“Big Box” American Medicine

Over the last several months we have been engaged in construction work on our home. The kitchen and adjoining rooms required new floors. To accomplish this goal, we went online and examined the types of floors, patterns and qualities that met our needs. We shopped at various venues including small privately-owned flooring shops and larger national chains. The one-stop-shopping aspect of the larger chains (cabinetry, flooring, carpets, appliances, etc. all under one roof) had a certain appeal. After considering our options we proceeded with one of the chain stores. Although we greatly appreciated and respected the expertise of the consultant who worked with the big box store, the results proved less satisfactory.

First, we needed our space measured. The big box store contracted with a group who did their flooring measurements. Second, we needed to purchase the material. This was done through the large concern acting as our purchasing agent. Finally, after the several weeks delay for the “special order materials,” our flooring material was delivered to yet a third party, the flooring installation experts.

Despite the delays, everything was moving along reasonably well. And then came the problem. Our contractor had needed to resurface a section of our entranceway. This left a gap from the bare wood up to the existing surface that was about to be recovered by the installation staff. We contacted the installation group the night before their scheduled   arrival to explain that they would need to match the new surface level with that of the old one. And then the wheels came off.

“We can’t do this job for a fear that there could be a need for asbestos remediation.”

“What asbestos?” I responded.

Their response, “We don’t know, but it’s a possibility.”

“Well then, come out and take a look.”

“Oh, no, we can’t do that, it will be at least a week.”

I felt stymied. Our carefully scheduled flooring, followed by appliance replacement, followed by painting, followed by cabinetry installation was now on indefinite hold. Luckily, I had a personal contact with a privately-owned flooring company who provided their own installers. They arrived the next day, examined the situation and explained that there was no asbestos risk whatsoever. They neatly matched the floor levels using a plywood sheet and proceeded to perfectly complete the flooring job.

After all was said and done, I suddenly realized that I had almost double the flooring material I actually needed. After much discussion, we convinced the big box store to accept the excess material in return and to compensate us for the difference.

So what’s this got to do with medicine? Quite a lot I would suggest.

Like the big box stores, American medicine is migrating towards generic care with each function contracted out to a different entity. The internist who diagnoses the problem is then forced to refer the patient to an outside contracted diagnostic service provider (i.e. radiology, CT, MRI). Results then slowly percolate back to the primary care physician who, one or two weeks later, recognizes the problem and recommends hospital admission. At this point a contracted hospitalist starts all over again, examining the patient and taking a detailed history in an attempt to uncover that, which the internist already knew. With the best data the hospitalist can accumulate, he then turns again to a contracted provider for a final intervention. The patient all the while has waited weeks, undergone numerous  interventions and investigations and more often than not gets more, or in some circumstance less, than what they really needed.

As we continue to undervalue the abilities and expertise of individual private physicians functioning as quarterbacks in patient management, we abdicate the management of a patient’s delicate problems to the intersecting tectonic plates of medical systems: HMO, PPO, VHA, Medicare, HHS, AARP, etc., etc., etc.

Like the big box stores that adequately meet the average needs of the average customer with an average problem, these medical behemoths lack the insight to meet individual patient needs. Duplication of services and inefficiency are the inevitable result. In retrospect I would gladly have paid a slightly higher fee for a privately owned concern to have measured, purchased and installed my kitchen floor. The savings associated with big box stores, are like those associated with HMO care . . . nonexistent.

So long as you are 42 ½ years old, have a viral respiratory infection and don’t have any allergies or prior medical history, HMOs provide great care. For everyone else,  Caveat Emptor!

About Dr. Robert A. Nagourney
Dr. Nagourney received his undergraduate degree in chemistry from Boston University and his doctor of medicine at McGill University in Montreal, where he was a University Scholar. After a residency in internal medicine at the University of California, Irvine, he went on to complete fellowship training in medical oncology at Georgetown University, as well as in hematology at the Scripps Institute in La Jolla. During his fellowship at Georgetown University, Dr. Nagourney confronted aggressive malignancies for which the standard therapies remained mostly ineffective. No matter what he did, all of his patients died. While he found this “standard of care” to be unacceptable, it inspired him to return to the laboratory where he eventually developed “personalized cancer therapy.” In 1986, Dr. Nagourney, along with colleague Larry Weisenthal, MD, PhD, received a Phase I grant from a federally funded program and launched Oncotech, Inc. They began conducting experiments to prove that human tumors resistant to chemotherapeutics could be re-sensitized by pre-incubation with calcium channel blockers, glutathione depletors and protein kinase C inhibitors. The original research was a success. Oncotech grew with financial backing from investors who ultimately changed the direction of the company’s research. The changes proved untenable to Dr. Nagourney and in 1991, he left the company he co-founded. He then returned to the laboratory, and developed the Ex-vivo Analysis - Programmed Cell Death ® (EVA-PCD) test to identify the treatments that would induce programmed cell death, or “apoptosis.” He soon took a position as Director of Experimental Therapeutics at the Cancer Institute of Long Beach Memorial Medical Center. His primary research project during this time was chronic lymphocytic leukemia. He remained in this position until the basic research program funding was cut, at which time he founded Rational Therapeutics in 1995. It is here where the EVA-PCD test is used to identity the drug, combinations of drugs or targeted therapies that will kill a patient's tumor - thus providing patients with truly personalized cancer treatment plans. With the desire to change how cancer care is delivered, he became Medical Director of the Todd Cancer Institute at Long Beach Memorial in 2003. In 2008, he returned to Rational Therapeutics full time to rededicate his time and expertise to expand the research opportunities available through the laboratory. He is a frequently invited lecturer for numerous professional organizations and universities, and has served as a reviewer and on the editorial boards of several journals including Clinical Cancer Research, British Journal of Cancer, Gynecologic Oncology, Cancer Research and the Journal of Medicinal Food.

One Response to “Big Box” American Medicine

  1. Elaine L. says:

    Dr. Nagourney, this post certainly hits home. I went through so much stress during the last three years of my father’s life, because as we went through this maze of doctors, the right hand didn’t know what the left hand was doing. I finally wrote and kept an updated record of my father’s health care in my car. I handed this to hospital staff and all of his specialists. It was a full time job and I had a full time job. It made me realize that as I get older, and health care continues to become more impersonal, I may have to hire an advocate to keep track of my records and medical care.

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