening jars. You search the internet and find the curbsidemedical site. You are informed that based on your clinical symptoms you most likely have CTS. You are informed that if your symptoms are not severe, meaning that the muscle mass in your hand at the base of your right thumb is not smaller than on your left normal side, you can start with hand therapy for 3, weeks which consists of the following: 1) either at a drugstore or online, purchase a wrist-hand splint to wear at night and during the day if possible; 2) perform Namaste Carpal Tunnel hand stretch exercises three times a day (see video). If your hand symptoms persist, then call your doctor and request a referral to a neurologist for an EMG/NCV study and, if the study is positive, see if you could also see a hand surgeon on the same day or soon after to discuss surgical options which include the following types of procedures: 1) a traditional open carpal tunnel release (CTR); 2) an endoscopic CTR; and 3) a minimally invasive thread CTR. Each has advantages and disadvantages which you should ask about but keep in mind that every surgeon has a preference based on their training and experience. All CTR procedures gave a high success rate when performed properly. Ask your surgeon how many he has done snd what his/her results are. Summary; 1 or 2 clinic visits followed by surgery if indicated over 3 weeks.
This example illustrates the power of using a Curbside Consult approach combined with a Medical Navigator internet based platform to help patients diagnose, initiate treatment early in some cases on their own, and navigate a very complex medical landscape in a more efficient and effective manner in terms of time, outcome, and cost.
Stay tuned for more…
Michel Kliot MD