internist's perspective


Dr. David Frost is a staff general internist at the University Health Network, and a clinician/teacher at the Centre for Excellence in Education and Practice at Toronto Western Hospital.

Just 32 years old, and only a few years removed from his chief residency in internal medicine, Dr. David Frost is among the youngest of the physicians recruited to work in Dr. Herbert Ho Ping Kong's Centre for Excellence in Education and Practice (CEEP). Although he says he derives most enjoyment from direct patient care, he devotes research time to an issue that looms over the health care system — the disproportionate use of resources (in dollars, equipment and medical personnel) by a very small percentage of the population.

"My work looks at optimizing patients with multi-system medical problems and seeking ways to care for them that reduce hospital readmissions," he explains. Such patients constitute about one percent of the population, but account for 30-40 percent of total expenditures. This lopsided statistic is the result of a paradox. On the one hand, improvements in the broader health care system mean people are living longer. But precisely because they live longer, they are more likely to develop what are known as 'co-morbidities,' overlapping chronic diseases such as diabetes, congestive heart failure and cancer.

"These patients, a tiny percentage of the population, in the last months of their lives represent a hugely disproportionate drain on health resources," Frost says. "The challenge is to identify who are they before they become high users of the system and keep them treated as outpatients. It's a very complex issue with many stakeholders, but we need to get on top of the problem if we are going to have a sustainable health system."

Frost says his medical ambitions began in childhood. "I don't really understand why — I'm the only one in my family crazy enough to go into medicine — but there was never been a doubt in my mind that that's what I wanted to do, and it was always the only thing I wanted to do. As I grew up, the academic side of medicine appealed to me." Later, in medical school, although he considered anesthesia and surgery, he chose general internal medicine because it offered "direct patient care with an academic side. I was more suited to being a generalist than a specialist. For me, the broader knowledge base was more appealing."

As an acolyte of Dr. Ho Ping Kong, Frost has tried to emulate some of his practices. One of these is making regular visits to the radiology department to talk to the specialists who read MRIs, CT scans and Ultrasound images.

"Herbert goes every week with a list of his patients who have had tests because, while he will have already read the formal report, he wants to dig deeper," Frost says. "It's surprising because, when you actually speak to the radiologist, things are often not as certain as they might make it seem in the report. They may have insights they don't actually put into the report or ideas they won't share in writing for medical-legal reasons or because they may appear too speculative."

Frost recalls a case in which the patient presented with fever, weight loss and leg pain. She had developed a hematoma in the leg, which made imaging tests difficult to read. "It was very difficult to sort out whether we were seeing blood leaking into the' muscle or an underlying mass; The radiologists and people who deal with soft tissue tumours did not know. Herbert was concerned about cancer and advised taking a biopsy, even though we had been told it was not possible and might make things worse. We never were able to override those objections. Months later, we did the biopsy and confirmed a carcinoma. The patient eventually died. But Herbert was helpful in making me question conventional thinking."

Frost says the exponential explosion of medical information makes it increasingly hard for general practitioners to play the role of quarterback in the affairs of patients with multi-system disease. "I think GPS — and my own wife is one of them — do an excellent job overall. They have a very difficult job, perhaps the most difficult in the health care system, staying up-to-date on every aspect of medicine, particularly given the volume of patients. But for certain patient populations, it's just not feasible for a GP to address all the issues in a 10-minute appointment. We need to do a better job of supporting them, and I think that will lead to a growing role for the general internist."

Complicating the situation is the system of subspecialization, which he says is necessary in treating many conditions, but "does have consequences." Subspecialists may not have a full awareness of other ailments the patient is dealing with, or they may offer advice that directly conflicts with suggestions made by another subspecialist treating a separate disease.

At Toronto Western Hospital, Frost runs a clinic in family practice, in which he liaises regularly with GPS. "That model could be more widespread and could use electronic records to identify patients with multi-system disease," he suggests. "That might be a way to directly provide support to family physicians. It's definitely on the radar of policy thinkers."

Over the past five decades, Frost says, technology has dramatically changed the way medicine is practised. But if technology's role is no longer up for debate, it should not lead, he adds, to an abandonment of traditional ways of coming to a diagnosis. In fact, the physical exam, which most patients expect, can be used to determine the extent of further testing required.

"You don't need to do an echocardiogram on every patient," he says. "But you need to know enough about benign and less benign heart murmurs to know when to order that test. The art of medicine here is using resources wisely. Having the technology makes it easier on the one hand to pick up these murmurs, but harder because you have to interpret them, know when to order them and, increasingly, to justify doing so."

Frost acknowledges the importance of the physical exam and says that in some cases "it is more reliable than the expensive test." Still, he thinks it is less important than it was 30 years ago, "because the same information can be gleaned in other ways, albeit at great expense. Some of the minutiae of ways of coming to diagnosis might be academically interesting, but they don't make a huge difference to actual patient care today."

The aspect of the art of medicine that needs more attention, he says, is ongoing patient care — managing what may be inflated expectations of a physician's ability to diagnose and cure and conveying bad news. "There are guidelines, but they are very hard to standardize. Do you touch the patient? Should you sit or stand? What is the right tone of voice? What is the proper setting? I think you learn this from observing people who are good at it."

The other major challenge, Frost allows, is time. Physicians are under constant pressure to "move cases along, keep lengths of in-patient stay short, come up with disposition plans, make management decisions quickly. It's a challenge to balance all of that with the need to take the extra time needed to establish rapport with the patient. But taking the time to ask where someone is from, or what kind of work they do, can go a long way to putting them at ease and getting important information from them."