From the Editor

Timed perfectly


 

When I entered the examination room, I saw his alma mater’s logo on his wristwatch. He was a retired physician with a new diagnosis of leukemia who drove to see me, even though he lived closer to his beloved medical school where he had practiced his entire career.

Dr. Matt Kalaycio, editor in chief of Hematology News and chair of the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute.

Dr. Matt Kalaycio

As is frequently the case, he came to see me because he could not get the appointment he wanted in his university’s clinic for another 6 months. He called us on Friday, and 3 days later, he and I were meeting. He is still an ardent supporter of his institution, but I am now his hematologist.

As it turned out, his leukemia was asymptomatic, indolent, and required no treatment. He could have waited 6 months to be seen. But, no; he couldn’t.

This story repeats itself over and over again. A sick patient calls to be seen and is told there is no availability for weeks or months. I do not understand how health care facilities, my own included, find this acceptable.

My father was very proud of his policy to see every patient in his waiting room no matter how long his office needed to stay open. He felt that access was of primary importance to his patients and to his practice. If he didn’t see them, somebody else would. Those of us working in large academic centers do not always feel the financial consequences of patients lost because of poor service.

Luckily, I work in a large cancer center that values access as much as a small practice would. When a patient calls us with a hematologic problem, we see them in less than 7 days, unless the patient prefers a different time frame. We monitor the time it takes to see patients and proactively assess upcoming appointments to ensure insurance coverage and the availability of records. If an obstruction is identified, the case is escalated to administrative leadership to be addressed and resolved. We are very proud of this work.

However, our focus on access does not end there. Once seen, we expedite patient evaluation by assessing workflows to obtain all necessary testing as quickly as possible. By doing so, we accelerate the time it takes from diagnosis to the time we start treating (time to treat). We have always tried to reduce time to treat for acute leukemia and we have applied those lessons to patients with lymphoma and solid tumors, resulting in a 33% improvement over the last 5 years.

We not only lessen the anxiety that comes with a scary diagnosis, emerging data indicate outcomes are improved with faster treatment, too (PLoS One. 2019 Mar 1;14(3):e0213209. doi: 10.1371/journal.pone.0213209).

These efforts will be criticized by those who feel the delivery of medical care should be structured more around the physician than the patient. Certainly, the system has developed to support a mindset of “physician first.” Not only do patients have to make an appointment for the privilege of seeing us, they have to navigate significant geographic and financial hurdles for that privilege.

Once at the appointment, physicians have historically been the provider giving the “orders” while others correct them, carry them out, follow-up on the results, manage phone calls, and schedule follow-up. This hierarchy has served physicians very well, but the pyramidal structure of health care is on the verge of being upended.

Too few physicians for an increasing demand for medical attention has led to the rise of advanced practice providers (APPs), who often serve as the only provider a patient may have, particularly in rural areas. In our center, we evolved from thinking of APPs as similar to house-staff who saw patients with us and did most of the work, but could not bill, to independent providers who work with us, do most of the work, and bill for their efforts. This slow transformation of our practice will soon seem quaint as we face the rapid disruption coming to our current conception of the health care delivery system.

Technologically savvy patients already demand immediate access to unlimited supplies of consumer goods, video, audio, books, magazines, and just about anything else you can think of. Immediate access to health care at a time convenient to the patient also will become an expectation because plenty of health care delivery models already are providing it. The local pharmacy or retail store may have a physician or APP right there ready to see a patient at any time. Some physicians are already online ready for an electronic interaction. See MDLIVE and Teladoc as examples.

The nimble cancer center that embraces these trends to become more patient-centric will be the center that captures national – if not international – market share, as insurance companies and governments adjust their reimbursement models to include these services. With blood work obtained just about anywhere, what would keep a patient with immune thrombocytopenic purpura from consulting with any online hematologist she chooses, whenever she chooses?

If first impressions are important, then patient access is important. Refrains of “I don’t have clinic that day,” “the pathology has not yet been reviewed,” and “that is not a disease I take care of,” ring as hollow to me as I suspect they do to our patients. When someone in my family has a significant illness, I want them to be seen now, not later. I believe we all would want prompt, efficient service.

We should strive to provide the same level of care to our patients as we expect for our family. Patients do not know that chronic leukemia is not an emergency. Time may not be critical to us, but it is to them. The perfect time to meet their needs is now.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

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