Mission creep: a census grows and genomics comes now comes retail


Does a thousand seem likes it’s cheap?

Beware the assumptions you keep.

Don’t think that it’s strange,

There will always be change,

And ever the mission will creep. 

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

Last night I took the handoff for a hospital census of 4, a record low since I started with this clinic.  Even though I arrived for rounds before 7:00AM, that number had grown by 3.  I whizzed through two admissions, three patients with kidney failure, one each with alcohol withdrawal and complex pneumonia, five diabetics, a newborn, and two coronary patients.  (Do the math, you’ll figure out that a patient rarely enters the hospital with one problem.)

The longer a person lives, the richer their life story; and in the course of half an hour I had the treat of listening to a wonderful family history unfolding over the course of three generations.  I left them hope that the specialist would be able to cure the problem. 

But I squandered 15 minutes trying to educate a nurse, who overhearing me speak Spanish, made disparaging remarks about immigrants. 

Still I finished at the one hospital before ten.  At the second hospital, still in the throes of transition from paper charts to a new Electronic Medical Record (EMR) system, I only had to round on the pediatric floor, and I held onto hope of getting to the office early. 

I discovered an EMR quirk: one now needs 9 keystrokes, not 1, to edit a dictation.

I got to the office early, but not nearly as early as I’d hoped.

After half an hour of buffing documentation and messages, I attended what had been billed as a provider meeting.

The man who brought the lunch didn’t pitch a drug but a lab test.  Using material on a cotton swab from the inside of the mouth, for a mere thousand dollars, his company can provide us with genomic information about how fast or slow a person might metabolize a range of medications. 

For example, a single standard 30mg dose of codeine provides good pain relief for 80% of the population.   But 20% of population lacks the enzyme to convert codeine to morphine; for those people, codeine might suppress a cough but won’t relieve pain.  The super enzyme found in 1 in 3 Somalis converts 100% of the codeine to morphine on the first pass through the liver, enough to kill half of those who try it.    

Our clinic prescribes almost no codeine.  For whom will the test bring a thousand dollars with of benefit when it comes to choosing an antidepressant, antipsychotic, or ADHD medication?  We requested more information.

I didn’t ask the larger question: how long will it be till an entire genomic sequencing becomes available for that price? 

Mission creep remains a permanent fixture on the constantly shifting medical landscape.  Whether a doctor deals with a growing census, or a company sells technologic improvements, we all know that the world, at the end of the day, will not be the world we had at the beginning.

 

 

Advertisements

Tags: , , , , , , , , , , , ,

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s


%d bloggers like this: