Is there such a thing as a truly collaborative medical diagnostic facility?
April 1, 2011 11:03 AM   Subscribe

Does there exist, in the USA or anywhere else, an actual medical clinic where the doctors definitively work tag-team, sort of a la House M.D. (okay, minus the verbal abuse), to find diagnoses?

I went to the Mayo Clinic in 09 and found this to not be the case there (which was not what I had expected). Yes, there was an intake physician whose job it was to coordinate all your tests and doc visits to people they thought you should see, but never did they all get together and confer and deliver a joint report, and never did it seem like one hand really knew what the other hand was doing, outside of knowing doc A sent you to see doc B, and whether certain tests were done at the lab corral or not.

Another example: there's a local practice of specialists here in my town (all the same specialty) which is considered the largest in the area, over 20 of the same kind in the same building, easily within 10 feet of each other. Yet to get any kind of opinion from any of the other doctors besides your 'own', you must request permission to xfer to another doctor in their practice.

Now, I work myself at a job where I find it extremely beneficial to have the opinion and input of others who do a job similar, if not the same, to what I do. All the time, every day. Why is this not more common? Especially in tough cases, you'd think this would be super beneficial.

Thank you mefiters.
posted by bitterkitten to Health & Fitness (18 answers total) 2 users marked this as a favorite
 
I have Chiari (yay, weird brain stuff!), and, though I haven't been there in a couple years (yay, symptom controlling drugs!), I see the folks at the Chiari Institute. I don't know exactly what goes on behind the scenes, but there is a definite collaborative vibe to the whole place. Nurses, neurologists, surgeons, all working together, visiting and evaluating the patient at the same time. It was wonderful, and it makes me sad that it doesn't happen more often. (Especially if I get sick or something when my PCP isn't available and I have to see another doc in his practice--and I have to give the whole damn spiel over again you'd think they'd at least compare notes or something ugh.)

I've never experienced it at any other specialists' practice as a patient. (I shadowed a plastic surgeon back in high school who was part of a 10-person practice, but they hardly even looked at each other passing in the hallways--it was really weird.) My place is pretty highly specialized, though, which might be why it's so close-knit.
posted by phunniemee at 11:16 AM on April 1, 2011


As to why it is not more common: a few things. One, we have a system that prioritizes speed. Time=money. So doctors by and large do not have time to huddle and review all the facts from a given case, medical history etc, then go and visit the client to get a feel for who they are dealing with and so on. I have not really watched House, but caught a few scene here and there. The notion of three or four doctors standing over a patient arguing the best method of care is about as accurate as CSI labs allocating 3 or 4 crime specialists to every murder. Not enough people, not enough time.
From a billing standpoint you are now simultaneously using the resources of multiple people with the same skill set. Which may make sense, in some cases, for the best care, but makes no sense from being paid, or time allocation.

Additionally, there is a strong culture of individualism within many institutions as far as physicians are concerned. The doctor is "suppose" to direct the care, figure the problem out and be assertive, be knowledgeable, be correct! Alright... that might be overstated a little bit, but there are many doctors who would view collaboration too often as a sigh of weakness that a given doctor does not know what they are doing.


Having said that, i have read accounts of where some physicians have asked for limited assistance, especially from specialist. usually it is informal and very sporadic.
posted by edgeways at 11:20 AM on April 1, 2011 [1 favorite]


This does exist, including at the Mayo Clinic - it exists at most if not all academic medical centers.

The only thing is you're applying the team approach to a scenario in which it doesn't typically apply, the outpatient scenario. Even House MD sees patients alone as outpatients. It isn't generally cost-effective for teams of doctors to see outpatients - heck, it's hardly cost-effective for one doctor to see you as an outpatient these days, unless they make your visit disturbingly short so they can see a lot of other patients in one day.

There are two exceptions I can think of to this rule, one being "Tumor Board", which is a meeting of cancer specialists (oncologists) that is typically held on a monthly basis at larger medical centers, where cancer patient cases are discussed with the room. The other one is if you're a VIP like Ted Kennedy - he got a team of specialists from across the nation to confer about his diagnosis and treatment. But most of us are not VIPs. We doctors also meet to discuss difficult cases together in "Morbidity and Mortality conference" ("M&M"), but if you're the patient in those cases, you're either already harmed or dead, the discussion is to benefit future patients.

The situation in which this does happen every day routinely is on inpatient services in academic medical centers (i.e. medical centers that have a medical school and residency programs, like House MD's medical center). The team, like House's team, is usually made up of residents, medical students, and an attending physician. The team will make 'rounds' on each patient, at which point the resident caring for that patient will make a presentation about the patient's situation that day, and all the team members will discuss the case and the plan, and the team will go in and talk to/examine the patient, in most cases.

On certain specialty services, the team is multi-disciplinary. For example, the kidney transplant team may have a transplant surgeon, a transplant coordinator, residents, medical students, and one or two infectious disease doctors who specialize in transplant patient care.

In the ICU, there is also often a multi-disciplinary team, for example, in the surgical ICU, the trauma surgery team attending, residents, and medical student will meet with the critical care attending, residents, and medical student, and make rounds on the critical trauma patients together with a pharmacist and the patient's nurse.

The difference is that these patients are highly complex and have a lot going on with them on any given day, so having the whole team talking it through together is much more crucial than it is for your average outpatient who just needs a few screening exams and medication refills every year. As an outpatient, your primary care physician is in charge of speaking with or receiving letters from any other specialists you see, and coordinating your overall care.
posted by treehorn+bunny at 11:30 AM on April 1, 2011 [12 favorites]


p.s. I work in an emergency department, where we're typically rushing around and seeing patients as quickly as we can on our own. But if one of us comes across an x-ray, lab finding, or story that is puzzling, we definitely ask each other quick questions about the case to get each others' opinions. This happens at least several times a day.
posted by treehorn+bunny at 11:32 AM on April 1, 2011 [1 favorite]


Even on House, this style of care is seen as exceptional. His department exists solely because of the unusual circumstances of his genuis, interests and his inability to work anywhere else.

The "team of doctors" does exist; but it's a) for treatment, not diagnosis and b) for several people, not one baffling case.
posted by spaltavian at 11:37 AM on April 1, 2011


At the risk of commenting too many times in a thread, I also want to respond to the comment by edgeways that due to a culture of individualism, only "some physicians ask for assistance from specialists on an informal, sporadic basis". That's incorrect.

Every primary care physician corresponds daily with specialists on a formal basis.

However, this is different than the scenario the OP is proposing, in which people who have the same training and background (i.e. a team of PCPs or a team of the same kind of specialist) get together to give a 'joint report'.
posted by treehorn+bunny at 11:41 AM on April 1, 2011 [2 favorites]


Not *exactly* what you're referencing, but I work on a pediatric interdisciplinary diagnostic team, however our focus is not necessarily medical: autism, developmental disorders, mental health, etc. My current team consists of developmental pediatrics, psychology, speech-language pathology, audiology and occupational therapy, but I have also worked with physical therapists, neurologists, psychiatrists, social workers, pediatric nurse practitioners, ENTs and plastic surgeons - depending on the population.

This interdisciplinary model is considered the gold standard for diagnostics, and we are the only facility that I know of in our state/region that does such assessments. We are also bleeding money, and are under constant threat of budget cuts, layoffs and closure. Our teams have, over the years been dismantled or consolidated because quality patient care is not profitable.
posted by lilnublet at 11:56 AM on April 1, 2011 [1 favorite]


(I meant "not necessarily medical" in the sense that I think the OP is referencing)
posted by lilnublet at 12:00 PM on April 1, 2011


After my 2nd round of cancer, there was a question of whether or not I'd need followup chemo. The answer waffled for a while, and I believe part of the eventual decision came out of a periodic "hey, let's look at a weird case" meeting of some sort among a bunch of doctors in several related disciplines.

So, not like "House", but definitely getting it in front of more eyes than just the oncologist and gynecologist I'd been working with.
posted by rmd1023 at 12:01 PM on April 1, 2011


When I was at Johns Hopkins, there was a little of this with the fellows and my oncologist. That's a teaching hospital, though, so it might be different.
posted by lettuchi at 12:02 PM on April 1, 2011


The NIH has a program for diagnosing rare diseases: http://rarediseases.info.nih.gov/Resources.aspx?PageID=31.

I saw a documentary about it and it reminded me of "House." From what I saw, it's very difficult to get into the program, but for people who do get accepted, a team of doctors tries to provide a diagnosis for people who have not been able to be diagnosed elsewhere.
posted by parakeetdog at 12:17 PM on April 1, 2011 [1 favorite]


From the NIH's webpage:
http://rarediseases.info.nih.gov/UndiagnosedDiseases/FAQ.aspx

The Undiagnosed Diseases Program at the National Institutes of Health

The National Human Genome Research Institute
The NIH Office of Rare Diseases Research
The NIH Clinical Center
Frequently Asked Questions

* What is the program's purpose?

This trans-NIH program has two main goals:
o To provide answers to patients with mysterious conditions that have long eluded diagnosis and
o To advance medical knowledge about rare and common diseases...


Sorry this is a sketchy answer, but I only know about this program (in Bethesda, Maryland) third hand.
My understanding is that, yes, there is a "House-style" approach taken. We know a family with an extremely sick child who is about to be admitted into the program.

Also from the FAQ page:

Patients must be referred by a physician or health care provider. Information your physician must provide directly to NIH includes:

* A summary letter describing your condition, when it was first noted and your current health status
* A list of treatments and medications that have already been tried and their effects
* Copies of reports and results of pertinent diagnostic tests, along with X-rays, MRI results, and other imaging records/studies. Copies of the actual imaging studies are preferred...

posted by Jody Tresidder at 12:18 PM on April 1, 2011


The situation in which this does happen every day routinely is on inpatient services in academic medical centers (i.e. medical centers that have a medical school and residency programs, like House MD's medical center). The team, like House's team, is usually made up of residents, medical students, and an attending physician. The team will make 'rounds' on each patient, at which point the resident caring for that patient will make a presentation about the patient's situation that day, and all the team members will discuss the case and the plan, and the team will go in and talk to/examine the patient, in most cases.
Ok, that's interesting. I have a confusing autoimmune condition, and I'm treated at a university hospital. At one point, one of my doctors suggested that I come in and be presented at rounds for the dermatology department. I've never been hospitalized for my condition, and the suggestion was that I would make a special trip to the hospital to be presented at rounds. (Actually, I think it was "grand rounds." Is that different?) In the end, I decided not to do it, because it involved taking my top off in front of like fifty doctors. (The thing that she wanted them to look at was a rash on my breasts.) And now I sort of regret not doing it, because I still don't know what the hell, if anything, is wrong with me.

It would still only have been dermatologists, though. And I'm in the weird situation where my different specialists don't really talk to each other and have sometimes kind of badmouthed each other and dismissed other doctors' proposed diagnoses in front of me.
posted by craichead at 12:23 PM on April 1, 2011


I think part of the reason this doesn't happen more is, as usual in health care, the billing system. I'm no expert on medical billing, but as I understand it, insurers, by and large, don't have much of an interest in paying a bunch of doctors to sit together in the same room and discuss a patient's care. Doctors get paid for doing things, not for talking to other doctors, and paying a whole bunch of doctors to have a meeting gets really expensive really fast. The main exceptions, as treehorn+bunny mentions, are really complex critical situations like transplant and trauma patients and academic medical centers, where the attending physician will discuss a patient's care with residents, interns, medical students, etc... In the former case, I believe there are some special billing codes that can be used in critical care settings, and in the latter case, it's a part of medical education and most of the parties involved aren't paid for the time.

At the risk of commenting too many times in a thread, I also want to respond to the comment by edgeways that due to a culture of individualism, only "some physicians ask for assistance from specialists on an informal, sporadic basis". That's incorrect.

Certainly physicians receive consultations from other specialists all the time, but that's different than an interdisciplinary team approach. I don't think the OP is just describing a situation where a bunch of PCPs or neurologists or whatever together to give a joint report, I think it extends to getting a, say, PCP, a cardiologist, a oncologist, a neurologist, a pharmacist, a social worker, and if it's appropriate, the patient and/or a family member to sit in the same room and create and manage a patient's care plan. There's an enormous difference between the consultation model and a team approach. True interdisciplinary teams provide superb care, but they will continue to be exceedingly rare unless someone is paying for them to happen.
posted by zachlipton at 12:23 PM on April 1, 2011 [1 favorite]


At cohesive medical centers, in oncology at least, any case that is a little complex or bewildering is discussed at tumor board, or new patient conference, or the leukemia/lymphoma conference, or similar.

It is very common for physicians to bring in their 'problem' cases to get the input of the group. It is also fairly common to send pathology samples to outside centers to ask for help with a diagnosis.

However, it is much less common for physicians to sit down wilth doctors outside of their speciality to discuss patients. If a person has oncology, orthopedic, GI and nervous system problems, any communication between the docs will be by phone or e-mail, or some such. Or by reading the ogther doctors notes. There is not a system set up to facilitate inter specialty confabs.
posted by SLC Mom at 12:36 PM on April 1, 2011 [1 favorite]


I have a really rare congenital syndrome and I had teams of doctors working together since my birth to figure out what was going on and what to do. This was in various hospitals in the midwest. To me it's completely normal for doctors to confer with each other, although usually only one presents their findings.

Two examples: three years ago, I had to be taken to the ER in suburban Chicago. Their doctor didn't know what was wrong and called a specialist at Northwestern. I was transfered to Northwestern and saw 4-5 doctors while I was there, who no doubt conferred with each other. Last week, for a different problem, I went to a clinic. I had one doctor show my X-rays to another doctor in the same clinic to get his opinion. They did not have a conclusive opinion, so I'm going to Doctor #3 in a hospital and taking my X-rays from Doctor #1 with me. I'm sure there will be some phone calls between #2 and #3.
posted by desjardins at 1:09 PM on April 1, 2011


At one point, one of my doctors suggested that I come in and be presented at rounds for the dermatology department. I've never been hospitalized for my condition, and the suggestion was that I would make a special trip to the hospital to be presented at rounds. (Actually, I think it was "grand rounds." Is that different?)

Yes, grand rounds is different - regular rounds is usually made in the hallways of the hospital while seeing patients every day. Grand rounds is usually held once a week or once a month in an auditorium setting where physicians gather for an educational lecture. I can understand the hesitation in taking your clothes off in front of a crowd, but on the other hand, it's a free opportunity to get other opinions on your condition.

zachlipton makes a good point - in academia, we are typically not paid per patient encounter, the physicians who staff those care teams are paid on salary. Agreed that there is a difference between making a typical consultation and taking a team approach to healthcare, my comment referenced the assertion that physicians are averse to asking specialists for help at all because collaboration might be seen as a sign of weakness. I think it's more the opposite, especially because people like the idea of sharing the liability in this malpractice environment...
posted by treehorn+bunny at 1:44 PM on April 1, 2011 [1 favorite]


I'm not medical staff, but I work as an admin at an academic hospital. My doctors (who are oncologic surgeons) have a weekly tumor board meeting where they discuss cases with medical oncology and radiation oncology doctors. They also have weekly grand rounds, of course. I also see them conferring on cases in clinic all the time - usually that's a resident talking to a fellow and/or an attending about what they think should be done, and it's part of the learning process for the resident (as well as being good for the patient). If two attendings have clinic at the same time, which is pretty common (they see patients on opposite sides of the clinical space but share a workroom), and a patient has something really exceptional wrong with them, or had an exceptional recovery, or something like that, then sometimes everybody will gather around the computer to look at the scans and sort of troubleshoot, and those (completely informal and afaik not billed) discussions might have two or three residents, a fellow and two or three attendings all talking about one patient. This latter scenario is rare but I see it at least once a month.
posted by joannemerriam at 5:47 PM on April 1, 2011


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