What’s wrong with medicine

Recently, I’ve read three articles by brown doctors (Darshak Sanghavi, Atul Gawande, and Sandeep Jauhar) all of which claim that there is something systematically wrong with the practice of medicine today. All three argue that we pay too much and get too little; Gawande goes the furthest by claiming that doctors and nurses routinely fail perform simple tasks they claim to be carrying out, thus endangering lives [Thanks Rahul].

Jauhar argues that poor incentives lead to gigantic amounts of waste in almost all medical practices:

In our health care system, where doctors are paid piecework for their services … overuse of services in health care probably cost hundreds of billions of dollars last year

Are we getting our money’s worth? Not according to the usual measures of public health. The United States ranks 45th in life expectancy, behind Bosnia and Jordan; near last, compared with other developed countries, in infant mortality; and in last place … among major industrialized countries in health-care quality, access and efficiency. [Link]

The other two go deeper than just the reimbursement system. They argue that doctors are not doing the routine tasks of their profession well, which reduces the quality of health care across the board and even kills patients:

… a team of researchers … reviewed children’s medical records from 12 major American cities and found that fewer than half of children got the correct medical care during doctor visits…A similar study of adult quality of care was published in 2003 with similar results. [Link]

<

p>

<

p>

While Sanghavi blames medical training that emphasizes diagnosis over execution, Gawande argues that medicine has become too complex for doctors to remember to do all of the simple things they need without some form of codification:

A large body of evidence gathered in recent years has revealed a profound failure by health-care professionals to follow basic steps proven to stop infection and other major complications. We now know that hundreds of thousands of Americans suffer serious complications or die as a result. It’s not for lack of effort. People in health care … are struggling … to provide increasingly complex care in the absence of effective systematization. [Link]

<

p>To address this, Gawande supports greater use of the humble checklist, an activity that makes airplanes safe to fly. One ICU checklist, listing five simple steps that all doctors are supposed to know and follow already, quickly saved money, suffering and lives:

Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in….These steps are no-brainers; they have been known and taught for years… in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs. [Link]

<

p>In Michigan, where the same checklist was implemented on a broader basis, the results were even more profound:

Within three months, the rate of bloodstream infections from these I.V. lines fell by two-thirds. The average I.C.U. cut its infection rate from 4 percent to zero. Over 18 months, the program saved more than 1,500 lives and nearly $200 million. [Link]

<

p>Other checklists have had similar effects, yet the use of such checklists is restricted to a small number of hospitals (and even then on a limited basis) rather than being routine and widespread.

<

p>The fact that a simple codification of existing practices could save so much makes me heavily discount my doctor friends when they tell me that “they’re doing all they can.” The checklists didn’t reduce the load on doctors, nor did it change their incentive systems, it simply held them accountable for the things they said they were already doing, although they clearly were not. Honestly, I can’t see how doctors can, in good conscience, oppose such changes.

Related posts: Atul Gawande’s Medical ‘Complications’, Childbirth in the U.S. and India

99 thoughts on “What’s wrong with medicine

  1. So what I’m trying to say is that unless you think we should shut down Nobu and “allocate” the “savings” to better soup kitchens (surely food is more of a “basic human right” than health care . . . but I think most would agree that such a policy is surely, as Hayek would say, “The Road to Serfdom”) then I’m not sure we should buy into comparing individual expenditures on health care to aggregate outcomes in health.

  2. ‘No’ to the cost of the neonatal ICU stay and the lifelong care your premature 23 week old infant boy will require. ‘No’ to your 65 year old grandmother with a potentially resectable pelvic sarcoma when she will likely develop metastasis in the next 6 months. ‘No’ to the 30 year-old father of two who wants everything done to save his leg after a car accident, even though he has an unsalvageable injury.

    Its all money those patients are perfectly entitled to. In a desperate situation its a perfectly rational decision to use your entire savings to salvage whatever you can. Its easy to propose that the society as a whole takes these steps but when it comes to your own personal case, I’m sure the ideas will change at some point.

  3. The store sold the same stuff as any other Albertsons.

    I disagree–the supermarkets in inner city neighborhoods I’ve been to have crappy produce, but aisles and aisles of processesed food. The same neighborhood has plenty of fast food joints within the vicinity.

    In the nicer part of the city, there is a Trader Joes and Whole Foods within 2 miles of each other…and no fast food places.

    Also people who work muliple jobs or odd hours to make ends meet may not be able cook fresh, healthy meals, esp if they have other issues they have to deal with.

    somehow, inner city neighborhoods can produce phenomenal basketball players, but their broken sidewalks prevent middle-aged folk from exercising at all??

    what are you implying, this means the the streets of inner cities are safe? elite basketball players coming out of inner city neighborhoods are the exception, not the rule, in the grand scheme of things. i wouldn’t want to jog through there at night.

    Also things like diabetes type II and high cholesterol do have genetic factors, it’s not just lifestyle. They do affect people of color with disproportionately, esp South Asians. I wouldn’t be so label them as simply as “lifestyle diseases,” though that does play an important factor.

  4. These patients are only entitled to this because we as a society have made that decision. None of these patients will use their personal savings to pay for their care. I am not saying that they should have to, but our society dictates that they are “perfectly entitled.”

    Each of these anecdotal cases in another country’s health care system would be handled differently… 23 week old premie can not be saved, 65 year old pelvic sarcoma grandmother goes to hospice care, 30 year old father gets an amputation. American doctors as much as American patients push for treatment to the nth degree even when the chances of successful outcome are remote. Part of this mentality stems from the fact that it is easier to throw technology and resources at a problem in our country than it is to tell somebody, “No… What is best for you is not necessarily what is most expensive or most invasive.” Such a scenario is facilitated by a third-party payer system where there the costs of few are borne by many.

    This is a complex issue because it deals with health care costs, individual patient rights, physican responsibility, medicolegal environments and what constitutes compassionate care. I think that it is a dialogue that we have to begin if we want to “fix” healthcare.

  5. Given that a person is rich, its more likely that he/she is not obese . Given that a person is poor, its more likley than he/she is obsese than if he/she were rich. Given that a person is fat, its more likely that he/she is poor than rich

    Where you live influences your obesity riskThe study found that people living in low-income, urban neighborhoods had access to at least one convenience store and a liquor store that sold convenience foods, but very few supermarkets or grocery stores. The produce that was available to these neighborhoods included few fresh fruits and hardly any vegetables.” Many Americans are really disconnected from where (real) food comes from, and how to make better choices. Elementary schools ought to teach basic nutrition. That may be a hard case to make when the arts, physical education and the mandatory 3 R’s are being short changed.

    Rahul #34- in the same link you provided, there was a side bar story called “The Farmer’s Market Effect” which mentioned a study showing that vouchers given to low income people to use at the market increased vegetable consumption. I know in some cases that city gov’t entices a supermarket to open in undeserved areas- I assume that would give them a clause to prevent any green groceries to open in the same area.

    As far as obesity and (poor)lifestyle issues being the cause/(in large part) of the heath care crisis: Here is a second opinion. Changing demographics and medical technology pose a cost challenge for every nation’s system, but ours is the outlier. The extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization. The dominance of for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players raise costs and distort resource allocation. Profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent, but the more serious and less appreciated syndrome is the set of perverse incentives produced by commercial dominance of the system.

    Markets are said to optimize efficiencies. But despite widespread belief that competition is the key to cost containment, medicine — with its third-party payers and its partly social mission — does not lend itself to market discipline. New England Journal of Medicine “Market-Based Failure — A Second Opinion on U.S. Health Care Costs”

  6. I often shop at Fiesta – right in the middle of low-income neighborhoods….somehow, inner city neighborhoods can produce phenomenal basketball players, but their broken sidewalks prevent middle-aged folk from exercising at all??

    With that low income neighborhood diet and “enviormental factors” , can you dunk now?

  7. I’m sorry PT, but your comments sound like the sales blurb of a health insurance company. The European ‘socialist’ systems may be flawed, e.g. with long waiting lists and referrals through the GP instead of direct access to a specialist, but at least there are not (yet many) insurance companies deciding that important life-saving operations are not implemented because they would have to reimburse too much money. Of course everybody is entitled to the best health care available. That is a civil right. I’m not talking about people with too much time and money on their hands who want to go for ‘preventative scans’ without actually meeting any criteria for needing them, or people who want corrective cosmetic surgery for purely asthetic reasons, etc. I’m talking about salvaging what can be salvaged. I’m glad that we at least have a good basic government health plan which means patients don’t have to fork a rib from their body to pay for highly necessary, specialised meds(I have an autoimmune disease so I would fall under this category), and it’s not such a huge disaster if people fall sick once in a while. Nor does anyone have to share their medicines with friends as is wont to happen with the uninsured in the United States. It sounds like I am criticizing just for the sake of, but I do see some merits in the private healthcare system. However, I deeply disagree with the idea that ‘healthcare is a business’, just as much as ‘education is a business’, it is morally reprehensible to me.

  8. 57 · Meena Of course everybody is entitled to the best health care available. That is a civil right.

    Interesting slogan, but can’t possibly be correct. If (as seems obvious) the quality of health care varies, what can it mean that “everyone” is entitled to “the best”? Setting standards too high above a “decent social minimum” (which, btw, would/should be quite a bit lower than “the best”) is, I fear, the path to loss of economic dynamism, restrictions on immigration, etc. . . .

    However, I deeply disagree with the idea that ‘healthcare is a business’, just as much as ‘education is a business’, it is morally reprehensible to me.

    Do you feel the same way about the provision of food, clothing, and shelter? If not, why not? If yes, I think we know how that goes (USSR, Cuba, N. Korea, Albania, etc.).

  9. As far as obesity and (poor)lifestyle issues being the cause/(in large part) of the heath care crisis:

    Also, from a purely economic perspective, my understanding is that the impact of obesity on costs is vastly overrated because obese people cost the healthcare system much less than the standard projections over the long run, since their average lifespan is lower. This doesn’t mean that education and preventive care are not warranted, but just pointing to one more reason why obesity, while convenient to blame, might not be such a big villain.

    And stating that obesity is a lifestyle disease vastly oversimplifies things, in my opinion.

  10. Also, from a purely economic perspective, my understanding is that the impact of obesity on costs is vastly overrated

    can you provide a reference for that? because almost every other (or possibly, every) patient in the inpatient setting (which is expensive care) seems to be overweight or obese. these people also tend to be “repeat customers”.

  11. can you provide a reference for that? because almost every other (or possibly, every) patient in the inpatient setting (which is expensive care) seems to be overweight or obese. these people also tend to be “repeat customers”.

    Here is a study in the Netherlands.

    Conclusions Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures.
  12. can you provide a reference for that? because almost every other (or possibly, every) patient in the inpatient setting (which is expensive care) seems to be overweight or obese. these people also tend to be “repeat customers”.

    From the same NEJM link;

    Great health improvements can be achieved through basic public health measures and a population-based approach to wellness and medical care. But entrepreneurs do not prosper by providing these services, and those who need them most are the least likely to have insurance. Innumerable studies have shown that consistent application of standard protocols for conditions such as diabetes, asthma, and elevated cholesterol levels, use of clinically proven screenings such as annual mammograms, provision of childhood immunizations, and changes to diet and exercise can improve health and prevent larger outlays later on.Comprehensive, government-organized, universal health insurance systems are far better equipped to realize these efficiencies because everyone is covered and there are no incentives to pursue the most profitable treatments rather than those dictated by medical need.

    If the market can’t do it- doesn’t the govt step in? Even when its not Bear Sterns?

  13. That’s the same study–uncanny–apologies! (tho’ I did post it first!) ;-)

    No worries, rob. Seeing as it is probably the only study so far on this subject and is very recent (published Feb 2008), no wonder we are both citing the same thing :)

    One thing to note though is that this study is purely about the contribution of obesity to health care costs. There are factors such as productivity losses which this study does not account for (on the flip side, it also does not account for things like reduced social security payments to these folks either), so the study does not obviate the need for obesity reduction as a public health goal.

  14. 64 · dilettante If the market can’t do it- doesn’t the govt step in?

    Well, but that’s like saying that the market doesn’t provide nice apartments, wholesome food, HBO, and trendy clothing to low-income people, either. . . . so, no, I don’t think the gov’t should “step in” to provide the former to the latter, either. A “decent social minimum,” perhaps, but not “what everyone else gets,” unless you’re really going to undermine the whole well-spring of our prosperity (which is tied to markets/incentives).

  15. From the Netherlands study’s conclusion (that Rahul and Rob posted):

    Until age 56 y, annual health expenditure was highest for obese people. At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers. Obese individuals held an intermediate position.

    Rahul – the point you make about productivity losses (#62) could be borne out by further analysis. Given that the health costs for obese people are highest until 56 years, it might mean that obese people are the most expensive (wrt other non-obese people) in the most productive period of a citizen’s life. So we might be losing a lot as a society, not only in the form of extra health care expenditures.

  16. Also things like diabetes type II and high cholesterol do have genetic factors, it’s not just lifestyle. They do affect people of color with disproportionately, esp South Asians. I wouldn’t be so label them as simply as “lifestyle diseases,” though that does play an important factor.

    Thank you! I know plenty of folks who suffer from (probably genetically-driven) hypertension despite a lifestyle that includes low-fat, low-sodium, low-refined sugar, no junk food, pro-whole foods diets and moderate, regular exercise.

    PT, most communities do not have access to charity or low-income hospitals. I don’t think you can legitimately equate a two-tiered market structure with a two-tiered delivery or organizational structure.

    good food is not expensive! whole grain bread costs the same as white bread, cooking a simple meal at home costs way less than fast food. it may involve a little more effort than driving through and stuffing your face. Again, its a matter of culture. If there were incentives to eat well, people would devote some of their tv-time to eating well. Thank you !! Finally some common sense. I have heard this “healthy food costs too much” for way too long. No one seems to even try to counter this fallacy. Liberals try to turn it into some kind of guilt also …

    What inner city neighborhoods do you two live in? I’m genuinely curious, because in all the cities I’ve lived in, it is almost impossible to find a full-service grocery store within walking or accessible public transit distance in the inner city, let alone fresh foods. If this is in fact a fallacy, I’d encourage both of you to gather empirical evidence and disprove it, just as the studies discussing the Hunger-Obesity paradox began to do in 1995.

    There are many vectors that impact the food choices of low-income communities, but I think you can break the driving factors down into 1) accessibility [mentioned above], 2) affordability, and 3) food choice.

    As dilettante mentions, many low-income neighborhoods do not have access to fresh fruit/vegetables via specialty grocery stores (TJ’s, Whole Foods) or farmers’ markets. And, in the event that a market may exist somewhere within a city’s borders, many do not take WIC or food stamps. We know empirically that people eat vegetables/fruits when they’re made available and affordable.

    Additionally, for many low-income communities, children are especially influenced or limited by their food options in schools. For some kids, they’ll eat 70% to 100% of their food that day at school through the federal subsidized breakfast/lunch program. If you live in a place where 70% of your classmates are enrolled, and you live in any city that is not Hartford or Berkeley, you’re probably eating highly processed, and not particularly nutritious, food. You may never see a fresh vegetable in your entire eating day. Is that your parents’ fault for being too poor to afford food?

  17. Oh, also, checklists == rock.

    rob, I’m not sure your analogy holds because it sounds like there’s a basic difference in conceptualization of what kind of good/service health care is. For some it’s a voluntary consumption item — just like HBO or the Wii –, for others it is as important/necessary as food, water access, or shelter, and should thus be prioritized in a different way than a “market good.” How you frame your definitions (including questions around things like, “what is the responsibility/role of the state?”) frames your policy preferences.

  18. Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures.

    But don’t the life-years gained contribute to increased productivity during those years?

    With that low income neighborhood diet and “enviormental factors” , can you dunk now?

    Classic example of humor at the cost of all validity and logic! Brilliant!

  19. 58 · rob said

    Do you feel the same way about the provision of food, clothing, and shelter? If not, why not? If yes, I think we know how that goes (USSR, Cuba, N. Korea, Albania, etc.).

    Rob, that is a little bit unfair. I agree with you on that bit about how everyone cannot possibly be entitled to the best health care available. Resources are finite, and will run out at some point. So someone will have to get less so that another person may be treated. For instance, flu vaccines are routinely in short supply and are allocated to the neediest populations first (the elderly, infants, young children, and so on). Astute social investments financed by governments, including American and European, have produced better health and quality of life outcomes. You mention only socialist failures, but think of the GI bill and the Marshall Plan. Especially the GI bill which provided for educational grants, business and home-ownership loans that provided economic security to a class of people who could not hitherto expect such a standard of living (including health gains). The GI bill was responsible for much American prosperity. Ditto Europe. Also, that government managed health care can be superior in terms of health outcomes, cost saving, and implementation of technological improvements. The VA health system is a shining example. Even low-income vets experience health status equivalent to more affluent persons insured by managed care. The VA system a single-payer system which can keep its costs down. It can negotiate reasonably with big pharma. Unlike insurance companies which are very reluctant to invest in quality improvement (because if they get a doctor to buy better equipment or an electronic information system, other insurance companies will also benefit from the reduced medical costs, while they bear the costs for the initial investment), the VA hospital system has been very successful in implementing electronic records and other quality improvements. Sometimes a market structure might actually undermine efficiency and distort incentives. Health care may be such a market. * [PS:The Jan-Feb Hastings Center report has a nice article on the advantages of a single-payer system (ie a govt system financed by taxes). It addresses objections point by point and may be of interest to you.] * JAMA: What Is Different About the Market for Health Care?

  20. 71 · Camille said

    How you frame your definitions (including questions around things like, “what is the responsibility/role of the state?”) frames your policy preferences.

    Good point. Some people think (Rawlsians like Norm Daniels, see this):

    … health care, both preventive and acute, has a crucial effect on equality of opportunity, and that a principle guaranteeing equality of opportunity must underly the distribution of health-care services.
  21. I agree with you on that bit about how everyone cannot possibly be entitled to the best health care available. Resources are finite, and will run out at some point. So someone will have to get less so that another person may be treated.

    Isn’t it curious that this point always has to be made whenever health care comes up? If you advocate any Gov’t involvement- the immediate conclusion is you want a USSR style of govt in every aspect. I wonder why Japan, Germany Australia and the UK (who all have some form of national public health) are never invoked.

    Rob;Well, but that’s like saying that the market doesn’t provide nice apartments, wholesome food, HBO, and trendy clothing to low-income people, either

    .

    Yeah it’s also like saying the US should topple the Govt in China, because people in Tibet deserve democracy the every bit as much as the Iraqis do.

    A “decent social minimum,” perhaps

    I haven’t proposed any thing beyond that.

    #72 Classic example of humor at the cost of all validity and logic! Brilliant!

    Sorry, I didn’t realize you were serious when you introduced phenomenal basketball players from ‘low income areas’into the discussion.

  22. 75 · dilettante said

    Isn’t it curious that this point always has to be made whenever health care comes up?

    Dilettante, I am actually in favor of a a single payer system – so I am in favor of the government involvement in health care. Also, I do not think the NHS/UK are the best examples of a health care system. It’s true that I didn’t mention the other countries (but alluded to them). Also – there is the American tendency to not accept the resource scarcity in terms of health care. The truth is that there is no evidence to back up the benefits or cost-effectiveness of a significant number of medical procedures. Other systems of health care financing recognize this, and that is why they are better able to obtain more bang for their health care buck. Health care costs as a %age of GDP are the largest in this country, and yet we know that spending on education will have a much greater impact on health than medical interventions themselves. Second, if we continue to endorse that it is OK to spend on medical procedures that are of dubious value in a system, we are diverting physician and medical personnel time to those practically useless procedures. Today we are aligning incentives that work against doctors who want to provide better care for their patients. You get so little money to counsel and advise diabetes patients, and a lot more to amputate limbs when primary prevention fails. On the other hand, the VA does a great job with diabetes care because their bottomline and the best interests of the patient coincide. So to divert our money to social investment that is more useful, and to make sure that the system is set up to help people to get the most evidence-based medical interventions, we have to recognize that resources are finite. It is time that the public knows which medical procedures are actually usefuL. NICE is a medical technology assessment agency in the UK that is geared to do that – it is a great investment by the UK government that will save them a lot of trouble down the road.

  23. (canadian context) Dr Jagdish Butany takes your questions today in an online forum to discuss the recent breast cancer scandal in newfoundland and the systemic problems with the country’s healthcare system.

    The focus here is quality assurance in reporting results from the pathology lab.

    Potential solutions the medical associations have identified include:– the creation of large laboratories where all medical tests in a region would be analyzed by specialists rather than general pathologists; – a mandatory requirement for a second pathologist to sign off on tests showing malignancies; – the creation of standardized terminology, interpretation measures and handling procedures to ensure all staff in a lab, and across the country, use the same thresholds to make a diagnosis;– requirements for all foreign pathologists to receive the same accreditation in Canada.

    in the meantime the scandal is growing.

    Authorities in New Brunswick announced last month they would hold an inquiry and review about 24,000 pathology tests after an audit of pathologist Rajgopal Menon’s work showed some were incomplete or misdiagnosed. Now, many residents in the Miramichi area of the province, where Dr. Menon worked, are concerned they may have been wrongly diagnosed, or that a diagnosis was missed.
  24. Well, I don’t know about how useful checklists will be in the not so distant future as current med students are getting hammered with washing hands and correct sterile techniques as much as we are with the approach to someone with chest pain. All doctors and nurses know the importance and principles of preventing hospital acquired infections and how to go about doing it. Perhaps addressing why they aren’t doing it may be better than a checklist. An infection control unit or officer or something could be used to ensure that everyone is complying.

  25. one of the biggest mistakes people make is look at the canadian experiment and say that single payer health care system can’t work because you have to wait many months before you can get life saving surgeries. But they fail to take into account that it may be more of a healthcare infrastructure problem than a health system problem. USA has one of the best health care infrastructure in the world due to the many hospitals that have been built in the 1950′s and 60′s. But the problem now is accessability to the great medicine is pathetic and unaffordable for the most part. Right now there are two for profit parties taking a piece of the healthcare pie. the providers get their share and what ever cost savings that HMO’s gives themselves credit for goes to them. If we have a single not for profit single payer system, it will keep cost in check as well as increase affordability of health care.

  26. Dilettante, I am actually in favor of a a single payer system – so I am in favor of the government involvement in health care.

    portmanteau Yes, I got that. I’m in agreement with you. I was just wondering out loud,why the Soviet Union, always works its way into discussions about reforming US health care,and making an observation on the countries Rob,did and did not, mention.

    I have Private insurance (employer provided)on top of the NHS. I haven’t had to use either for anything crucial, but I’m happy to have the option.

    Also – there is the American tendency to not accept the resource scarcity in terms of health care.

    Indeed, as if services aren’t being “rationed” now.

    I’ve heard of NICE;”People who are grossly overweight, who smoke heavily or drink excessively could be denied surgery or drugs following a decision by a Government agency yesterday. The National Institute for Health and Clinical Excellence (Nice) which advises on the clinical and cost effectiveness of treatments for the NHS, said that in some cases the “self-inflicted” nature of an illness should be taken into account” Seems like a common sense approach to me. Individuals do have a responsibility for their own well being. I know that we can’t just ‘cut and paste’ some other countries solution onto the American populace-but it’s past time the conversation got started. With out the Hammer and Sickle references always cropping up

  27. Perhaps addressing why they aren’t doing it may be better than a checklist.

    Does it matter why they aren’t doing it? The point is that they know they should do it, but they don’t do it normally, and they do it when a checklist is involved. The difference in compliance levels seems quite large if it’s producing such a large difference in ICU outcomes.

    The claim in the article is that people are overwhelmed and so forget small but important things, routinely. This is why airplane pilots started using a checklist, because it reminded them to do everything they knew already to do and made sure that they did it.

  28. Rob:

    Do you feel the same way about the provision of food, clothing, and shelter? If not, why not? If yes, I think we know how that goes (USSR, Cuba, N. Korea, Albania, etc.).

    Right. And I’m sure Scandinavia, Germany, et al are communist failures? Oh wait, they’re not. Seriously, this is the most useless point to bring up in discussions – dilettante was right. Everytime there is some mention of government involvement into healthcare or education people bring up the most extreme examples they can think of.

  29. Btw, a healthy diet IS expensive. I’m a penny-pinching student renting a room so I have to cook for myself. Every week my grocery bills amount to around E40. This for fresh veggies, whole grain bread that runs out at a train’s pace(I don’t buy the cheapest on offer – those taste like cardboard), cheese for the bread, sauces etc. I don’t spend anything on junk or desserts. It is expensive.

  30. Btw, a healthy diet IS expensive. I’m a penny-pinching student renting a room so I have to cook for myself. Every week my grocery bills amount to around E40.

    Wha…!!! dude! what are you eating yaar? that’s a bit on the high side.

    p.s. this comes from a person who would build a budget around a 69c burger [no cheese] for lunch from mcd and a bean burrito [i think it was 49c] from taco hell at night – and i used to be really gaunt in those days. there was no way i could cook cheaper than that. shit man! how long ago was that. remembers fondly and pats his Tondh

  31. Eww Taco Bell? I said healthy food haha :) I do admit the high number has to do with eating out at least once a week with clubs, committees etc. But still, cost of living is lower in the USA I think. 49 c sounds really cheap for a burrito. Even the local fast food wok restaurant and the University cafeteria charge around E6 for a meal. At the latter it might be more including salad and dessert. Btw, where’s your breakfast?

  32. Eww Taco Bell? I said healthy food haha :) I do admit the high number has to do with eating out at least once a week with clubs, committees etc. But still, cost of living is lower in the USA I think. 49 c sounds really cheap for a burrito. Even the local fast food wok restaurant and the University cafeteria charge around E6 for a meal. At the latter it might be more including salad and dessert. Btw, where’s your breakfast?

    hey… i didnt say i ate healthy in THOSE days . for breakfast i used to have a bearclaw (which is a fried pastry) and a coffee for the princely sum of $1 at the student lounge. Funnily, i eat organic grain and all and i’m like a walrus now compared to those days.

    i did eventually discover healthy eating + cooking. but it involved a (totally illegal) rice cooker in the dorm and a little fridge. I’d still be targeting a monthly budget of about $240 at max. I remember this because I’d do this weekly trek to the local grocery store with a backpack with $25 in cash for breads and les fruits. sigh. vaat memories. I guess you’re right. North american food is totally cheep.

  33. Off-topically still, I have a little fridge as well and although it’s ‘illegal’ everybody has one…and I also have the perennial rice cooker ;) My flatmates are jealous…I think over here the coffee at the Uni automat costs 70 eurocents…which is more than $1.

  34. khoofia, are you not doing strength exercises with the parents? out hiking the wilds of cananda with the geese? Oh well, who doesn’t love a walrus coo coo kachoo?

    As for good food on a budget there’s nothing like a bit of beans and rice esp. if it’s frijoles negros! Leave out the animal fat and bring on the vinegar.

    Topically, at my local hospital I know for a fact that at orientation everyone is asked to wash their hands and afterwards shown -using a special light- just how dirty their hands still are…mostly around the fingernails. You think you’ve done enough to wash the things but no, apparently one needs to be vigorous and patient to get the hands clean.

  35. 14 · JGandhi said

    11 · razib said
    s noted in the USA today article groups like the AMA have a vested interest in doctors not being too plentiful lest the premium on their skills be de-valued.
    This is a losing battle. The AMA can restrict all they want but alternative professions and pathways are cropping up. Podiatrists, dentists, optometrists, clinical psychologists, naturopaths, nurses and physician assistants are slowly given more and more leeway to practice medicine that once only MD doctors had permission to practice. Osteopathic medicine is now considered as legitimate as traditional allopathic medicine and new DO schools are opening all over the place.

    As a first year brown med student at an osteopathic school i’d like to point out that we receive an identical education to that of md schools and can practice in every speciality from neurosurgery to pediatrics as well as attending the exact same residencies. (just a clarification, we’re fighting the same battle as the mds against midlevels as we are both physicians one and the same).

  36. North american food is totally cheep.

    certainly food is way cheaper in the USA than in Europe or Australia. First time I went to the USA I was astounded that one had to get an appointment to see a specialist – Pure supply and demand mismatch.? If you want to look at a free market in healthcare – india comes pretty close although it does have government hospitals. A few govt hospitals are excellent while the rest are atrocious. As everywhere, the upper class get better healthcare although it is debatable if they are healthier than the lower middle class.

  37. Jauhar argues that poor incentives lead to gigantic amounts of waste in almost all medical practices:

    Jauhar is the name given to the act of mass suicide committed at the time of partition of India, isn’t it? “The women committed jauhar”.

    Thought it an interesting point since there’s another topic of the same on here right now.

  38. Ok, sorry if I went over the top with the USSR comment, but I think that statements like “for profit parties taking a piece of the health care pie” are extreme on the other side.

  39. NY Times article today on trends in choosing medical residencies (‘Specialties in Vogue’), and why they might be problematic:

    It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time,” said Dr. Eric C. Parlette, 35, a dermatologist in Chestnut Hill, Mass., who chose his field because he wanted to perform procedures, like skin-cancer surgery and cosmetic treatments, while keeping regular hours and earning a rewarding salary. Medical school professors and administrators say such discrepancies are dissuading some top students at American medical schools from entering fields, like family medicine, that manage the most prevalent serious illnesses…
  40. One thing I have noticed it seems that US doctors are generally less conservative with the type of meds they prescribe than the docs in my country. E.g. I have an auto-immune disease and was started on some lighter meds first of which the dosis was steadily increased if my body did not respond. I haven’t had to resort to steroids yet. On the other hand when I speak with US patients for some reason even during their first attack they are started on Prednisone right away. From where this difference? It would seem rather more expensive to prescribe corticosteroids rather than anti-inflammatory drugs.

  41. very interesting discussion string… I haven’t read all of it, but to answer meena’s question, although I don’t know the exact context, I think that part of the “highest quality care” available in the US is that we offer the most aggressive treatments, without consideration of ability to pay. This, as we have learned now, although rooted in the All-American ethos of rooting for the underdog, or turning a blind eye to class, or in the modern day, ability to pay. Although the rich in America probably get better care, it is marginally so because even the homeless man who sustains a trauma gets, rather has the right to, be an inpatient at America’s finest medical institutions. Is this wrong? No…America allows us in some ways to be true to our Hippocratic oaths, however we are doing it in a way that is not sustainable. This, as well as the push to get away from anecdotal medicine, and practice evidence-based medicine I hope is guiding your doctor’s prescription decisions.

    Back to the topic of the looming health care crisis, there are some things for which we as doctors definitely must take responsbility. I agree that the impact of a simple checklist is remarkable, and simple, and doesn’t take any additional time. But don’t think that some of the “mistakes” aren’t actually misconceptions and misunderstandings on the part of the general public. Take, for example, if I have a postop patient who normally takes a certain number of medications at home. In the acute postop setting, many are not that important to have taken, for example zocor, or even antihypertensives. Would I mind if the patient gets them? Not particularly, but I didn’t order them because they aren’t that important.

    This, to hawkish family or patients, is seen as a “mistake.” Whereas in fact, it is more of a “misperception.” This is a very mundane example, but as many things that we are not doing that we should, rest assured that there are just as many if not more things we are being forced to do that we shouldn’t. Does anyone ever study the time or efficiency lost in that?

  42. Some of these mistakes are pretty brutal:

    A 78-year-old woman in a German hospital for leg surgery underwent an unnecessary operation on her anus instead. [Link]

    There’s really no reason for something like that to happen, it’s fully preventable.

  43. What’s wrong is that for most part everyone, including physicians, seem to be overworked. Everyone has to succeed, do well, etc. before they can retire. It’s not that the health care providers do not wish to follow a checklist, which includes washing hands, etc. it’s just that they seem to get away with it a little more easily. At the end of the day (I am not referring to the literal end of the day), the physician will perhaps still have a publication, a fancy conference etc to attend or present a medical paper. Whereas if a basic life science researcher, such as a biochemist, microbiologist, or an immunologist does not follow a protocol or a checklist, the scientist might never have any meaningful results in the lab that can be presented. The scientist might have nothing to show for in terms of an accomplishment. Whereas an health care provider can move on from a patient to patient. An infection caused due to negligence cannot be pinned on any one staff member at an hospital, whereas it is not the same in case of a scientist. Therein lies the difference! Laju K.http://lajuk.blogspot.com