Clinical innovation - Innovation in the System at Large and in a Dermatologist’s Office: Mohs than Meets the Eye

The other day I was in a dermatologist’s office to have a small squamous cell carcinoma on my left temple excised. In the waiting room, I met a distinguished elderly gentlemen. Upon learning I was a doctor, he bluntly informed me, “The system is broken, and it has to be fixed.”

Greed and Corruption as Problems

As it turned out, he had done his part, serving on a hospital board and on a focus group for a large physician group. His position was that “ Greed” (with a capital “G”) has “Corrupted” (capital “C” here too) health care. He cited the 600 pharmaceutical lobbyists carrying “satchels of cash” to influence the recent Medicare Part D decision, the 100,000 pharm reps crowding doctors’ offices, and the 30% of national spending devoted to marketing and administration by private health plans. “One man’s greed is another man’s livelihood,” I thought, but I held my tongue.

Government as the Solution

His solution was government care for all, as administered by fair-minded and even-handed government managers. Presumably these managers would wipe out inequities, end private greed and waste, and correct glaring deficiencies, such as waiting endless hours in the ER.

I can’t say I blame him for his cynicism. He recently had chest pain and spent 9 hours on a gurney in the ER while ambulances whisked patients in and out, patients who took priority over him, and this in a hospital in which he was an incorporator.

How to Fix the System

What do people mean when they want to “fix the system?”

• Do they want to “fix it,” as my friend does, by federalizing, streamlining, and equalizing health care. We may inching close to federalization. On February 21, The Wall Street Journal carried an article “Government Pays Growing Share of Health Costs,” which said government already pays for 45% of all care.

• Do they want the states - like California, Massachusetts, and Pennsylvania, - to lead the way by implementing their own universal solutions requiring businesses, health care providers (hospitals, doctors, health plans), the self-employed, and the uninsured (either individually or through government subsidies) to kick in and make health insurance mandatory?

• Do they want to “fix it” by slashing out-of-pocket costs by whatever means possible? We could partially do this by rationing care and limiting choice by limiting the number of drugs in pharmaceutical formularies doctors and patients could choose from.

• Do they want to “fix” it by herding physicians into large groups like Mayo and Kaiser-like programs to decrease “fragmentation?” That way consumers could go to trusted highly-rated, high performing institutions rather than patronizing independent physicians, whose performance may not be rated or measured. That might save consumers the trouble of looking for just the right specialists, create a kind of one-stop medical shopping center, and lead to more consistent and measurable care.

• Do they want to “fix it” by unleashing market forces so well-informed consumers can pick and choose on the basis of price and quality?

Dealing with Specialists in the Present System

But what, pray tell, are we going to do with the present system, particularly those specialists practicing alone or in small groups dotting the health care landscape? Are we going to regulate their fees, buy up their practices, compel them to follow government guidelines, force them into larger groups? I have no idea.

Anyway, there I was, by choice, at a solo dermatologist’s office, a Mohs dermatologic surgeon no less. Mohs “surgeons” are dermatology sub-specialists who devote their professional careers to excising basal cell and squamous cell carcinomas of the skin.

They’re in demand. They combine surgery with doing periodic frozen sections on the spot to determine, as they proceed, margins of the tumor. If the initial excised tissue shows tumor, they re-excise to make sure the margins are clear. Some Mohs dermalogists think of themselves as a combination of dermatologist, pathologist, and surgeon.

Why Am I Telling You This?

Because Mohs surgeons show complexities of a highly specialized system and difficulties of transforming the present system into a unitary enterprise. I suppose we could just superimpose government-financing on the present system, but even fools know that would break the federal bank. Or we could leave it the market and judgment-calls of individual consumers. When push comes to shove, we’ll have to combine top-down reforms with bottom-up innovations.

My Real Purpose

My real purpose is to show little innovations can make a big difference. Small things based on patient convenience are important. Here the first innovation is outpatient surgery performed in the office. The second innovation is reduced costs because office procedures cost less than inpatient procedures. The third innovation is getting the whole thing done as one setting, rather than coming back at a latter time for another procedure.

These are trivial innovations in the larger scheme of things -- making the system equitable, affordable, and accessible for all -- unless you're the patient. My personalinterest in this, I trust you will recognize,is only skin-deep.