September 2004

Extensive Care

By Michael J. Katin, MD

The term "crisis" is sometimes liberally used, ranging from the Cuban Missile Crisis, in which Global Thermonuclear War was imminent, to the Scottish football crisis from earlier this year . In the United States, most surveys would show a linkage of the term "healthcare" with "crisis," overlooking the true crisis, which is why "healthcare" has to be run together as one word, just as "swiftboat" or "J-Lo." Every aspect of health care is associated with crisis, from the AIDS crisis to the Medicare crisis to the malpractice crisis to adrenal crisis.

One crisis with which the field of radiation oncology is very familiar is the staffing crisis, whether it be for physicists, dosimetrists, radiation therapists, nurses, or radiation oncologists. It became obvious that the educational system was not going to produce enough qualified persons to deliver increasingly sophisticated modern radiation therapy to the growing number of patients appropriate for these techniques. The solution was to create categories of medical "extenders" to fill these gaps. "Extenders" had certainly been used in many other settings, from sports to food and in the field of medicine was now applied to nursing, podiatry and pharmacy Although these occupations were created to help deliver health care to the maximum number of patients possible, they were sometimes criticized as an way to reduce the number of higher-paid positions in a blatant attempt to maximize profits. For some reason, this same accusation was never made about such fields as accounting assistant, legal assistant, or Assistant Secretary of Commerce for Manufacturing and Services Albert A. Frink, Jr.

Truly, the goal of using physician extenders is not to save money, but to improve patient care, at least until somebody can figure out how to outsource this industry to India. Development of a superb system of physician support has been one of the major developments of the past two decades, ranking possibly only second to the invention of the lighted ear curette.

The availability of midlevel practitioners (physician assistants, nurse practitioners, certified nurse midwives, and nurse anesthetists) has dramatically enhanced the practice of medicine in terms of availability and scope of delivery of medical services. Working out the regulatory details of the powers and responsibilities of these professionals has been completed, with minor differences among states, and to the satisfaction of all these practitioners, with the possible exception of nurse midwives, when it was discovered that this is the only group that might still be accused of gender discrimination, when it was realized that there were, in fact, no nursemidhusbands. This was eventually worked out, but not without causing many professionals to undergo a fairly disruptive midwife crisis.

Physician extenders provide valuable assistance in hospital rounds, with obtaining histories and physical examinations on patients coming for intitial consultation and re-evaluation, and, since it is difficult to try to make sure every patient is seen on a regular basis during the treatment course, they are very helpful in making sure this gets done. This can then free up the physician for hospital committee meetings, special procedures, research, and other activities.

There is another person involved in this interaction: the patient. It is somewhat burdensome for him or her to have to come in for treatment planning and then 5 or even (for b.i.d.) 10 times a week for the treatments themselves, and then to have to be available to be checked in an examining room away from the treatment unit (with this not always able to be done immediately before or after the treatment). Patients have to work their schedules around home responsibilities, business, and other activities, making it difficult to have to hang around to see the radiation oncologist or physician extender or both, just to be told that the treatment is going on schedule and nothing needs to be changed. After all, the goal of modern radiation therapy is to minimize side effects and with more complicated imaging and planning it would be assumed that there will be fewer adverse events and minimal interruptions or changes in the treatment schedule because of morbidity. In addition, the initial consultation was probably tedious for the patient, since he or she would probably have already had such an examination from at least three other physicians in the process of diagnosis and prior to referral for radiation therapy, and probably has ongoing appointments with these other physicians even during the radiation therapy course.

It might therefore be appropriate for the patient to be able to be represented by a patient extender, someone knowledgeable about that person's disease and overall condition, who can replace the patient for virtually all interactions short of the actual radiation therapy treatment. Possibly one patient extender could represent several patients, particularly those with similar histories and diagnoses, thus improving efficiency for both the patients and the medical personnel.

email: mkatin@radiotherapy.com