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Who Should Choose – Digital Scope Creep

In the consulting world and other venues there is a phenomenon called scope creep. This refers to a project getting bigger and broader as the client and consultant dig into the project and find more issues and assign more tasks, etc. The result is, inevitably, higher billing fees and extended deadlines.

A more public, but less costly, example of this is watching a photographer with a digital camera and an automatic shutter. With old-fashioned film in a camera a photographer would make their composition and take the shot. Then they would adjust focus and other settings and go again. With fancy digital cameras the artist rips off 3-5-10 exposures right away, with perhaps minor adjustments along the way. The marginal cost of the old-fashioned approach was significant – it at least increased the number of images on the contact sheet and thus the size and number of those sheets. The marginal cost of one more digital image is darn near zero.

Healthcare.  My last round of scans and digital images started out with a thoraic CT scan – pretty much the same as the ones preceding it. There were specified scans to the chest. Pretty straightforward. This time the oncologist added orders for a bone scan. I don’t know enough about bone scans to be able to describe them well, and to what extent those orders are carefully targeted to an area of the body or more open-ended. In my case the doctor was checking to see if the sarcoma was spreading to my spine or other bones. (Probably some small growths on either side of my knees – in the bone. There are variations of sarcoma that are bone-related, but we’re not going to worry about them at this stage.)

[The question about CT vs bone scans, which use different technologies, is another side question about aggressive vs. conservative diagnostic decisions - but I don't know enough about these specifics to weigh in right now.]

So, CT scan finished I’m now strapped on a platform in the bone scan room. “Strapped” is too pejorative – I was comfortable enough –  padded platform, pillows, gentle restraints to help with wayward arms and legs, etc. I just lay on the platform and the scanner moved along my long axis. It did this several times – with particular attention to my pelvis and targeted areas of the spine. Then there was a long pause (10 minutes or more) and then back to some more scanning. It turns out – after I asked – that the radiologist had gotten a preliminary look at first scans (pretty magic – sitting in her office next door or across town – reading these images and making new orders, etc.) and wanted to explore one area more specifically.  Here’s an example of digital creep. It’s a more thoughtful, considered alternative to the photographer firing off multiple, nearly identical images, but in this case there are marginal costs. The physician needs to read those images (time), and with some probability those readings will lead to further treatment, chances for false positives, good or bad outcomes, etc.

And then the same thing happened in X-Ray. X-Rays were not originally ordered but I believe the same radiologist decided that they wanted to see things from that perspective or spectrum. So, off I went in my skimpy gown down to x-ray. And there the automatic shutter analogy was pretty close. The x-ray techs still had to position each shot, step out of the exposure area, and rinse and repeat, but still it was pretty fast. And another pause for diagnosis, I imagine, followed by more exposures. Same deal with marginal costs, positive or negative outcomes.

So here I am not part of the decision making – clearly out of it. I’m not drugged but I don’t jump into a discussion. My oncologist is another step removed from the decision. Whatever the skills and experience of the radiologist we delegated treatment and further diagnostic decisions to her. This does not feel like a good set up.

And a little sidebar… I spent quite a bit of time in the bone scan room – probably 90 minutes or more. It was comfortable enough – enough so that I could doze if I wanted. And apparently I became just part of the furniture. Scanning techs came and went. Some supervisor worried they were out of some kind of supply and was contacting the sales rep for replacements. A party was being planned for later in the week. I just wasn’t there. There’s some meaning there somewhere.

Moral to this story – if I haven’t beaten this horse too much…the digital capabilities in healthcare enable increased use of services and increased costs. Those capabilities might help with outcomes, or not. It’s had to believe this pattern saves system-wide costs.

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5 comments to Who Should Choose – Digital Scope Creep

  • Graham Lewis

    Hey Doug,

    Glad you are feeling up to typing a few paragraphs.

    Cameras will make adjustments for us was we shoot, changing shutter speeds or aperture (f/stops)up or down. I seldom use this feature as it’s too much fun to shoot in the manual mode.

    As to feeling like furniture: I suspect that the techs dehumanize patients as a defense against their own mortality. Supervisors ought to train them to keep the conversations out of the treatment rooms. I once had a contract to train docs and staff in an HMO in LA. This was high on the list of patient complaints when we did the initial surveys.

    Blessings,

    Graham

  • Leslie Gershon

    Doug,
    I could write a book on all this…not from an economist’s perspective, but from my own experience with Dick’s heart condition. I know, everyone has a story and I’ll spare you the details of ours. In his case, I felt we were almost given too many options and we were asked to make choices/decisions which as laypeople were way beyond our expertise. Do you take the tried and true, crack the chest by-pass surgery or do you go with the newer, well-tested robotic route which is less painful and with a much faster recovery period? One set of pooh-bahs said you must use the tried and true; the pooh-bahs at another hospital insisted robotics was the way to go. A third prestigious hospital surgeon couldn’t see us for three months. (We opted for robotics and it went seamlessly).

    Then, five years later when he had a massive brain bleed (due in part, I’m convinced, to the coumadin he was taking, tho’ no doctor in NY or at UCLA ever “went there”, and which he would have taken no matter which procedure done), I was given so many possibilities and time frames for possible “recoveries” that it made the decision to take him off of life support weeks later triply difficult.

    I’m fairly convinced that a lot of the over-testing and extension of impossible odds with too much information is all about avoiding litigation for the doctors and institutions involved. It’s another element that propels the “creep” of tests and costs.

    There are humorous notes occasionally and you have to laugh–early on before Dick’s heart bypass, they were doing yet another round of pre-surgical tests, they couldn’t get the EKG printout to work and after having him hooked up for about 40 minutes with no results, some genius figured out that the printout machine was out of paper. No one knew either where the paper was or how to load it if they found it. With his wry sense of humor, Dick suggested to them that they go across the street to Staples.

  • Joe Peterson

    Hi Doug,
    I have been following your blogs only recently after finding out about your health issues in front of our old office together (T114). Jim Phillips had heard far more than I knew as a part-timer about your health battles.
    I am convinced your blogs on all of this are extremely helpful to others. If you have the energy keep it up because you are making a difference.
    Best,
    Your old office mate Joe

  • Doug Gentry

    Great to hear from you, Joe. I miss our hallway conversations. Did sequestration impact your history program?

  • Joe Peterson

    Huge pressure on the entire campus to live with a smaller budget but not a result of sequestration.
    Bigger classes for tenured professors and far fewer adjuncts. Funding is just not there–an old story in Oregon.
    Great to hear from you as well!
    Joe

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