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]
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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]
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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]
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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]
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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.
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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
Dr. Gawande’s checklist approach would seem to have a lot of virtues! I’d be a bit cautious, though, about the (implicit) association of the fact that health care delivery can be improved and the life expectancy/child mortality figures–the latter have a lot of causes beyond just medical care.
to be clear, the checklists were not gawande’s idea, they were another doctor’s idea. he reports on them in the new yorker article…
I don’t know if this will make a dent in overall life expectancy, but it’ll certainly save lives and money. If Michigan ICUs alone could save $200 million in 1.5 years by implementing a simple 5 step checklist, then the US could probably save at least several billion by implementing this single checklist more widely. Given multiple checklists, this could scale up further, to the hundreds of billions. (I’m making up all these numbers, but they sounds reasonable to me).
If that much surplus was generated, at the very least the savings might be able to make a dent elsewhere.
how about decentralizing and distributing some of the power that doctors have? no offense, but a lot of low level stuff that GP’s do could be performed by those with a lot less training and education. the fact that certain professions choke labor supply (via admissions for medicine, bar passage rate for law) keeps the salaries up but fewer person-hours to go around. that being said, it isn’t just medical doctors who are a problem here. at my doctor’s office the receptionist told me that a lot of people refuse to come in for appointments when the nurse practitioner is subbing because they want to get their money’s worth; but for basic check-ups or treatment of infections and what not there isn’t a big difference. but people want their “money’s worth.” ultimately, many of the issues here are psychological; both doctors and patients. doctor’s wouldn’t have such big egos if most people weren’t kind of tarded 😉
Yes, this seems unconscionable.
I am with Jauhar. The incentives are all messed up. Regular preventive visits, which catch problems very early and take of them cheaply, are poorly paid for. Surgeons and specialists of all kinds are paid enormously to fix train-wrecks. This private sector – insurance based system is nothing but chimera. The willing 80% fork over their money to subsidize the care of the negligent (and to be fair, sometimes unfortunate) 20%. And people are seeing through it. I know several upper middle-class folk who refuse to carry insurance anymore. You can’t fault their reasoning. If its something they can pay, they will. If its catastrophic, there is always the county hospital.
Which brings me to a question we must all ask ourselves: do you think that every patient walking in the door should be cared for, regardless of their ability to pay. If you say yes, you are for nationalized healthcare. If your answer is no, hope you sleep well at night.
Full disclosure: My wife is a physician. I have spent many hours thinking about how twisted this system is.
If it takes a check list in order to do what we as physicians know is the right thing to do, then I am all for it. A lot has to do with how you were trained. Did your upper level resident or attending do things the right way or did he/she cut corners?
In defense of physicians, I would like to say that we are not all golf-playing, Porsche-driving, money-hungry bastards. There is a fair amount of overhead that goes in to being a physician (loans, malpractice. licensing fees and board exams). As far as the shortage of physicians a lot has to do with hours, re-imbursement, and lifestyle. How can I live in small town without an upscale department store like Neimann Marcus for me to valet my 911 after playing 18 holes on the golf course?
Seriously we’re not all bad and some of us even have a sense of humor…
SkepMod
I am in favor of a two tiered system – a nationalized health care system and a private system. If you have the cash and want to pay for something that you probably don’t need (i.e. plastic surgery) or you want the newest drug for your hypertension, that’s terrific. However if you really don’t have money you should still be able to get your blood pressure/diabetes/asthma etc medicines. I do like the idea of forcing people to buy health care of some kind since it may force people to prioritize instead of forking over $500 for an iPhone or Sidekick.
There is also a lack of emphasis on preventative medicine with little financial incentive to practice a healthier lifestyle.
3 letters AMA i.e. not happening. It will go over as well as, say, h1-bs for foreign doctors
Ultimately it comes down to patient safety and saving people’s lives. I don’t think that doctors and nurses are necessarily less prepared to deal with a more complex system. The reality is that systems are setting health professionals up to fail. So, the implementation of a checklist is a way of improving a systematic process and in doing so, ensuring that doctors/nurses are forced to follow steps leading to safer patient care. By preventing central line bloodstream infections, you are not only saving lives but saving hospitals tons of money in hospital-related expenses and that should be incentive in itself. Many in the health professional field feel overwhelmed with the amount of additional safety checks they are being asked to do these days, but i agree with you Ennis that it is disconcerting when doctors/nurses feel they are “doing all they can.” We are dealing with more complex diseases and therefore the standard we hold health professionals to, when it comes to saving patient lives, should also be raised.
As far as the shortage of physicians a lot has to do with hours, re-imbursement, and lifestyle.
how so? i know lots of doctors complain about the state of the profession, some are discouraging people interested, some drop out of the profession. many people for various reasons who are smart enough to be doctors (i.e., they could get the MCAT scores, have the GPAs, interpersonal skills, etc.) don’t want to be doctors. the reasons you list are ones i’ve heard. that being said, until medical schools stop turning away applicants they’re constraining supply. to some extent that’s a good thing, we don’t want tarded doctors, but from what i recall of my friends’ experiences rejection wasn’t purely a function of intelligence (i.e., life experience, whether someone on the admissions committee decided they didn’t want anyone admitted with engineering degrees, etc.). as 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.
medicine is one of the highest prestige fields in the nation. it is highly remunerated. the grass always looks greener on your side. but note that ph.d. scientists in academia are probably the least compensated professions for how many years of education they have to get, but people keep applying. legal work is often very boring & mind numbing (at least stuff that pays well), but people keep applying to law school. unlike software engineering the ABA and AMA are major players in determining supply, not just the market. the theory is that medical or legal malpractice is such an important issue that we need these professional groups to serve as watchdogs. but you know what? the software that runs the medical instrument might have been designed by an engineer who is overworked and has to satisfy arbitrary deadlines from the MBA who is overseeing his project.
some of the issues that we have are due to the fact that many of the institutions around particular professions emerged during the 20th century. but we live in the 21st century where the social dynamics are very different. there’s a crap load of information available on someone’s iphone the moment they walk out of the doctor’s office. there’s a crap load of information they’re checking out as they walk in.
We are dealing with more complex diseases and therefore the standard we hold health professionals to, when it comes to saving patient lives, should also be raised.
an important point: patients need to get less passive. there are many resources out there. doctor’s aren’t omniscient and the sample space of data is getting bigger and bigger….
4 · razib said
For many people there is a disconnect between how much healthcare they use and how much money they spend. I wonder how many of these people would still insist on seeing a doctor if the difference for the copay for seeing a doctor and a nurse practitioner was say $100.
11 · razib said
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.
I think that same as with the Las Vegas case this is a problem of not having a good governmental healthcare system…with private clinics popping up all other the place, there is no inspection and no way of knowing if the staff knows what they’re doing.
How can med schools turn away applicants btw? Here we have a tiered lot system and everybody who scores 8 average or higher for their high school end grades gets admitted immediately. Below that the higher the grade the more chance of admittance into medicine…
Pronovost first implemented checklists at Johns Hopkins, one of the very top hospitals in America. This is about problems that are consistent across the entire medical profession, including the best establishment:
Checklists seem like a good idea to fix SOME of the issues with healthcare. It’s simple, cheap and effective. That said, the reason why ideas like this aren’t widespread is that most doctors practice a combination of CYA and Reimbursement medicine. I don’t blame them.
I wanted Ennis to write something and he has! Bravo.
To be fair, the problem is much larger than docs failing to do what they need to do, such as simple check lists (which are helpful). I’d say the whole profession – docs, nurses, techs, hospital administrators and hospital CEO’s, and even patients themselves are responsible. You can certainly train more doctors and that would help, but doctors themselves resist to keep salaries high and also, tuition doesn’t cover all the costs because medical schools are money sinks for bureacrats. They spend and spend and I don’t see much for it.
To tell you the truth, no salary is worth what I’ve been going through the past few years. I seriously considered leaving the profession, I was so concerned with the direction of things and I’m not the only one. No amount of money can make up for feeling like you might make a mistake because you are short-staffed and have more cases than you feel comfortable with. I just don’t care about money that much; I care about the patient more.
As for Gawande – he’s interesting, but his New Yorker articles aren’t peer reviewed journals – they bring up good points, but they are just a beginning of a discussion. I saw him at a Grand Rounds once and when I asked him if he was going to publish any of his New Yorker stuff in a peer reviewed journal (his cystic fibrosis article), he looked kind of surprised. I dunno, he’s a good guy but he’s not the only one saying what he’s saying.
You know what else? He doesn’t discuss the life expectancy stuff very well; there are lots of reasons we may have lower expenctancy in the US that doesn’t relate to our health care system.
MD:
briefly, Gawande has a list of his medical journal articles here, on the left hand side of the page. I don’t know if the Annals of Surgery is peer reviewed.
In this case though, the New Yorker article isn’t about his own research, it’s about work done by Pronovost. You can find one of his NEJM articles here.
Oh, and it’s not just doctors resisting. Every doctor has a story where they went to a hospital adminstrator to say something wasn’t safe and nothing really changed. I think desi emotionalize this issue because so many desis are docs. We need to stand back from that. No one is an enemy here and people are trying to do their best.
MD – the life expectancy stuff was from the Sanghavi article, sorry, I mushed them together to save space.
Nor do I want to give undue credit to Gawande. The fact that I had three desi doctor written articles was the hook for writing the piece up here. He’s not the only person talking about this stuff, nor should he be.
I stand corrected! No wonder he looked surpised; he probably thought – stupid person, I have published this stuff already!
Last quick comment and then I have to go. I agree that this isn’t a problem that should be placed on the doctors, it should be placed on the system. And doctors aren’t the only ones resisting change or improvement. Still, I wish doctors had a more constructive attitude, rather than being defensive and claiming that all the problems are external to them, and that there is nothing more they can do.
When my grandparents were in the hospital, a very good one, I saw that lots of little things go wrong or don’t get done unless you bug doctors or nurses to do them. To me this is a very basic form of failure, and one that we should be serious about fixing. Checklists are just a start, they’ll only fix some things, but they’re an important step.
Point well taken Ennis – doctors emotionalize the issue too, and it doesn’t help. I agree with Asha’s Dad, if it is better for the patient, I am for it.
Speaking of unconscionable, this New Yorker piece describes the “new, entrepreneurial breed of physician-researchers,” who are cutting corners in clinical trials. The article talks about the financial incentives that can lead professional guinea pigs and industry-sponsored researchers to tolerate unacceptably high risk levels during clinical studies and ultimately, jeopardize the validity of the trial. It is full of pretty egregious examples of physician behavior and details harrowing clinical trials (including a particularly inexcusable case of a psychiatrist under whose supervision a full forty-six patients were injured or died.)
1 · rob said
Rob, this is true. I doubt your Conservative credentials as we type 🙂 Usually, fiscal conservatives vehemently deny the ‘socioeconomic determinants’ of health, and are all about personal responsibility. So they are anti-investments in the welfare or educational system, which have a documented effect on health outcomes. I favor a middle-ground approach myself. Statistically, however, it is possible to construct a model which clarifies what percentage of improvement in health status can be attributed to health care versus how much can be attributed to non-medical interventions. For instance, this AJPH article, “Giving Everyone the Health of the Educated: An Examination of Whether Social Change Would Save More Lives Than Medical Advances.” There are some other article which try to analyze how much of health outcomes improvement is separately attributable to advances in medicine and social development more broadly.
This isn’t a US only problem. Doctors not washing their hands is a big source of infections in Canadian hospitals. Apparently, doctors see handwashing as a waste of their valuable time. One hospital in Toronto is setting up a sophisticated electronic monitoring system to help physicians remember to wash their hands. At a cost of $300 per bed!
I’m not a doctor, so perhaps I’m not recognizing the complexity of the issue — what’s so hard about remembering tio wash your hands between patients?
A peer-reviewed article on the effects of improving health-care delivery systems, which is quite accessible and sensible, if a bit unoriginal:
29 · Ikram said
and cant forget the brampton horror story of the granny who had her wrong leg cut open. the same hospital was also responsible for a man’s death who had to wait twelve hours for a bed. the sad thing is that the local community (a lot of them desis) had invested immensely in getting this hospital up and started. it was supposed ot be a celebration of community participation. things are muchly sucky.
personally – i’d rather invest in preventative care. for those of us with older parents/grandparents, in addition to the usual care in diet, I’d recommend the following.
a. do some weight bearing exercise to improve bone density. even a 2.5 lb dumbell helps. b. take up swimming or water running. we do have women only sessions out here, but am yet to get the mum to go. c. switch to honey for sweetening the chai instead of refined sugar. [hey. cant get them to cut out the chai:-] d. take up brown rice instead of white basmati rice.
I also encourage baba ramdev’s daily exercise and diet regimen. he communicates way better than i or any hectoring news article ever could. i know he is held in ill-regard among some, but the guy talks a lot of sense.
p.s. asha’s dad had sum goo pvaints in #8.
And to top it all of it, it happened to Dennis Quaid. How could you do this to a Hollywood icon, doctors? HOW COULD YOU?
I agree with this. I am kind of perplexed with a system where we need to keep paying hefty insurance for something that we don’t use it at all ( i.e. when we don’t fall ill ). I understand it is like “hedging” against some possible future illness but it would be a good idea to introduce features like the prepaid and “carry-over” system in cellphone service so that our health insuracce payments don’t go down the drain and we pay for only what we use.
apologies if someone has already mentioned it, but there is a great blog that’s been breaking down these and related issues, over my med body
This is is also a good book which puts together many of the factors upsetting the health care system in the last decades: Overtreated. (Don’t be deceived, it’s not as simplistic as the title.)
To Razib’s points, it also has a (basic) economic analysis of misplaced incentives, for example, the difficulty in surviving as a primary care doc vs. a specialist, how geographic areas with more high specialty medical care available results in much higher usage, but not better outcomes, etc, etc.
Speaking as one who has been in the system for many years from the patient side, I’d go to a good acupuncturist first:)
This sounds similar (at least at the high level) to what Britain has. Although there have recently been issues at the margins about people using both private and public care.
You overlord! What else would you mandate? 😉
The best way to do this, is to give away preventive care cheaply and make the consumer responsible when things go wrong (to a point). In fact, Asha’s Dad, I like a three-tiered system (which may already be taking shape in the US). Insurance pays generously for routine visits/checkups and for catastrophic care beyond, say, $10K. The consumer is responsible for the in-between. Patients should pay for Type2 Diabetes, Hypertension etc, because for the most part, they are diseases of lifestyle.
“Patients should pay for Type2 Diabetes, Hypertension etc, because for the most part, they are diseases of lifestyle.”
Yes it’s lifestyle but it goes back to the fact there are so many other factors tied in and it’s a visious circle. The issue here is that lower income people are probably more prone to some of these diseases not for lack of trying but costs of ‘healthy’ food is expensive compared to cheap fast food. Many children don’t have access to areas they can play in and so all these preventative measures are great but how well do people implement them.
Hence even though the result is a ‘lifestyle’ disease – a system penalising people for these will just aggravate the situation as these are the exact people who may need help with healthcare costs.
The whole healthcare system is overburdended and complex and I just can’t see any easy solutions.
I think both issues are red-herrings. I don’t think there is a lack of outlets for physical activities. It doesn’t take much to put on sneakers and run. What’s missing is a culture of physical activity – especially among young/middle aged adults.
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 …
I’m glad to hear that I’m at least occasionally grounded in reality–hopefully more frequently than the proverbial “stopped clock” which is correct twice a day! 😉
in middle class areas, access to playgrounds or healthy food may not be difficult. on the other hand, lower income areas lack proper grocery stores that offer a good supply of fresh fruits and vegetables. not everyone access to a farmers market, or even time to find one. with regard to exercise, you’re right it doesn’t take much to strap on a pair of sneakers and start running. but if a girl has to worry about running past shady guys or a kid has to dodge broken sidewalks, it’s not so appealing to run in the neighborhood.
Have you been to a poor neighborhood? I have lived very close to one. There was an Albertsons right in the middle. The store sold the same stuff as any other Albertsons. In older cities, the market is more fragmented and bodegas play that role, but they always stock produce. Here is Dallas, I often shop at Fiesta – right in the middle of low-income neighborhoods. The produce is fresh – but it doesn’t make for fast food. It’s inconvenient to spend an hour cooking.
somehow, inner city neighborhoods can produce phenomenal basketball players, but their broken sidewalks prevent middle-aged folk from exercising at all??
don’t forget, obesity isn’t only a poor-person problem. I can show you a lot of rich fat folk.
While your statement is true on face value, at least in the US, the following observations are valid… 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 Given that a person is not too fat, ……..hmmm, in this case I dont think I can draw that conclusion..
Note that the above conclusions don’t hold in other countries, say india…. might even be quite the opposite to truth in some cases.
This is a great discussion because health care is an arena of politics that South Asians can really impact based on our representation among health care professionals. There is no doubt that the frequency of hospital acquired infections can be improved by reinforcing basic tenets of germ theory. In fact, of the four most common reasons for in-hospital death (failure to rescue, bed sores, post-op sepsis, and post-op pulmonary emobolism) (http://www.medicalnewstoday.com/articles/11856.php) the latter three can be drastically reduced by improved standardization.
As far as a tiered system goes. We already have one. If you are indigent or uninsured you are treated at a county/charity/teaching hospital. The tax payers of that region bear the cost burden of this patient group through state hospital subsidies. Care at these hospitals and clinics may be delayed and perhaps even inferior to a private system. If basic health care is a right, then we should funnel resources to these end-providers, so they can fulfill their missions of caring for and educating indigent communities. Forcing families to have health insurance for themselves or their children alone will not make people take better care of themselves, and it will not curb our medicaid crisis.
In my opinion, the cost cutting for our health care system has to include care at the beginning and the end of life. 25% of medicare expenditure is in the last year of life* The challenge we have to face as a society is to learn to say ‘No’. ‘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. These are the difficult, frontline decisions doctors have to make every day, and the decisions must be made in an era on cost containment. All the checklists in the world won’t improve the state of our unsustainable, inflationary spending, if our society can’t decide how to allocate what are ultimately limited resources.
*(A. E. Barnato, M. B. McClellan, C. R. Kagay and A. M. Garber, ‘Trends in Inpatient Treatment Intensity among Medicare Beneficiaries at the End of Life’, Health Services Research, 39:2 (April 2004), 363–75.
there are lots of reasons we may have lower expenctancy in the US that doesn’t relate to our health care system
A more important stat is probably the infant mortality, which are pretty damning to the US
The US spends the most money on health care per capita, but has the worst return for that investment, of course due to 30% of the dollar going towards beurocracy and red tape.
One has to be careful about comparing individual expenditures (largely from private health insurance, but still individual expenditures) with aggregate outcomes across the population. Most expenditures aren’t aimed at curbing infant mortality, for example–so, it’s apples v. oranges to claim that those expenditures are “wasted” or “ineffective.” Granted, if one were to collectivize the whole health care enterprise, it’s plausible that one might get better aggregate outcomes for similar or even lesser expenditures. But that would come at the (considerable!) cost of overriding a whole host of individually consented-to transactions. To analogize, just b/c 10% of the population is eating terrible food doesn’t mean that an individual buying a great meal at a top restaurant is getting a “bad return for that investment.”