Craig Be Nimble: “Disruptive” Medicine or Inefficient Method?

Posted on March 16, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

I came across this very thought provoking post by Dave Chase on Kevin MD today, outlining “nimble medicine”. A little bit of googling revealed that a vastly better version of it, again by Dave Chase, ran on TechCrunch in late Jan. Yes, I’m that late to the party, and I will admit I’m feeling a little cheated by Kevin MD (really, how much trouble does it take for you to point out that a version of this article ran elsewhere?) But I digress.

To exemplify nimble medicine, Chase talks about a few interesting cases:
– Dr. Craig Koniver, who has closed his B&M clinic, and now runs a mobile clinic visiting patients at their homes or workplaces
– Medlion, a Silicon Valley company, completely bypasses the insurance brokered model of primary care and uses the Direct Primary Care model instead
– Companies like 2nd.md have made it easier for patients to get a second opinion.

Ladies and gentlemen, here’s medicine, as it perhaps should be practiced in this age of 4GS. Of the many cases that Chase discusses, the one that is most iffy for me is the mobile clinic one. Don’t get me wrong – I’m as much a sucker for a David-Vs-Goliath story, and if Dr. Koniver’s story were on Hallmark tonight, I’d be reaching for the tissues right about now.

However. The idea sounds awesome in theory. In practice, I’m not sure the model is sustainable. In fact there might be plenty of inefficiencies built into it.

Let’s say Dr. X sees about 8-10 patients a day. This is well below the 20 minute per patient average that most PCPs see their patients for.

Patient 1 lives in the North east quadrant of the city, Patient 2 work in the heart of downtown, and Patient 3 is in a city suburb, and so on.

One way to see all his patients is to go on a strictly First-Come-First-Serve basis, based on whatever his medical assistant has scheduled. This is not a feasible alternative at all. What if Patient 1 is 20 miles W from patient 2 and Patient 3 is far, far East of Patient 1. Horribly inefficient, which is exactly why algorithms such as the Travelling Salesman were invented in order to optimize travel paths.

The other alternative for the good doc is to apply the Travelling Salesman algorithm to his situation and base his visits to patients on geography. He might schedule his patients in such a way that he first sees all his patients that live in the Northeast quadrant and so on. Except now, the most pressing patients might need to wait till Dr. X actually services the patient’s part of the city.

Dr. X can of course optimize his travel path based on location as well as patient priority/needs, which is enough to give any grown person a raging migraine. And it doesn’t even get to the bottom of Dr. X’s biggest headaches, which is that
a) he spends an inordinate amount of time in traffic in
b) a gas guzzling vehicle that houses his medical equipment.

Waste of time, money and maybe even lives (imagine a patient dying while Dr. X is negotiating rush-hour traffic in DC)

So how can Dr. X compensate for this? By charging his patients for his time and attention. Or cutting down his clientele to a tiny sliver of a neighborhood. And yet, it makes for a wonderful story on “disruptive” medicine.