A fix in healthcare: a rare gem

A grandmother is holding onto her granddaughter's hand as they head to the park. Mom and Dad are away for their first night from the family. Life is good. However, the child trips over and Grandma holds onto her hand to pull her back up. The child immediately cries and begins to hold their arm, refusing to move it. Has Grandma broken her arm? Is the arm paralyzed? What has happened? What should Grandma do? Should she call the parents, and should they rush home, go to urgent care or the ER? Now, both Grandma and the toddler are crying.

This scenario is very frightening for everyone involved and creates a fever pitch of anxiety for parents and grandparents alike. For an untrained provider, a physical exam showing no swelling and normal x-rays raise further anxiety, resulting in a transfer to the pediatric ER.

However, a trip to a trained pediatric clinician can turn this fervor around quickly. For those who see this often, it's one of the most satisfying visits one will see. It's one of those complaints that we can actually fix. For those who don't practice clinically, medicine is really hard, and most of what we do is not simple. We can't cure the common cold or a viral illness. We are most often trying to rule out bad diagnoses, alleviate symptoms, and spend very little time actually "curing" anything.

This case is the simplest we see in emergency medicine. With the right history (a pull on a toddler's arm) and normal physical exam (no swelling or bruising), we can "manipulate" the arm and instantly cure this problem. Within minutes, the child will begin smiling, laughing, and moving the arm with ease. Grandma will be the happiest person you ever see. The utter relief for everyone with rapid recognition and a simple cure is the best. Nothing is more satisfying or rewarding.

Nursemaid's elbow is the diagnosis. For toddlers, with the right twist and pull, an elbow ligament slips into the joint. Any movement of the joint causes pain, so children hold their arm still. For us, we can simply move the arm in a way that the ligament slips back into place. No X-ray or further treatment is needed. Pure joy for everyone involved, except for the bill of an ER visit or multiple bills until one finds a trained clinician.

Unfortunately, too many disruptors think there is a "nursemaid's elbow" approach to fixing healthcare. If we just move this way or add this app or streamline technology or focus on convenience, can we really just fix healthcare? Is it really that easy? In the clinical practice of healthcare, the easy is rare. The dramatic "cure" is even rarer. Healthcare is all about slow and steady progress.

Can't you see a disruptor thinking about "wow, we can fix this nursemaid's crisis!"

Let's first look at the total addressable market -- let's guess 10% of kids get a nursemaid's elbow between 6 months and 5 years... that's 2.5 million kids or so annually, and an ER visit is 1k for nursemaids.. so that's a 2.5B cost... we can fix this with an app.. let's call it the "Kid Not Moving Arm" app... it connects you to a random clinician who talks the parent through reducing the injury and charges $100 per visit... we could save $900 per encounter and sell it to every parent on the planet... our revenues could be huge... Uber Nursemaids Elbow, here we come...

Far-fetched? As a pediatric ER physician and innovator, this seems very much to me like how outsiders seek the fix to healthcare. Sadly, healthcare is not a nursemaid's elbow or a quick, convenient prescription or procedure away from solving anything. These quick fixes have many ripples that most ignore.

First, can everyone download or afford the app? Does it work? Do the clinicians on the other end have the training needed? What could we miss?

Second, what if this child could have seen their own physician instead of a random offering? What other issues does the child have that this visit could be used to check in on? Do they need immunizations, screening, or other needs of social determinants?

Finally, what if this is a recurrent problem or could there be other concerns? social challenges?

The quick fix that can be done in a fragmented system is rare and even the quick fix often has many more considerations. However, it sadly does not slow the push of disrupters who see how convincing consumers of convenience is the "fix" to healthcare. They ignore the evidence that the better care is continuous care. These disrupters undermine the perception (and evidence) for well trained and trusted clinicians to be valued over just the drive thru app for this or that. They often claim a cost savings per episode just like this model. Unfortunately, someone seems to be making money while our quality is decreasing and healthcare costs are going up.

Can we please recognize the difficulties and need for more investment in relationships, caring, and continuity? Maybe we need to twist more arms of the disrupters to help them see a much larger picture. The fix in healthcare is incremental, long and slow while constantly putting the patient-clinician relationship at the center. My .02...