Evaluating Care Models at Top Hospitals to Fit an Individual Patient

Posted by mpflood7 @mpflood7, Sep 26, 2020

I have never been hospitalized so am a novice at choosing a hospital. That said, and especially as an out of state patient, how can a patient distinguish between top hospitals to identify which is best for his/her specific condition(s) ... particularly insofar as the specific patient care model? (In a sense and by analogy to business terms, what are each top hospitals real, “competitive advantages”?) This is especially important in that I likely have a single chance to select a hospital and therefore must get it right. More specifically, I have systemic disorders that I’m told requires the “multispecialty, integrated, collaborative team” (MICT) approach offered by Mayo Clinic. The individual, “ad hoc” doctor approach has also not worked.

How does this MICT approach actually work at Mayo and don’t all hospitals take this approach? (If so, how is it a true competitive advantage?) As to how the MICT approach works, does the team of specialists actually physically sit together and discuss the case? If so, are they trained well-enough to understand the other specialties? And wouldn’t it be more appropriate to directly admit the patient as an inpatient into a hospital so as to make a truly collaborative approach more effective?

In practical terms, how can a “collaborative” approach even work if the patient is treated on an outpatient basis? Is it also a team of teams - in that is it a team of general internists who get together with a team of specialists (team of neurologists, hematologists, psychiatrists, etc) or simply a team of a singular internist, neurologist, hematologist, psychiatrist, etc?

I want to say more on this but am quickly writing this now to get it started. Insights that even partially answer the (admittedly) many questions is appreciated. Hopefully, this can also be expanded upon.

Interested in more discussions like this? Go to the Visiting Mayo Clinic Support Group.

Funcountess | @funcountess | Sep 28, 2020

In reply to @jenniferhunter "@mpflood7 You've asked a great question, and you are already ahead because your medical providers have..." + (show)

@jenniferhunter

@mpflood7 You've asked a great question, and you are already ahead because your medical providers have recommended Mayo for your needs. My first experience at Mayo was for spine surgery and after being refused by 5 spine surgeons, it took me 2 years to realize that I wasn't going to get surgical help locally, so I turned to Mayo. This is my experience of how medical should not be in comparison to the way it should be. I didn't know there was a better way until I came to Mayo.

At first, I had tried to stay close to home, and when that didn't work out, I consulted at a major university teaching hospital with a med school in the nearest city. I thought that the problem was because I also had thoracic outlet syndrome which created similar symptoms making it hard to figure out what symptoms could be spine related and which were TOS. I had already seen a specialist at this university facility for my TOS and had been a patient with him for ten years, so it made sense to me to consult there about my spine. I thought the spine and the thoracic surgeons would consult each other about my case, but it never happened. Each told me to see the other specialist, and the visit results were not sent to the other. When I had an MRI, those results were mistakenly sent to the wrong office (because there were both downtown and suburban offices for the doctor), and I would get to my appointment that I had waited 5 or 6 weeks for, and my results had not arrived, and the computer network was separate for downtown, so they could not lookup my records. This should not happen and it wasted my time.

In the first visit with the spine surgeon there, he missed part of the diagnosis because he told me that my cervical disc problem would cause arm and scapular pain, and that my reported leg pain was not related. He didn't consult other doctors about that. This was a error that I would find about 5 months later. He asked me to do an epidural injection as a diagnostic test to see if it would take away my pain symptoms. I didn't want a spine injection, but I did as requested because I thought it would lead to getting help. The injection took away all the pain I had everywhere temporarily. The surgeon never gave me an opinion about this, he just ignored the result. Later, this clue helped me find the reason why I had leg symptoms and how it related to the diagnosis of cervical stenosis of spinal cord compression in the spinal canal. Stenosis was evident on my MRI's, but the doctors could not connect my symptoms to the imaging, and because they couldn't explain it, I was refused help. I was put in the position trying to convince the doctor that my leg pain was connected to my spine issues and I knew that because I could turn my head and change the pain to turn it on or off with my head position. He didn't listen.

I was told to follow up in a few months and also to consult with the neurologist who I'd seen before. I had to wait 6 weeks for the steroid crystals to be absorbed from the spinal injection before a new MRI could be done. I was getting worse, and the neurologist ordered the MRI. I tried to consult with the surgeon about the new imaging, and his nurse refused to make an appointment for me. I had reported real symptoms of spinal cord compression to her which she didn't recognize, and her response was to tell me to see a doctor about it. The neurologist called another spine surgeon at that facility to see me about the MRI. His recommendation was to do more spine injections and to do nerve conduction tests. Just a few weeks later, I learned this other surgeon was leaving to take a job elsewhere.

One day I happened to call when the nurse was off, and another one made a followup appointment with the main surgeon. This was the last time I saw him. I had diagrammed my pain as it progressed over the few months since the spine injection and given this to the surgeon. I was relieved when he finally mentioned surgery, but he said he didn't know if it would make me better or worse. He commented that I had pain in every dermatome (all over my body) and that it could be from an inflammatory problem like MS, so my efforts backfired because he didn't understand what caused it. It wasn't long after this, that I had vertigo caused by the muscle spasms associated with the spine issues and I sent a message to the surgeon. The response came back from the nurse, that he would not offer surgery at this time and to stay in physical therapy. That's when I looked at Mayo surgeons and I read their medical literature that was available online. One of the papers mentioned leg pain in relation to cervical issues and "funicular pain". I looked up that term and found medical cases similar to mine, so I knew what the doctor had missed. I asked both the neurologist and the thoracic surgeon who knew my case to help me bring this to the attention of the dismissive surgeon, and neither would help me. That was a shock to me, but it seems that no one wants to point out a mistake to a highly respected leader. The best advice they gave me was to get another opinion, and I discussed Mayo with them. I wasted 6 months waiting for appointments and jumping through hoops only to come to a dead end and I was living with advancing disability and loosing the coordination of my arms.

This is the medical literature that changed my course and this type of spine symptoms was already known at Mayo which gave me hope that a surgeon would understand this and believe me.
https://www.ncbi.nlm.nih.gov/pubmed/20938789
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111492/
I sent this literature in with my imaging and request to be seen at Mayo and was given an appointment. They scheduled a neurology consult that would lead to other testing first before the surgery consult. I was sent for blood tests, nerve conduction tests, and to testing to confirm thoracic outlet syndrome, and from that to a consult with a thoracic vascular surgeon to consider which of my issues of the spinal cord compression or the nerve and vascular compression from TOS was the greater of the issues. The TOS testing and consult was in the morning and on the same day as my spine consult. While I was at the neurosurgery spine consult, the surgeon's phone rang and it was the vascular surgeon calling with his opinion on my case. All of my testing at Mayo was done in just 3 days total in the same week, and I was offered surgery at the first appointment. That is how medicine should be, and everyone at Mayo came together efficiently to help me, and not only that, I was treated with kindness and respect. I didn't need to try to prove my case anymore or to beg for help. I was an artist who was loosing the coordination of her arms, and at Mayo, that mattered. The doctors at the other institution also knew this, but it didn't matter there.

Though all of this, I also looked at US News and World Report rankings, and Becker Spine Review. I did look at patient reviews, but I took them with a grain of salt. I looked up where surgeons were educated. I looked to see if they were leaders in their field and respected by their peers. I knew a lot about spine surgery because I had been watching online videos of surgeons presenting at conferences and reading literature and research and papers of any surgeon I would want to see. Hospitals also have rankings too, and some hospitals have lower success rates. One thing of concern is infection rates, and some hospitals are better than others. I learned to advocate for myself and ask questions, and I learned enough to know when I was getting good answers. Always ask and advocate for yourself. No one else can do that. I'm glad I didn't have surgery with a surgeon who didn't understand my case. He could have done the surgery, but why trust someone who doesn't understand and who doesn't really want you as a patient? I would have saved myself a lot of trouble if I had come to Mayo first.

My Mayo Patient story
https://sharing.mayoclinic.org/2019/01/09/using-the-art-of-medicine-to-overcome-fear-of-surgery/

Jump to this post

Hi Jennifer,
What you went thru before Mayo is called being on a medical merry-go-round.
Glad you got off the merry go round, got answers, and are feeling better.
How are you doing with your ankle?
Funcountess

Jennifer, Volunteer Mentor | @jenniferhunter | Sep 28, 2020

In reply to @tdrell "jenniferhunter....wow....what you have gone thru!!! hope all is under control now...and stays that way. May l..." + (show)

@tdrell Thank you, yes, my spine health is great since my Mayo surgery 4 years ago. My insurance was "in network" at all the places I consulted for my spine. I prefer not to name names or locations because I want to be able to be brutally honest in these discussions. I didn't make any public comments or review the prior surgeon, but I did send him a kind letter along with the medical literature I found in the spirit of sharing information. As you might expect, there was no response. His staff could have discarded it and not shared it and I'll never know. That doesn't matter because my Mayo neurosurgeon told me he will always be my doctor and that he will stay at Mayo until he retires, so there are perks to having a surgeon younger than yourself. If I need spine surgery again, I would only want to see my surgeon at Mayo because I respect his knowledge, expertise and talent. He was also very helpful to me in recommending an orthopedic trauma surgeon at Mayo after I broke my ankle 4 months ago and sent me to a surgeon he trusts for his own family. I had been asking around locally and had called a few surgeons, but some couldn't see me or would only see me in a downtown location with all the crazy traffic, covid risk, and I couldn't drive, and my husband wasn't good with aggressive traffic. I had to get an appointment so they could decide if they wanted to help and that makes no sense that I would need to supply imaging before they would agree to see me. I already had an emergency surgery while on a trip that cleaned the wound from the compound fracture and placed a fixator cage to stabilize my ankle that was screwed into my shin and heel. This provides a couple weeks to allow for swelling to decrease before bones are set with plates and screws, so this was perfectly obvious that I needed further surgical help. I did have the 2nd ankle surgery at Mayo and am currently rehabbing my leg. All I had to do was contact my spine surgeon, and he responded that he was sending my request to another surgeon who would reach out to me for an appointment, and they did within an hour. I had appointments right away for the surgery itself and to come 2 days earlier to be tested for Covid and get further imaging and have the surgical consult. That was so easy, no jumping through hoops (as if I could!) and I had another great surgeon. I think that the first doctor you see at Mayo is your contact for future visits and that they arrange other specialists for you. I also saw a pulmonologist on one of my visits, again recommended by my spine surgeon. It is wonderful to have that kind of relationship where all I have to do is ask, and I can get medical help.

One other consideration is that at many facilities, surgeons practice there, but they own their practices, so they own the risk of malpractice or negative reviews that could affect if their business is profitable. They want to cherry pick cases they know will have a good outcome because the success rate for specific surgeries is recorded for each surgeon and hospital. Insurance companies track this too. If you are the patient who comes in with a confusing case, or with other health problems that can affect recovery, it's easier to refuse an offer for surgery, or to treat symptoms to postpone surgery such as spinal injections in the case of spine surgery. At Mayo, everyone is an employee and not in private practice, so there is no incentive to do surgeries for extra profits, so the opinion there isn't colored by financial motives. Mayo is known for taking complex cases that others refuse. I am sure this was part of my problem with the surgeons who turned me down because they were afraid to ruin their reputation if my surgery wasn't successful, and because they didn't understand the complete problem, they backed out. They should have looked farther, but they didn't. There are lots of other patient dollars walking through the door and they didn't want to invest any more time. Some were doing 30 minute spine procedures in comparison to the 2 hour spine procedure at Mayo which for the surgeon was an hour and a half of his time for the same procedure. I would rather be the patient of a surgeon who isn't rushing through the job because he has ten patients on his assembly line.

As for your question about admitting patients so other specialties can also consult, I think insurance companies would frown on this. They are in the game for profit and can refuse claims that don't follow correct protocol. If there is a valid reason why a patient should be admitted to the hospital, that is different. I was in the hospital 2 days after my ankle fracture because I couldn't manage to navigate well enough with a walker or be able to go up and down stairs. I had to figure this out with the therapists while I was in extreme pain and so nauseous and dizzy from the pain medications. I did better on lower doses that were more frequent. The doctors need to know a patient can navigate safely at home after release. If I had been more functional, they would have released me after one night. The problem of being an outpatient and seeing multiple specialists is the waiting time in weeks and months to see those doctors. That is not an issue at Mayo because they have figured out how to do it efficiently and usually complete it within a week.

Jennifer, Volunteer Mentor | @jenniferhunter | Sep 28, 2020

In reply to @funcountess "Hi Jennifer, What you went thru before Mayo is called being on a medical merry-go-round. Glad..." + (show)

@funcountess Thanks for asking. I am getting better every day making small gains on ankle and foot function so it is forward progress. My injured leg is smaller since I had not used the muscles for 3 months, so it takes time to get it all working better, and it fatigues quickly and hurts. I was encouraged to wean off the crutches and I walk with a limp. I have pain and tightness in my hip which makes me short strided because my leg doesn't want to go backward. When I step out of bed, my foot doesn't want to support my weight, but gets better after I walk on it. I do have limits on how far I can walk before I tire out, and the little bit around the house is not bad. I am taxing my abilities when I visit my horse in the distance I have to walk to get him, keep pace with him as I lead him to the barn to work on his hooves and back to his paddock. I couldn't take care for his feet for 3 months when I could not bear my own weight, so now I am treating a thrush infection for him. He will be fine, but it takes a few weeks of persistence to clear it up by cleaning his hooves, disinfecting, and packing a disinfecting mud into the cracks and crevices. After standing for awhile, I just have to get off my feet. That being said, I am doing pretty well.

Funcountess | @funcountess | Sep 28, 2020

Hi again Jennifer,
You have some atrophy, which is normal after your ankle incident. It should go away after p.t. I have a very slight limp after my ankle/foot injury from years ago.
I get tired standing also, as we age, our ability to do what we once did goes bye bye.
You are such a wonderful painter/artist, please keep that skill going.
Your orthopedic problems are only one part of you, I hope you post more of your art work, as I’m sure it brings pleasure to whoever sees it.
As for horses, my speed is probably the miniature horses. Had a friend years ago who had a miniature horse who she would let in the house.
I found it interesting, as she said the horse was housebroken.
Could that be true?
The only thing I’d be willing to ride at my age is a 2 wheeler with training wheels.
Stay well,
Funcountess

Merry, Alumni Mentor | @merpreb | Sep 29, 2020

In reply to @mpflood7 "Thank you Merry. You sound very knowledgable and yes, my insurance covers out of state care...." + (show)

@mpflood7- Good morning- Yes, this is my view as well from many of the members on Connect. I have also met some of the interns and doctors even if Mayo isn't my hospital.

Jennifer, Volunteer Mentor | @jenniferhunter | Sep 29, 2020

In reply to @funcountess "Hi again Jennifer, You have some atrophy, which is normal after your ankle incident. It should..." + (show)

@funcountess Yes, mini horses can have house manners. There is a group called Gentle Carousel that takes mini horses into hospitals and nursing homes for patient visits and bedside visits and they are house broken, trained in walking on slick floors and to receive attention and hugs. They also wear fun costumes sometimes. Horses can be very therapeutic.

When I saw my horse on Sunday, I saddled him and got onboard and walked him around in the arena. That is therapy for my back and hips because it's the same walking motion, and I compensate for the bigger hip movement of the horse. It builds core strength. I also rode my horse when rehabbing from my spine surgery a few years ago. There are therapeutic riding programs that provide this service to people. OK, now for everyone who just gasped and said wow, only 115 days after ankle surgery, are you crazy to get back on a horse.....you should know that I didn't get hurt with my own horse. He's an older calm guy that is "broke to death" so he doesn't spook at dogs, cats, mailboxes, traffic, etc. He's got enough experience to know those things won't eat him, and he trusts me and knows that I won't ask him to do something that is unsafe. He also knows how to unzip my jacket with his teeth just in case I stashed some carrots inside. I trained him to stop and stand still when I would be returning from a ride, and he would get rewarded with a carrot. That is for safety because you can't let a horse hurry home like they want. They are herd animals and prefer not to be out alone, but back home where they eat and have their horse friends. So when we were out on a trail, he would look back at me in the saddle just to check and see if it was time for a carrot. He follows me around like a big dog and he comes to the gate when he sees me or I call him.

I took the precautions of using a 3 step mounting block and had my husband hold him so he wouldn't move, and I tested stepping up into the stirrup with the good leg and then I swung the healing leg over and sat in the saddle. Same procedure for the dismount, so I didn't drop onto my foot. Some of the time I just had him stand and we walked around the arena. I got off after 15 minutes and untacked him, then cleaned each hoof. I had my husband stand right behind me with his hand on the horse's side to prevent him from side stepping and I made sure my feet were a foot away when I picked up his hoof. One time before, he started to step on my toe when I was working on his hoof and I pulled it out before he could get his weight on it, so I learned my lesson and stand as far away as I can.

Thanks for your kind words. You can find me on social media and online. I am feeling well enough to get back to painting again and it will be good for my spirit.

2011panc | @2011panc | Sep 29, 2020

@funcountess I am intrigued by your PT and proud of your functionality with your horse. I am sure he appreciates it! Have you ever tried walking backwards? I have found it to add an extra bit of challenge that improves my focus and quickens my healing. You should probably check with your doctor and therapist before trying it though. You wouldn't want to undo any of the hard work you have already done. I am always amused that such a simple thing can have such a profound effect.

Jennifer, Volunteer Mentor | @jenniferhunter | Sep 29, 2020

In reply to @2011panc "@funcountess I am intrigued by your PT and proud of your functionality with your horse. I..." + (show)

@2011panc I think you were responding to me. I am officially going to PT for my ankle, but that doesn't involve my horse. I work with him on my own and need to care for him. There are different programs for therapy on horseback around the country. My horse does really appreciate my attention and is always happy to see me.

JK | @contentandwell | Oct 18, 2020

In reply to @colleenyoung "@mpflood7, this is such a great question. I'm going to invite a few members like @sueinmn..." + (show)

@mpflood7 Hi, and I too welcome you to Connect. You joined on my birthday! Sorry, I am a bit late in responding to you, I am not on Connect as much these days as I once was.

I live in southern NH and all of my care was here until I had an undiagnosed problem that went undiagnosed for almost a year and a half. It was finally diagnosed as non-alcoholic cirrhosis. My PCP here recommended me to one hospital but neither my husband nor I liked the doctor with whom we dealt so I researched and chose to go to Mass General in Boston. Now I have most of my care, other than my PCP there, except for my endocrinologist because I am certain I could not do better than him.

I chose MGH after looking at rating sites and learning about which hospitals are good for varying specialties, specifically transplants for me of course. You have had some great responses, and there are some excellent resources out there. I know US News was mentioned. I think their ratings are considered the gold standard for hospital ratings. Most years Mayo is #1 followed by MGH, and Cleveland Clinic in the #2 and #3 spots, with Johns Hopkins up there also, so none of those are too shabby. MGH has been tops in more specialities than any other hospital in the country also so that is also something you might want to check - how a hospital is rated in that discipline. Teaching hospitals tend to be the best I think if you live in an area where one is available to you.

Another resource that many people are not aware of is Medicare hospital ratings. You may not be old enough for Medicare but hospital quality is the same whether you are under or over 65. Looking at my own state, NH, and also Massachusetts, I think they are fairly accurate. I think that Mayo's MICT approach sounds great and tremendously helpful. When I had cirrhosis my symptoms were so varied I would have had no idea what type of doctor to go to. It sounds as if MICT would have been the best choice. I have a problem now also that has me befuddled and I am not sure what type of doctor to see. I think I will ask my transplant team if they have suggestions.

The other possible place to look is for ratings for specific types of conditions. There is a site that rates transplant hospitals, perhaps there are sites that rate other hospital specialities too.

I hope you can find a hospital that you really like and feel in which you feel confident. I think that's key, to feel confident of the doctors affiliated with a hospital. I very recently changed PCPs. I really like my prior PCP from a personal standpoint but I felt like he let me down a couple of times, that I had fallen through the cracks, so I changed. So far I am more confident in my new doctor. I will never have a rapport with her that I had with my prior PCP but my healthcare has to take priority.
JK

mpflood7 | @mpflood7 | Oct 18, 2020

In reply to @contentandwell "@mpflood7 Hi, and I too welcome you to Connect. You joined on my birthday! Sorry, I..." + (show)

@contentandwell

@mpflood7 Hi, and I too welcome you to Connect. You joined on my birthday! Sorry, I am a bit late in responding to you, I am not on Connect as much these days as I once was.

The other possible place to look is for ratings for specific types of conditions. There is a site that rates transplant hospitals, perhaps there are sites that rate other hospital specialities too.

Jump to this post

Thank you for the thorough reply JK. I hope you continue to get the best care and stay healthy.

2 Harvard / MGH professors each independentely recommended the Mayo Clinic, due to their Collaborative “MICT” approach. However, I still don’t really understand why MICT is unique to Mayo given it would seem to make sense that every hospital would follow such an approach. In any event, the earliest I could get in to see my local (Florida) doctor so as to call and make the referral is on November 11.

** What is really giving me major stress is the waiting - as I need to get healthy to work and make money to pay my bills. If you or anyone knows how to speed the process up, please let me know. **

In the interim, for example, I understand Clevelend Clinic has a MICT program modelled after Mayo. Their program, called “National Consultation Service” (NCS) can be googled and looks ideal. However, just this past Friday, they told me it would take 5-7 months to get the appointments (with various specialists) scheduled. 5-7 months !? That sounds crazy to me, as I don’t know who can wait that long for serious illness - and in my case, financially. Meanwhile, I haven’t learned of any MICT program at Johns Hopkins - a hospital that I find to be administratively a mess, though I understand that they have some of the best doctors. So right now, I am hoping on Mayo #1, Cleveland Clinic #2 and Johns Hopkins #3. Interestingly, I don’t know yet whether to really believe the rankings as to the quality of care but in my experience with the administrative staff, of those 3, Mayo Clinic is definitely #1.

Again though any tips on how to speed up the appointment process is appreciated. I just hope I can stay healthy and financially afloat while waiting.

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