April 2004

Here's Looking At You, Grid

By Michael J. Katin, MD

Despite the best efforts of Hallmark and American Greetings, there may still be some dates that are not claimed for any special cause, although this number is rapidly diminishing. Valentine's Day is February 14, Earth Day is April 22, National Medical Dosimetrist Day is August 18, Mother-In-Law's Day is October 24, and we have all very recently celebrated Doctors' Day on March 30, at least in the abstract. I didn't receive any cards or gifts, but the way things are going for our profession anything not involving a loss should be considered a triumph. In the distant past physicians were given valuable gifts, usually key rings or umbrellas, and at least brunch, by their hospitals, but this largesse seems to be coming to an end. This month, in Nottingham, England, Dr. Terence Hope was suspended with the accusation that he took extra soup from the hospital cafeteria. Dr. Hope denied this charge, claiming that he was in fact taking extra croutons. This defense may seem famililar to anyone ever accused in a Medicare audit, but regardless this event must have taken some of the sheen off the Doctors' Day festivities in the U.K. Croutongate became a topic through the medical community, with most physicians chagrined about this treatment, and most hospital administrators rather astounded that croutons were even available at all.

The hard line taken by the hospital could be supported since if Dr. Hope had gotten away with the croutons it might be a matter of time before he was sneaking out of the operating theater with someone's amygdala. Regardless, it is unlikely that twenty years ago a physician, let alone a surgeon, would be subject to this type of treatment. At that time it was the right of every physician to be treated with respect and be allowed to misdiagnose, inadequately treat, and double bill anyone he or she would desire. These salad days have wilted. Once extra soup is withheld from the medical profession, it is a matter of time before other symbols of recognitions are taken from us: lounges, parking spaces, and professional courtesy. It is obviously a matter of time before we lose all status completely, and it may be best to anticipate this and start adapting. One way would be to diversify into projects that can still make use of our medical backgrounds but can be guaranteed to remain profitable.

There is now a chain of prenatal ultrasound studios in nonmedical settings (i.e., malls) with sophisticated equipment designed to produce still and motion pictures of little fetal Emily or Jacob in black and white or color. Undoubtedly the technology will be there to get an image of the little treasure with Santa Claus or the Easter Bunny even before his or her 0th birthday. Obviously there is a lot to be said for marketing directly to the public. The fact that these are ultrasound units originally used to diagnose medical problems is irrelevant. If the bundle of joy happens to be carting around a meningomyelocele it is improbable that Heather at the checkout counter will pick up on it. Heather doesn't even have to worry about submitting the bill to Medicare or Aetna since the parents are happy to let Visa cover it.

We could already try to segue from the active practice of medicine into this type of business but it would seem appropriate to take this model and apply it to cancer-related enterprises with which we are familiar and could translate into consumer-friendly venues. For example, most women know the importance of getting mammograms on a regular basis but often have difficulty making the opportunity to get them performed, and there is controversy about the accuracy of readings to the point that many radiology practices are scaling back from mammography because of the liability for missed diagnosis. We should then envision a chain of mammography boutiques, in which women can obtain studies in easily-accessible locations open during day and evening hours and weekends. Presumably the technical charge can be collected, and it would need to be determined if the need for a reading of the mammogram is mandatory. After all, when people receive a credit card statement it doesn't tell them what to do about their pattern of spending.

This could still work out adequately well for the patient/consumer. That person could then go to another wing of the mall to a kiosk in which (for a price) the mammogram images or CD could be inserted and a computer-generated report, similar to a horoscope or biorhythm, could be produced. The kiosk could be operated by a company headquartered in the Maldive Islands. The physician, and liability, would effectively have been bypassed. Other diagnostic studies might be more difficult to implement, but not impossible. One could go to a colonosocopy suite, possibly affiliated with Bath and Body Works or another franchise, and walk out with a CD of the interior of one's colon, with that souvenir destined to go onto the shelf next to little Jacob's fetal pictures, probably never to be viewed again. Therapeutic procedures would be more of a challenge. Techniques to provide self-service radiation therapy could, and probably eventually will, fill several columns, but someday there could be a venue next to Glamour Shots in which an eight-field IMRT plan can be designed, with the customer receiving a swipe card that could be used in the linear accelerator department at Wal-Mart. Prostate brachytherapy might be more difficult to adapt, although with innovative design of the grid and other devices this could prove a reality. I could go on, but Costco closes at 9 p.m. and I promised myself I'd get my cardiac catheterization over with today.

Thanks to Drs. Randolph Knific, Stuart Bobman, and Brian Krivisky for conversations leading to a portion of one paragraph of this column.

email: mkatin@radiotherapy.com