Tuesday, September 23, 2008

Steps involved in medical care

I'm at a conference right now, and one of the keynote speakers said something that inspired this post - he said "Think how many health care professionals it takes to take care of someone when they're sick." It's hundreds. Let's just go through an example, one I'm relatively familiar with.

A woman - let's call her Mrs. Smith - finds a lump in her breast one day. So the first thing she does is go to her family practitioner (health care professional, or HCP #1). At the doctor's office, she's greeted by a receptionist (I won't count this person as a HCP) and a nurse takes her vitals or her visit information (HCP #2). The doctor feels the same lump during that visit, gets concerned and sends her for some bloodwork and a mammography. Mrs. Smith has to go get the bloodwork done at an outside lab because of her insurance and there a tech or perhaps another nurse (HCP #3) does it for her. At least one technician (HCP #4) performs the labs and sends the results back to the primary care provider. For her mammography, Mrs. Smith probably has to go to a different hospital or radiology center for her mammography. There, one or two techs (HCP #5) do the mammography, then they send the results to a radiologist (HCP #6) whom Mrs. Smith may or may not ever meet! Unfortunately, the radiologist sees a suspicious lump in the mammograph and sends his findings to Mrs. Smith's family practitioner. She goes back to see him (her second visit, at the very least) and of course, he's very concerned and sends her to an oncologist (HCP #7).

At the oncologist's office, she meets more receptionists and nurses (HCP #8) who take her info first, and then she meets the oncologist (HCP #9). The oncologist feels the same lump, looks at the mammography findings and says she needs a biopsy. The first biopsy they usually do is relatively simple. The oncologist inserts a needle into the mass, sometimes under ultrasound guidance (sometimes requiring another tech or radiologist) and gets some tissue, which gets sent to a pathologist (HCP #10). Often, the first biopsy isn't good enough and they need to do the biopsy a different way, or get someone else (another HCP) to do it. Let's say in this case, the biopsy sample was good enough and the pathologist says it's cancer. The pathology lab has some other techs and pathologists (HCP #11) who do additional studies on the biopsy sample to characterize what type of breast cancer she has. On Mrs. Smith's second visit to the oncologist, he tells her the bad news, and tells her she will have to have it removed by surgery, and because of the characteristics of her cancer, she will also need radiation and chemotherapy. The oncologist has now become her center of health care, and he sends her to a surgeon (HCP #12).

Again, at the surgeon's office, she meets another nurse who takes her vitals signs and her initial information (HCP #13). The surgeon says yes, we need to do surgery and after some more bloodwork and probably some cat scans or additional imaging, she's ready. Mrs. Smith gets admitted to the hospital the night before the surgery, and meets at least two nurses who take care of her while she's there (HCP #14 and #15). There are also techs who take her vital signs and may administer medication (HCP #16 and #17) as well as a tech who normally does blood draws (HCP #18) for routine labs in the hospital. Because she's in a hospital, a different lab and a different tech runs her bloodwork and interprets them (HCP #19), and she may have a different radiologist (HCP #20) interpreting her imaging studies. There is also at least one pharmacist (HCP #21) involved in giving her the correct medications at the correct times. Moreover, there are healthcare-specific social workers (HCP #22) checking her medical charts and information and making sure things are overall being done correctly. The next day, she's wheeled off to the O.R. (operating room). Before anything is started, she meets the surgeon again as well as the anesthesiologist (HCP #23). In the operating room, there is of course, the surgeon and the anesthesiologist, but there is also a scrub nurse (HCP #24), a nurse in the room (HCP #25) helping get extra supplies, answering phones, etc., and at least one resident or physicians assistant (HCP #26) helping the attending surgeon. After getting out of the O.R. the patient usually goes to a PACU, or basically a recovery room, where there are at least one or two other nurses that help her (HCP #27). From there, Mrs. Smith would probably go to the medical ward where other nurses and techs take care of her (HCP #28, #29, and #30) and the surgeon and his team (probably his resident or assistant) visits her to make sure she's okay after surgery. Hopefully there are no complications and she leaves the hospital within a day or two to go back home. Meanwhile the hospital pathologist (HCP #31) examines her breast tissue under the microscope, and a lab technician or another pathologist does further biochemical work to characterize her cancer (HCP #32).

After she's recovered from her surgery, it's time for her to start radiation therapy! So now her primary care provider refers to a radiation oncologist, at who's office she is again first greeted by a nurse (HCP #33 and #34). They get her set up with a planning cat scan, which is done by a tech on a second appointment (HCP #35). The radiation oncologist plans her therapy on a computer, which is assisted by a dosimetrist (HCP #36) and a physicist (HCP #37). Radiation therapy usually takes many many weeks of daily Monday through Friday treatment, over which time Mrs. Smith will meet many technicians, nurses and other doctors (HCP #38, #39, #40).

Finally, it's time for chemotherapy. Although this may again take a number of weeks, this is done through her oncologist's office, where she already has probably met the nurses and assistants that will be involved in her care. Depending on the type of chemotherapy Mrs. Smith receives, she may meet some new HCP's in a chemotherapy room or who help her to administer the chemotherapy at the office or at home.

As you may have noticed, even though I probably grossly underestimated the numbers of HCPs that helped Mrs. Smith out, in the story itself, that's a total of 40 health care professionals who have all helped Mrs. Smith during her medical problem! This story doesn't even take into account residents, medical students, nursing students, medical transporters, and other health care professionals who often play a large role in a patient's care and may more than double the number of HCPs who help her! Moreover, this story was relatively straightforward, and the patient didn't experience any complications, such as infection, adverse effects from chemotherapy or radiation, biopsy problems or anything else, which would of course result in more diagnostic procedures and treatments, as well as exposure to more HCPs. In addition, Mrs. Smith may have other medical problems and comorbidities not mentioned in the story which require the attention of even more HCPs.

The entire reason for this story is that I think it is amazing how many health care professionals are involved and how many steps are required for providing basic care for what has become a relatively commonplace problem. With this consideration, it seems like it would be a miracle if everything went smoothly, nothing went wrong, and the patient was satisfied with absolutely everyone that helped her out. It seems healthcare is so complex in the modern world that there will always be room for improvement despite continual modifications, and from the standpoint of a health care professional, I hope that patients realize all our efforts to streamline the process and make their own healthcare easier for them to go through.

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