Blog | Wednesday, May 12, 2010

How to Micro-Tweak Diagnosis and Treatment


This post by Alan Dappen, MD, appeared at Better Health.

A common problem in health care is the number of times that small adjustments are needed in a person's care. Often for these little changes, a physical exam and face-to-face time have nothing to do with good medical decision making.

Yet the patient and doctor are locked in a legacy-industrialized business model that requires the patient to pay a co-pay and waste at least half of their day driving to and from the office, logging time in a waiting room, and then visiting five minutes with their practitioner for the needed medical information or advice.

Today I'd like to visit the case of a patient I'll call "DD," who I easily diagnosed with temporal arteritis (TA) through a 15-minute phone call after she'd spent four weeks as the health care system fumbled her time with delays and misdirection via several doctors without establishing a firm diagnosis.

A single phone conversation with DD led me to immediately order an erythrocyte sedimentation rate (ESR), and I sent her to the lab near her home. A mere 24 hours later her test confirmed the diagnosis (ESR=90) and she was already feeling better. I called her the next day with the results, after having already called in her medicine (prednisone) to start immediately, based on the lab test. I wanted to move with utmost speed because delaying treatment increases high risk complications, such as going blind.

Since then, she's experienced enormous frustration trying to access her Medicare physician. She consequently has given up on this approach, which includes forced office visits and delays, and instead manages her TA by paying me directly each month for 10-minute phone conversations (when she can reach me anytime she wants to).

She calls at a time that's convenient for her and we follow her progress with TA and the prednisone dosing. As is typical with most people, she did not want to believe that TA usually requires a year of prednisone dosing and that tapering the medicine too fast can lead to problems. Once she called me with increasing headache because she was tapering the dose faster than I had suggested. A second time I measured her ESR that showed her that her level was still not normal enough to recommend lowering the dose even though she was not feeling any headaches. At this point, I suggested she increase the dose of prednisone slightly. She is by now familiar with the classic long-term side effects of prednisone, some of which she's experienced personally and some that we have reviewed via phone and then have taken steps to stay ahead of.

Today she called me with her monthly update. She is feeling "perfect" after a month of being on prednisone regiment of 7.5 mg/day. DD wanted to know if it's reasonable to reduce the dose to 5 mg a day. I agreed and as long as she has no headaches or body aches during that month we should consider rechecking her ESR at the lab in a month before considering further tapers over the next six months. I called her pharmacy with prednisone 5 mg/day dispense #30 and placed a calendar reminder in our medical record calendar for a month from today and charged her five minutes of my time (which is $25). Compare that charge to a typical $20 co-pay or billing Medicare for another $40, plus the cost of gas to get to the office and the lengthy waiting room delays, all to get similar advice.

The answer to DD and me is simple: Telemedicine wins hands down in both speed and, therefore, quality of diagnosis, as well as cost.

What, dear reader, do you think?

Until next week, I remain yours in primary care,

Alan Dappen, MD

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.