Are doctors the problem and can they be the solution?

This week’s New Yorker has another article by doctor and health care policy expert Atul Gawande. In the article he attempts to probe why medical costs in this country are spiraling out of control, singling-out one particular outlier in Texas:

It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.

McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami–which has much higher labor and living costs–spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns. [Link]

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p>By systematically eliminating all the likely suspects (e.g., it’s the lawyers and their malpractice suits that cause health care costs to soar), Gawande comes to a conclusion that many doctors probably already grudgingly realize through experience. It is doctors (not all, just the ones who increasingly advocate for tests that the patient probably does not need) who are driving up health care costs for everyone:

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted.

“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures. [Link]

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p>This issue will be of particular importance to the South Asian American community as we approach an attempt at comprehensive immigration reform by the Obama administration. As we well know, medical school students are disproportionately desi. These students will become practicing doctors who will have to choose to either be part of the solution or conform to the problem. I realize this choice isn’t as black and white as I make it sound but I assume there is some discretion. Some of it will boil down to the teaching philosophy employed where they trained and their motivation for becoming a doctor in the first place (e.g. wealth, intellectual curiosity, service, etc.). The greatest factor however, may be the market in which they serve. Gawande finds that there is a”keeping up with the Joneses” profit effect at work.

Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions–Boston, San Francisco, San Diego–became leaders in biotechnology while others with a similar concentration of scientific and corporate talent–Los Angeles, Philadelphia, New York–did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.

Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies–two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream. [Link]

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p>The article points to the Mayo Clinic as a hospital which bucks the trend through a concerted effort which puts the needs of the patient before revenue:

The core tenet of the Mayo Clinic is “The needs of the patient come first”–not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check. [Link]

I am guessing many South Asian American doctors read SM and I am sure this is a touchy subject. I would appreciate hearing your views after reading the whole piece in the New Yorker in addition to my post. Are there only two distinct choices as Gawande describes at the end? Do you feel you have a choice as to which type of medicine you choose to practice or are your hands tied by circumstance?

100 thoughts on “Are doctors the problem and can they be the solution?

  1. If we are going to change the culture of health care in this country, then we need to change the way we operate it. A for-profit system is clearly not working since the bottom line is being put before the needs of the patient. Universal health care, now!

  2. Couple of my quick opinions on Health Care - We need to have a system of health insurance that does NOT involve the employers. - Everyone should be mandated to carry insurance just like liability insurance for driving. - Insurance should be bought directly by the citizens from an insurance company - A Federal agency should regulate the workings of this insurance process (unlike Homeowners and Auto insurance which are done at state level) - Yes We can.

  3. And yeah, Kudos to Gawande !!! Here he goes again asking his medical fraternity yet another set of uncomfortable (yet very badly needed, IMO) questions.

  4. If we are going to change the culture of health care in this country

    but the point of this is that there are cultures in this country. any reform should keep that in mind. different regions have different outcomes based on the same monetary inputs.

  5. Abhi,

    This was quite interesting. But I sincerely believe that our healthcare is a luxury service, and it is insurmountably expensive. I believe that free-market forces are NOT allowed to function, and that monopolistic forces are at work which collude to make the cost of health care as high as possible.

    Here is what contributes to higher health care costs: 1. WE DON’T HAVE ENOUGH DOCTORS HERE! The entire fault, from what I understand, is on the AMA – American Medical Association. This entity limits the number of MDs graduating from American medical schools to 18,000/year, and this number hasn’t changed much in decades. In the USA, we are importing MDs from developing nations – like China and INDIA. Don’t you think that the Indians need their doctors more than we do?

    Moreover, the AMA is quite corrupt. They sell malpractice insurance to the doctors, and they sell legal/lawyer services to the plaintiff filing suit. They’re on the buy and sell side of a malpractice suit.

    We need to simply double the number of MDs who graduate from Medical schools here by simply doubling the capacity of the existing schools. This, IMHO, is much cheaper than building new MD schools. The bulk of the costs are FIXED – land, building, cost of the entire staff/faculty, and so on, and only a smaller portion – much smaller portion – is variable (i.e. the number of medical students). Moreover, the schools would probably LOVE to increase their revenue of medical students.

    I realize that the biggest rebuttal that people would have on doubling/increasing the number of MDs in the USA is that opponents would think that this would degrade our health care practicers. My argument against that is this: If we ONLY allowed college graduates with reflexes in the top 10% and hand-eye coordination in the top 10% to drive a car, then only about 5% of the population would drive a car. Of course, these drivers would be VERY good and safe, but society would be punished not because the existing drivers are not good enough, it’s punished because there are not enough mediocre drivers.Same way, we have too few MDs.

    Keep in mind that the rate determining step of becoming a MD is getting accepted to medical school in the first place. Once in there, there is a very high chance that you’ll graduate. So a lot of very qualified and smart and dedicated folks are not getting accepted to medical school.

    Also, by doubling the number of MDs, the costs of services will go down. This is NOT A BAD THING. Moreover, I’m sure that the medical schools would get more revenue/income from more medical students enrolling.

    1. The residents are over-worked like desi soccer-ball stitchers. This is inhumane, but the resident MDs seem to put up with this abuse as a badge of honor.

    2. There is very little geographic mobility in medical school, and credits are not transferable. Moreover, most MD students, it seems, are limited to their home state for medical school. I’ve seen how new families are strained. There should be more geographic flexibility here.

    3. Our American students are going to great lengths just to heal people already. They are delaying gratification just to help out people, so why should we further torture them by forcing them to go to the Caribbeans for 2 years for medical school? This service should NOT be exported, and this goes along with my theme of having more MD schools.

    4. Although, I’ve read that malpractice suits and insurance only adds like 2% to healthcare. I’m not sure that I believe this figure since malpractice insurance is $100,000s in some places. I believe that we must be more strict on malpractice suits.

    5. In corporate America, a janitor can become CEO. Ditto for salespeople, VP of IT, VP of finance, etc. They can all rise to the top. I believe that a nurse should be able to become a MD in some accelerated program. Let’s further delineate nurses from MDs. Moreover, let’s give more rights, compensation, and power to nurses – especially if their the hot blondes that I have many downloaded clips of.

    6. More power to nurses. Allow doctorates of nursing to exist. This DN carries with it the title of “doctor” which MDs are vehemently against this because of their conflated egos. Let’s do something about this.

  6. I’ve failed to mention the drug company’s complicity in all this. Did you know that: 1. drug companies are the most profitable companies in the S&P 500? They have the highest net profit margins along with software companies, like MSFT. 2. Drug companies spend more on marketing than they do on R&D? So those hot looking pharma sales reps who take the MDs out on fancy dinners are costing the company more than their R&D efforts. As a note, the pharma sales reps are bribe-agents. MDs will sell you drugs if they have a vested interest in doing so. This is very corrupt and anti-competitive (the drug company which “wins” has won because of their hot/sexy salesperson is a better briber, and not because the better drug has won).

  7. boston_mahesh makes a lot of nice points–the current system is way too medieval guild-like to provide any sort of legitimate baseline for a critique of “for-profit failure” that justifies some sort of killing off of competition–instead, we need to strongly prune back the guild(s), as boston_mahesh suggests. Something similar has, in fact, already happened in the practice of law in the US–mere possession of a law degree/bar passage no longer (correctly, I would suggest) confers monopolistic/oligopolistic rents on the holder.

  8. “1. WE DON’T HAVE ENOUGH DOCTORS HERE! T”

    Big myth. What we need is grass roots change, everybody should know what the hell they are eating, how much exercise they are doing etc.. We need more preventive care than doctors. In other words, we need to step back and look at the causes for most of modern day ailments coming from lack of enough sleep (fuck me it is 155am and I am reading sepia), lack of healthy diet. Instead we have become a culture of supplements, medicines to cure symptoms and post-ailment approach based society. The human body can fix a lot of things itself with proper diet, so stop popping pills which actually cause other reactions, leading us down a chain to polypharmacy.

  9. so stop popping pills

    Oh, give me a break–putting a finger on the scale against taking medicine amounts to nothing more than the BS of traditionalist and/or leftist anti-science know-nothings, equivalent and equally bad to rightist elements who are against evolution and/or stem-cell research. What’s your point?–You wish that you lived naked in the woods and didn’t have to deal with this “big bad” “technology stuff” delivered by (shudder) “modernity”?!

  10. I had read an article a while ago that had made a similar point, that what we call “health costs” is income for others, and they will probably have to be brought in “kicking and screaming”…

  11. My mental model of doctors says they are like mechanics — if you need to see them, you are in big trouble. Since we don’t yet have the option of selling your body and buying a new one, the best option is to maintain what we have well, and try not to get to the point where you have to see a doctor.

    The doctor-mechanic analogy works at another level as well. Most mechanics are troubleshooters, they have no clue about thermodynamics or fluid dynamics or control theory or mechatronics — all the deeper level stuff that makes your vehicle work. They have general ideas about how a car runs, and try to solve problems using some standard trial-and-error tricks. If you ask them why a problem arose or why a trick works, they will give you a folk theory about heat or blockages or wear and tear or some such thing. The deeper mechanisms are beyond them, they are quick-fix people. Doctors are similar, most of them have no idea why problems arise in the human body, and how their medicines solve a problem, if at all. Talking about drug interactions is taboo, as that would mean getting into deep biochemistry. Surgery is safe, as it is easy to explain — “you had a problem with your gall bladder, so we removed it”. Compare: “you had a problem with your gear box, so we replaced it”. But doctors strut about thinking that they save lives (even though they don’t, given the current model of “patient management”). Mechanics don’t do the strutting, thankfully, even though they could, too, as their actions save more lives in comparison.

    As an aside, I’ve found doctors as a group the most boring people. They are smart, and useful, but very uninteresting. And they are almost always very condescending, an attitude that stems from their implicit mental model that “after all you are a body”. Their training dehumanises them, kinda like policemen.

    As for the guild business, it is best understood as a cartel. I think the Indian system is better — graduate as many as possible, and let their performance sort the good and the bad. That is what you do with mechanics.

  12. I’ll make no bones about the fact that doctors indeed are responsible in a way, not only for the deteriorating healthcare situation, but for all other natural calamities like swine flu, recession and hurricanes hitting the US. I am however, deeply disappointed at the observations put forward by Mechanics, who in his utmost naiveness, endeavours to compare the abilities of a doctor to those of a mechanic. A doctor has to operate on a beating heart, with arteries brimming with blood, and a single wrong move would assuredly put an end to the life of his patient. I have never heard of a mechanic who has the gall to operate on a running engine, with pipes flush with gasolene. Moreover, his comment, that of the doctors being the most boring people on earth, is decidedly fallacious and appears to be borne out of prejudices, than out of either facts or conviction. I happen to be a medical practitioner from, as my ID would appear to suggest, India, and I am proud to say that I have, amongst my professional acquaintences, some of the most morbidly funny human beings who have ever blogged the earth.

    In support of my claims, I hereby present an anecdote, which shall put to rest the debate of Doctors v/s mechanics for good.

    A mechanic once forwarded the following sms to a doctor-

    Question: If a pretty woman faints, which part of the body shall you examine first. Clue: P–S-. Those who answered PULSE went on to become doctors. Others became mechanics and enjoyed life.

    The doctor replied:

    Correction please. Those who answered PULSE became doctors and enjoyed life at will. Others became mechanics and had to wait for the woman to faint before they could enjoy life!

    I hope Mr. Mechanic just sees the humor and takes it in his stride.

    Cheers.

  13. I am a physician of Indian origin. I can vouch for me and my fellow South Asian practitioners of medicine that as a community we are the vilest, greediest, most crooked scumbags that walked the earth. Unless we are prevented from profiting from our decisions, we cannot bring any form of reasonable control to the country’s health care costs. I myself have invested in a string of Surgery Centers in Texas which are extremely profitable since our shareholders (including me) refer patients to us. Honestly, I feel like part of the Cali cartel than someone who swore by the Hippocratic Oath. I am not complaining but reading the New Yorker article awakened me to the crime we are perpetrating on the public at large.

    Obviously I am only admitting the truth on SM since I can hide behind a pseudonym and not reveal my identity. I truly hope that Obama manages to bring Medicare for all, and eliminate Insurance companies from the equation. A publically funded health care system will make the US more like McAllen than the Mayo clinic. I am proud of what I do and that I chose such a rewarding profession. In defense of the crooks like me, we are only doing what is legally possible in a free market society and individuals who desire the most expensive solution rather than the most healthful one.

    The sicker the society becomes, the more profitable it will be for us. And if we can limit the number of new doctors allowed into the market, we can pretty much write our own ticket. I am happy with the way things are; and societies deserve what they get. It is clear to me that we are providing what the public wants. Now Obama has his work cut out for him – go figure out how to get the money to pay for all this.

  14. Quoting Seth Roberts,

    More inequality means less innovation means problems stacking up unsolved is not widely appreciated. In his New Yorker article, Gawande fails to understand that the big improvements to American (and world) health are not going to come from doctors or anyone now powerful in healthcare. They are too wedded to the status quo. (Notice that this recent innovation in affordable housing, the nano home, comes from a car company — an Indian one.) Gawande, being a doctor, surrounded by the powerful at Harvard (where he teaches), is in a poor position to figure this out. Where will the big improvements in health actually arise? From people who benefit from change. A reasonable healthcare policy would try to empower them.

  15. I strongly recommend that commentors actually read the Gawande article — especially for the commentors above that are trotting our solutions that would solve none of the problems identified in the article.

    Neither employer-mandated medical care or the “guild” system are behind the problems in McAllen, or the successes in Minnesota.

  16. @boston_mahesh: You can get a doctorate in nursing these days. I’m not sure what you can do with it, I think it’s more for teaching/academic purposes, than actual practice. But from what I understand, nurse practioners/physician assistants do function mostly autonomously as primary care physicians, if that’s what they choose to do. Regarding drug companies providing physicians with perks—my understanding is that sort of behavior is being phased out now; there were a few articles about it in the nytimes last year.

    Regarding graduating more doctors: I do know that some medical schools now are being asked by the AAMC to increase their class size. And in terms of “lowering” standards—ultimately, to become a doctor in the US, you have to pass Step 1, 2CK, 2CS, and 3. Plus the board exam of your specialty. So, those will (theoretically) keep the “clinical knowledge” standards.

    But I do agree with increasing the amount of US medical graduates, rather than importing them from places that despreately need doctors. Also I think the premed curriculum needs to be revamped here, focusing less on things like organic chemistry 2, which basically has no relevance in a practicing physician’s life, and more on socioeconomic issues, at least introducing them. And make the science-y subjects more clinically relevant. Like the biochemistry I learned in college was different from the biochem I learned in medical school. Just make us learn it once, in college, and make it relevant to medicine. Then we can have time for more important things in medical school.

    One regret I have is that I didn’t major in public health in college, choosing instead a science major that is popular with premeds. Now I spend a lot of my free time trying to “catch up” with these public health issues that are more relevant to the practice of medicine than the basic science stuff I learned in college.

    @Mechanics: hey, c’mon. You can’t stereotype an entire profession! You’ve obviously had a bad experience with a person or two, but it really depends on the company you keep. The kind of doctor that works in a suburban practice has different professional goals, ideas, and opinions than one that works in, say, an urban academic center.

    Back to the original topic…I haven’t read Gawande’s piece yet, but based on what has been posted here, I totally agree with what’s he’s saying. I think there are also a lot of structural things that add to the cost of medicine as well. Electronic medical records and access between hospitals would help. Some patients go from hospital to hospital. If they had a legit problem, that needs to be worked up, I would like to know if it had already been worked up at the hospital down the street two days ago. It’s so easy for doctors to order things like CT scans, etc…but they cost so much money!! If the patient already had a CT scan done 2 days ago, then it probably does not need to be done again. But if we don’t have access to those records, it’s gonna get done again, which is a waste of resources.

    Anyway, something about the whole path to becoming a physician results in an entitled person who doesn’t mind playing the system to make some extra dough. Medical school is expensive. Many people graduate with a substantial amount of debt. I know some of you will be like, “give me a break,” but it’s a perceived feeling that results in “how can anyone expect us to go into primary care with that kind of salary?!” And whatever “humanistic” reason that supposedly spurred this person’s path into medicine is lost. And then residency seems to be the ultimate entitlement builder, with backbreaking hours that force some to choose between their career and everything else in their life—including time with friends and family. So, yeah. I think a culture change (or upheaval) is in order.

  17. I believe that a nurse should be able to become a MD in some accelerated program. Let’s further delineate nurses from MDs. Moreover, let’s give more rights, compensation, and power to nurses – especially if their the hot blondes that I have many downloaded clips of. 7. More power to nurses. Allow doctorates of nursing to exist. This DN carries with it the title of “doctor” which MDs are vehemently against this because of their conflated egos. Let’s do something about this.

    Are you kidding? If you nurses want to become doctors, let them pass the boards and exams that International Medical Graduates take to become licensed to practice in the United States. However, this rarely happens because the nursing education has a totally different aim from a medical education. The former is well, focused on “taking care of the patient” and the latter is diagnostic/theoretical.

    And no, doctors are not vehemently against doctorates of nursing because of ego. Someone with an online degree should not be manipulating patients’ biochemistry with prescription drugs without passing the same exams that MDs do.

    http://www.elearners.com/online-degree/10268/Doctorate/DR/Doctor-of-Philosophy-(PhD)-Education-Nursing-Education/Capella-University/?cm_sp=Nursing--Doctorate--10268%20CU:Doctor%20of%20Philosophy%20(PhD)%20in%20Education%20-%20Nursing%20Education-1&

  18. Here are some real ways to reduce health care costs (and yes, this does mean the reduction of doctors’ and other medical professionals’ salaries):

    http://truecostblog.com/2009/04/09/lowering-healthcare-costs/

    The US health care system is majority funded by the federal government (via Medicare, Medicaid, tax deductions, etc), but it still responds to supply and demand.

    We absolutely do have to increase the supply of healthcare. Unemployment rates for physicians are 1% during our current deep recession! While this is great for physicians, this means that physicians’ salaries will be driven up because they don’t compete with one another for employment.

    We also have to cut demand for healthcare. Healthcare is the most subsidized activity in the US economy, with $250B in subsidies via the tax deduction on employer-based health care alone. Ending these subsidies would immediately reduce demand by over 10%.

    Finally, at the end of the day, the government will have to ration its healthcare dollars. Individuals should be able to buy as much health care as they like, but the government is going to have to make tough decisions. Not because I said so, but because the federal debt will exceed US GDP next year. We don’t have too much more time to keep borrowing and spending on health care.

    References:

    http://truecostblog.com/2009/04/10/us-debt-to-exceed-gdp-by-2010/ http://truecostblog.com/2009/02/05/healthcare-bubble/

  19. 11 · Mechanics on June 1, 2009 03:28 AM · Direct link As an aside, I’ve found doctors as a group the most boring people. They are smart, and useful, but very uninteresting. And they are almost always very condescending, an attitude that stems from their implicit mental model that “after all you are a body”. Their training dehumanises them, kinda like policemen. As for the guild business, it is best understood as a cartel. I think the Indian system is better — graduate as many as possible, and let their performance sort the good and the bad. That is what you do with mechanics.

    Mechanics, I agree with you. The bulk of desi MDs that I know of are the most arrogant and socially-unskilled people I’ve ever met. I’m still at a loss of words when i think of the things that they have done to me in the past, but that’s OK. This is simply the result of being locked up staring into books/pipettes for years, and not being out-and-about. So another words – they are like that kid-genius who memorized the capitals of the 50 states in the USA, but has absolutely no other skills (OK – he’s good at days/dates). But he has no friends and fun, and acts like an unsocialized being like many Indian MDs that I know of.

    That being said, two of my siblings and two of my best friends are desi MDs, and they agree with me on this as well!

  20. Back to the original topic…I haven’t read Gawande’s piece yet, but based on what has been posted here, I totally agree with what’s he’s saying. I think there are also a lot of structural things that add to the cost of medicine as well.

    He’s not talking about structural things so much as cultural things. The professional norms and ethics that underpin being a doctor and people’s expectations of what a doctor is supposed to do and what kind of lifestyle he is supposed to lead have been skewed. On top of that we’re in a culture where everyone wants the shiniest, newest gizmos when being worked on because they have no cost-consciousness since insurance reduces it all to “covered” or “not-covered” so they prize “thoroughness” over effectiveness and don’t make a peep when the doctor signs them up for 10 tests.

    When you have a bunch of geriatrics in retirement homes with nothing to do but fret about their health and a bunch of doctors who have decided they ought to live like some wealthy class of landed gentry, you’re going to get balooning costs. Stack on top of that incentives from pharmaceutical companies and the like to privilege pill-popping over lifestyle changes and a culturally ingrained fear of death (gotta squeeze every last minute of life out of Grandpa regardless of how crappy it is) and it’s easy to see that we’re sending a lot of money to places where we probably wouldn’t value it all that much.

  21. From Krugman’s blog:

    ” … The basic facts on health care are clear: government-run insurance is more efficient than private insurance; more generally, the United States, with the most privatized health care in the advanced world, has a wildly inefficient system that costs far more than anyone else’s, yet delivers no better and arguably worse medical care than European systems …”

    See http://krugman.blogs.nytimes.com/2008/07/20/does-not-compute/ for the full article.

  22. 18 · praveen on June 1, 2009 10:26 AM · Direct link Here are some real ways to reduce health care costs (and yes, this does mean the reduction of doctors’ and other medical professionals’ salaries): http://truecostblog.com/2009/04/09/lowering-healthcare-costs/ The US health care system is majority funded by the federal government (via Medicare, Medicaid, tax deductions, etc), but it still responds to supply and demand. We absolutely do have to increase the supply of healthcare. Unemployment rates for physicians are 1% during our current deep recession! While this is great for physicians, this means that physicians’ salaries will be driven up because they don’t compete with one another for employment. We also have to cut demand for healthcare. Healthcare is the most subsidized activity in the US economy, with $250B in subsidies via the tax deduction on employer-based health care alone. Ending these subsidies would immediately reduce demand by over 10%. Finally, at the end of the day, the government will have to ration its healthcare dollars. Individuals should be able to buy as much health care as they like, but the government is going to have to make tough decisions. Not because I said so, but because the federal debt will exceed US GDP next year. We don’t have too much more time to keep borrowing and spending on health care. References: http://truecostblog.com/2009/04/10/us-debt-to-exceed-gdp-by-2010/ http://truecostblog.com/2009/02/05/healthcare-bubble/

    BOSTON_MAHESH: This is very interesting, and it agrees well with my opinions at the very top. Doctors make too much money, and there is an investment-banker’s zeal/motivation at work which guides their practice and a “god-complex/master-of-the-universe” complex.

    There is so much torture and anguish that MDs (and investment bankers) must go through, which make no sense at all for the patient or the MD. However, due to status quo, the lack of a will to change, and the motivation to keep barriers in place for other market participants, these wasteful torturing devices are still kept in place. NOTE: I regret if it seems that I’m defending/feeling sorry for i-bankers.

    I believe that the quality of life for MDs should be made to be more humane. Let’s do this: 1. Allow more geographic mobility for MD students and residents. Right now, a perfect student with a 4.0 GPA and a 35 on the MCATs will not be able to get into to the U. of Mississippi medical school, because they ONLY favor in-state people. So, by extension, some states are severely handicapped, like California. They don’t have as many medical schools, and they are much more competitive than Mississippi (MS). All the borderline students won’t get accepted in CA, and, even though they are VERY SMART and competitive compared to the MS student, these borderline Californians can’t get into the MS medical school.

    If we allowed a more borderless and “free-trade” approach to medical schools, than MS/Iowa/etc. would see more Californians. The Californians, in term (or even the people from MS/IA, etc.) would see more and better physicians! It’s a WIN-WIN-WIN situation.

    1. Less hours for residents! By working 80 hour weeks, you’re going to accidentally leave your scissors inside the patient after she/he has been sewed up. Also, this isn’t how you learn! This is cheap slave-labor and work without pay.

    2. INCREASE THE NUMBER OF MDs, and drive down the price of services.

    3. Ban drugs/procedures/devices that do not meet a benefit/cost ratio.

    4. In India, it’s possible to go to medical school at age 20, I think, if not younger. In America, let’s make many many more programs like this. Becoming a MD at 34 serves NO FEmALES who are trying to raise a family. This is very unfair for females to start a family at 34 (or 40, etc.). if, on the other hand, they were allowed to start medical school at 20 (or even 26), AND IF WE INCREASED THE NUMBER OF MDs, they could have a true/real family life.

    5. Many aspiring MDs are not motivated by money. So let’s bring down the costs of all services: education, procedures, supply/demand, etc.

  23. By systematically eliminating all the likely suspects (e.g., it’s the lawyers and their malpractice suits that cause health care costs to soar)

    Thats the claim. In states where they have some form of malpractice insurance ‘reform’, the cost of malpractice insurance has not gone down.

    I believe the preventative cover your ass medicine, malpractice insurance etc. etc. contribute to less than 5% of the cost. Bare boned malpractice insurance amount to less than 1% of the health care costs. Some reform is of course needed. However, we need to put things in perspective. For example, primary care physicians are always bitching about the fact that they don’t make enough money. That of course is relative. Yes, they don’t make what cardiologists make but then they still clear 150K within 2 years of post residency practice.

    As we well know, medical school students are disproportionately desi.

    There are a lot of desi lawyers too :) Seriously, why dont desis go to law school in similar numbers?

  24. The level of “humour” in Rofl Indian’s comment supports my point. Not only are doctors boring, they don’t have the ability to figure out why/how they are boring. Mostly because they live in doctor bubbles with very little contact with the outside world. Most doctors marry doctors (another badge of honor), hang around with other doctors, and mostly talk doctor talk.

    BTW, most sensible doctors consider themselves mechanics. Especially these days, where 90% of medicine is engineering, and derived using engineering tools, either chemical or mechanical, or a combination of both.

    Sparky, I am not stereotyping based on a limited datatset, I know lots of doctors. In fact, as Boston_Mahesh says, many doctors agree with me on this. They do a lot of work, and lose themselves in it. They surround themselves with other doctors, and sneer at other people, because they don’t fit in very well outside the bubble. Especially with their sense of entitlement, saving-lives complex, and dark body humour which only they find funny. Treating patients as profit centres is just a step away once you have this setup in place. Strange thing is that many of them are nice people, so maybe there is some kind of banality-of-evil effect here.

    It is interesting that the investment banker analogy came up. I have noticed recently that a lot of educated people are actually very suspicious of doctors, wondering aloud about commissions when a test is prescribed etc. People also seem to consider them very elitist. I also see lots of knowing smiles when I dish out my doctors-are-boring thesis! :)

  25. Yes, they don’t make what cardiologists make but then they still clear 150K within 2 years of post residency practice.

    Your subjective appraisal of how well of you’re doing is going to be relative to your peer-group. Not the large statistical sample of society as a whole. So yea, an internist would be in the top 10% of income earners overall, but all his friends have brand new Lexuses and he only has a Camry. And all his friends have 10,000 sq. ft. houses and he has to get by with only 6,000.

    My first instinct is to be glib and write it off because in perspective it does seem petty and materialistic (and it is). But the point is they don’t have perspective. That’s the culture we live in and they’re down in the weeds and noticing that the medical profession left them behind in terms of compensation and prestige. From where they’re standing it seems like everyone is doing well except for them so they need to fill the gap.

  26. It is interesting that the investment banker analogy came up. I have noticed recently that a lot of educated people are actually very suspicious of doctors, wondering aloud about commissions when a test is prescribed etc. People also seem to consider them very elitist. I also see lots of knowing smiles when I dish out my doctors-are-boring thesis! :)

    I suspect it has something to do with one’s reason for being a doctor. If you do it out of parental pressure then once you get there you’ve busted your ass for all those years to go into a profession for which you have no sincere passion. What are you going to be there for if not for the money?

    Of course, medical school and residency being as grueling as they are leave few opportunities to pick up unique hobbies. So what are you going to spend money on once you get it but conspicuous consumption?

    I wager it’s not just a Desi thing either. Maybe the last generation of non-Desi doctors whose idea of what a doctor’s lifestyle is were formed in the ’70s before everything changes have more modest ideas. But something like 60% of undergrads in top 20 schools are aspiring doctors. Things seem to be structured such that the profession draw ambitious strivers rather than compassionate caretakers.

  27. Being a Canadian moved to the US, it’s always been strange seeing billboards advertising health services and getting billed for lab work in addition to co-pays, and for amounts of whatever was either not covered or ‘my responsibility’ (like a 50% of coupon).

    It is very nice to see a discourse on different options without the knee-jerk rants of socialism.

    The things that people seem to miss when the scream socialism, is that, like it or not, whether you ‘don’t want to pay for others’ – you end up doing it anyway. People who aren’t covered, still go in for health issues, but they end up going after the issue has been put off for longer because of cost and hence, they need more extensive care which results in higher expense. As opposed to those who can afford to go for ongoing, preventative health care. Indigent care (non-covered patients) is one of the largest expenses hospitals deal with. We still end up paying for it.

    Hell, even people who are ‘covered’ have to watch how many times they go to the doctor, with certain tests being only covered once a year for check up. And I have many Republican colleagues who always have the same old statements re: ‘In Canada people have to wait for certain procedures and I heard from so and so about one time when this person suffered / died / etc because of their health system’. As if there are never any issues, deaths, etc here. And we don’t pay ludicrous amounts for medication that comes from the same US companies (or manufactured here and shipped north).

    And I always say that absolutely no Canadian would trade their Healthcare system for the American model. Does that mean it’s perfect ? Of course not. Yes there are some major issues, just like with any of the government provided healthcare models around the world – but if we are America, the greatest country in the world, why can’t we take a look at every one else’s system and take the best parts and make our own ? Especially since the US spends more than everyone else anyway. And – in Canada, people don’t go bankrupt from health debts – and generally people will be healthier and happier if they can get ongoing care which in turn leads to a more cost effective model.

    Again, not saying CDN system is perfect – lots of issues – but no debt burden or patients putting things off until they get worse because they can’t afford it. No ambulance bills or charges for ER visits.

    Most US citizens would be ok with slightly higher tax rate for improved access to care. Blows me away that people don’t think of the amounts they pay yearly in health out of pocket when they scream about taxes. No one is saying that the health care provided sucks overall or is low in quality – the main issue is the access – it is the former that people get defensive about. The public needs more facts to make an educated decision.

    Absolutely nothing wrong with discussing alternatives rather than screaming communism. Otherwise we have not come very far from the 40s and 50s where the AMA would put out propaganda scaring the masses that the big evil government could choose their doctor and deny their care (which now happens anyway with private insurers).

    All the talk of doctors’ personalities is interesting. Future brother-in-law is a resident and he is shocked by some of the people he’s studied with – that anyone who can memorize and do well academically can be a doctor but it doesn’t mean they will be good doctors. If you’re doing it for the money – wrong reason to practice.

    Fav doctor joke: What is the difference between God and a Doctor ? …. …. God doesn’t think he’s a Doctor. :)

  28. Yoga Fire: Of course, medical school and residency being as grueling as they are leave few opportunities to pick up unique hobbies. So what are you going to spend money on once you get it but conspicuous consumption? I wager it’s not just a Desi thing either. Maybe the last generation of non-Desi doctors whose idea of what a doctor’s lifestyle is were formed in the ’70s before everything changes have more modest ideas. But something like 60% of undergrads in top 20 schools are aspiring doctors. Things seem to be structured such that the profession draw ambitious strivers rather than compassionate caretakers.

    BOSTON_MAHESH: Yoga, you made a very nice and interesting quote. I agree 100% The bulk of pre-meds that I knew in college were rude, cliquish, type-A, left-brained geniuses who were good at memorizing. The desis in the pre-med program were nasty and cocky. I don’t buy for one second that they are any more compassionate than the bulk of these people here. Heck, I think that Shawn Valentino is much more compassionate. I resent that many of these pre-meds spend ~$2000 for a plane ticket to India to do $30 worth of social – work, but they don’t have the decency to be polite to any non-doctors. But their rude attitudes is besides the point. I think that when they grow up, they become more mature and they develop personal skills and all.

    What’s funny to me are these Caribbean medical school and now Polish -based medical schools. This is like a diploma mill. At least they fill a void, and their USMLE pass rate is quite high.

  29. A doc has to pay for the malpractice insurance.. And just to prevent a malpractice suite, he has to be absolutely sure about the diagnosis.. And to be absolutely sure, he has to prescribe a number of seemingly useless tests.. This is just a spiral of problems that has led to escalation of healthcare costs..

  30. 27 · GurMando on June 1, 2009 12:57 PM · Direct link Absolutely nothing wrong with discussing alternatives rather than screaming communism. Otherwise we have not come very far from the 40s and 50s where the AMA would put out propaganda scaring the masses that the big evil government could choose their doctor and deny their care (which now happens anyway with private insurers).

    BOSTON_MAHESH: It doesn’t surprise me that the AMA has always been on the wrong side of ethics, morality, and social norms. These propagandists are bandits with stethoscopes. In the past, they were actually racist against Black Americans. I don’t know the details of this, but my MD girlfriend (ex, btw) told me this. The AMA are sleezy monopolists with gold-plated stethoscopes.

  31. I know a Doctor who is just a general practitioner and he drivers around in a $400,000 car. He is the type that would order ever thing in the book if you went to him for a stomach flu.

    If there is a Doctor shortage then why cant they let more students in? If they cant handle it then wouldnt the system naturally get rid of students who cant cut it? Just because you are a great student it doesnt mean that you would be a great surgeon.

    I would rather have someone who wasnt the best student, but has the hand-eye coordination of a tattoo artist cutting me open over some perfect student who never did anything with his hands.

  32. I know a Doctor who is just a general practitioner and he drivers around in a $400,000 car. He is the type that would order ever thing in the book if you went to him for a stomach flu.

    If there is a Doctor shortage then why cant they let more students in? If they cant handle it then wouldnt the system naturally get rid of students who cant cut it? Just because you are a great student it doesnt mean that you would be a great surgeon.” - Shallow Thinker

    Anecdotal evidence of one doc driving a ferrari means nothing. New graduating doctors are graduating with 200K(NOT INCLUDING UGRAD) in debt usually and are driving corollas until their 35 at least. Becoming a doctor with no time off between college and med school means graduation at 26 and finishing residency earliest by 29-30. 30 is when loan repayments start and when you start making any real salary. Starting a family, buying a house, all those things are expensive and doctors start out from a far deeper whole than the rest of the population. Also realize that its hard to get in the first time out and many students complete masters degrees to get in. You want to socialize healthcare, do a one payer system, fine, but make medical school education affordable and pay doctors a fair wage for the number of years they’ve studied.

    I agree that medical school enrollment should be expanded, but I dont think it can be doubled without hurting quality. The caribbean schools profit on taking 400 people, half of which are qualified for American schools, but perhaps unlucky. The carib schools then slowly fail a third of their class the first two years before boards, so when the test comes up, they have a pretty strong passage rate (this is only true of the big 4 carib schools, Ross, St. George, AUA, SABA, the others blow).

    Also, you can be like mechanics and graduate a ton of people and let patients sort through them to see who is quality, but you’ll invariably have healthcare quality decline as the bad doctors practice for some years before their patient source runs dry. And hell, a bad doctor with a great personality may never lose his patient source and may never be sued, so the lack of oversight will not be a good thing.

    About Healthcare being expensive: One-third of each dollar in healthcare goes to insurance companies, 1/3!. Make things single payer and hopefully the overhead will go down as redundant office workers processing things for the gazillion insurance companies will be put out of work. Add in the fact that the government, because of legislation its own senators and representatives passed, cannot negotiate rates on drug prices with the pharm companies and you have the reason why healthcare costs so much. Doctor pay has stagnated since 1994, they are not the problem.

    About the Doctor Shortage: There isn’t a doctor shortage, theres a shortage of doctors practicing in undesirable locations. Better incentive programs to practice in those areas would alleviate this shortage and hopefully reduce the insane concentrations of docs present in every major city, suburbs of every major city and the overpopulated state of NJ. boston_mahest talks about having no in-state preference, but this would only cause the southern states to lose doctors as students with higher stats from cali, ny and nj and other states take their spot. It takes a 33 MCAT average to get into a cali state school, 31 in NJ and a 27 in MS. MCAT isnt everything, but it is important. (Source: AAMC Getting Into Medical school, 2007)

    About Doctors being Turds: Look you can hate on doctors for their personality or whatever, but I sense some of this underlying hostility is from people who couldnt cut it and perhaps their fathers let them know about it a little too much. I know guys who went into ibanking and consulting, whatever the hell that is, straight out of college, and the ones that still have jobs are 24 yo and making 6 figures easily. If you want to rail on a profession, rail on one based on taking extreme risks and then depending on a government handout when allowing dudes who studied “finance” and “business” after failing out of organic chemistry, to keep their mouths in the 6 figure troughs. Something tells me this is going to hit close to home to the “doctors have no personality crowd”.

    • A second year medical school student
  33. If you want to rail on a profession

    No one has said here that doctors are useless. Every profession leaves its mark on its people, I was just commenting on the mark of the doctor. You could make similar comments about accountants, lawyers, journalists and policemen. The only difference is that the current doctor personality is so much at odds with the one a doctor ought to have, and also what people would like a doctor to be. I also know doctors that don’t fit the stereotype I painted, but they are few and far between. They are also highly respected in general, have interesting lives outside doctoring, and carry on conversations about the weather without moving it to talk on flu.

    As for not cutting it, not everyone wants to be a doctor, surprising though that might be. As you may have heard, “an apple a day keeps the doctor away”. The moral I drew from it is that doctors (and doctoring) should be kept away. And it is looking more and more like that was the right moral.

  34. mechanics writes: “The only difference is that the current doctor personality is so much at odds with the one a doctor ought to have.”

    Who are you? As if you have authority to speak on “the current doctor personality.” I’m not a doctor (am a lawyer) but there seems to be incredible insecurity shining through in the comments of “mechanics” and “boston mahesh.” I know many doctors, lawyers, i-bankers, teachers, secretaries, and blue-collar workers. There are as many varying personalities in the medical profession as there are in any profession. Those who say otherwise reveal more about their insecure selves than contribute any knowledge about those of whom they speak.

  35. I understand all doctors should be gentle, emphatic caring people, and some just dont cut it , but I just dont agree that doctors that fit the bill are few and far between. There is no doctor personality, you can choose to create one and have doctors fit that mold, but that is up to you alone. I’ve seen doctors argue relentlessly for medication and care that insurance company bean counters reject with a few words over a phone call. Many times its the doctor that has to attempt to explain why this has happened to the patient. I’ve also seen the same physician accused of ordering too many and too little tests by different patients in one day, both accusing the doctor of doing so based on profit. You add in the fact that doctors have to see more patients to pay the rent, staff (1-2 just responsible for billing, coding and referral management) and other overhead and this takes an emotional toll. Most doctors dont have surgical centers they own a piece of and insurance companies that readily pay out for referrals and tests, these things are hard-fought in many places where a culture like that in McHalen has not developed.

    Razib above stated correctly that there are “cultures” of health care in this country. You have the Cleveland and Mayo Clinic models Gawande rightfully admires that are low cost and high impact due to the team based approach and you have the McHalen model which is driven by profit and thus by overreferral and overutilization. If you find a way for doctors to just be doctors and take away the fact that have to wonder if its all right for the guy with the MI to get tPA or the insurance company will only pay for streptolysin, then you would take a huge load off of doctor’s backs.

  36. This is a great topic for discussion because it impacts the South Asian community based on our numbers in medicine, and it directly impacts the future of this country. I think the first and most important rumor to address is that the number of physicians has any significant impact on the cost of healthcare. It does.. more doctors means more expensive healthcare, not less expensive. Medical reimbursemnt is set up on a piecemeal basis. The more procedures I perform, the more money I make. The above analogy of the electrician, plumber etc is a good one. If you pay per faucet, you will end up with a lot of faucets. If you pay per cardiac catheterization, you will end up with a lot of people getting needless cardiac caths.

    This is only part of the problem, though. If individual doctors think this way, you can be sure that medical-industrial complexes like the Cleveland and Mayo Clinics think this way. It’s no shocker that Cleveland Clinic is world renowned for cardiac care and not pediatric immunizations. Gawande is deluding himself if he thinks the Mayo Clinic and Harvard haven’t played major roles in pushing our healthcare economy to its current dismal state.

    The essential problem in this country is that of overtreatment (http://www.overtreated.com/home.html excellent book). We order far and away more tests and do more procedures than we need to. We do this because for medicolegal reasons, patient care reasons and financial reasons. The problem is medical culture, but it is also American culture. A culture where everyone expects the best regardless of cost. This will translate to expenditures up to 20% of national GDP. Like it or not a rational discussion about health care rationing is the politically incorrect flipside of evidenced-based medicine that everyone loves to tout.

    It’s a difficult topic but as a community we need to be involved with figuring it out.

  37. It’s been such a long time since I’ve commented on this blog – look at all these new people!

    I’m a 2nd year resident in a surgical subspecialty so I wanted to weigh in some things. First, can we ask who these costly tests and treatments are being ordered for? Are they for the healthy 55 year old who watched her weight, diet-controlled her diabetes and exercises her joints everyday? NO WAY. They’re for chronically ill end-of-lifers. And the ugly truth is many of these chronic illnesses (coronary artery disease requiring 4 vessel coronary artery bypass graft, end-stage renal failure secondary to diabetes requiring dialysis, diabetic retinopathy, chronic osteomyelitis from diabetic foot ulcers requiring perpetual antibiotics, cirrhosis related to Hepatitis C and/or alcohol, hemorrhagic stroke resulting in paralysis from your uncontrolled hypertension) could have been prevented with ongoing care and preventive medicine.

    Isn’t there some stat that 50% of Medicare dollars is utilized in the last 2 months of life? Can you imagine what that money could do had it been spent on preventive care and education of patients? But that will never happen…for 2 reasons:

    1) Preventive care isn’t hot and sexy!!! People want to hear about their tax dollars going towards stem cell research and exciting new surgical advancements, not towards teaching adults that fast food is bad for you!! (Because well…DUH. A lot of preventive medicine is just common sense. Exercise=good. McDonalds=bad…and yet, so many chronic illnesses (diabetes, HTN, osteoarthritis, cardiovascular disease) are related to the pandemic of obesity.

    2) It’s unappealing because the burden of healthcare then falls to the PATIENT, not to the physician. If our government organized a symptom (like the private insurance my hospital has purchased for its employees) where citizens could receive lowered-cost healthcare coverage IF they could show blood pressure control, a normal cholesterol panel, a balanced diet, and aerobic exercise 20 min/day 5d/week, how many people do you think would be eligible for such a thing? And for as much as this seems like common sense, its not. The truth of the matter is nobody likes to blame themselves…just think about it, some 60 year old grandfather suffers a major stroke, now has the R side of his body paralyzed, can’t talk and has to be fed with a G-tube because he can’t chew his food anymore. How can you tell him that it was his obesity that led to his hypertension, and if he would have taken his bp pills he wouldn’t have had a stroke, so..yeah, dude, welcome to your new room at the nursing room ps it’s all your own fault.

    Additionally there’s no shortage of doctors. There’s a shortage of primary care docs…y’know, family practitioners, general internal medicine doctors, that type of thing. To be honest (I’m sure I’ll catch a lot of flak for this) the return’s not that good. You worked your ass off in college majoring in biomedical engineering while your friends majored in philosophy and econ. You then proceeded to sweat through 4 years of medical school (while your friends went to law school/did ibanking and laughed at you, while you would emerge from under a rock every 3-4 months after some set of exams to come get wasted with them), 3-9 years of residency, depending on what you’re going into, COUNTLESS board exams (general medical and then in your subspecialty), then 2-4 years of a fellowship. Nobody becomes a doctor to get rich (like HELLO don’t you think I would have gone to business school?) but to be honest after spending at the VERY least 7 and at most >15 years of your life AFTER college getting paid peanuts, working “80″ hours (which…HA. HA. Dream on.) a week, being $200,000-$300,000 in debt by the time it’s all said and done (oh and if you’re a woman putting off your child-bearing til you’re “done with training” so now you’re 35 and your kid’s at increased risk for Down’s Syndrome – SUPER), you’re kind of ready for a little bit of a pay-off at the end.

    Also, I think as far as preventive medicine not being glamorous to taxpayers, it’s also less and less appealing to doctors…I mean, most people are drawn to the exciting cool stuff (there is TONS of cool stuff) about medicine, like cutting edge procedures and more advanced, exciting surgeries. The answer might be to hire more nurse practitioners, who can write Rx, and usually work with a doc to deal with straightforward primary care type stuff.

    Anywho, that’s just my 2 cents! Carry on.

  38. Couple of my quick opinions on Health Care - We need to have a system of health insurance that does NOT involve the employers. - Everyone should be mandated to carry insurance just like liability insurance for driving. - Insurance should be bought directly by the citizens from an insurance company - A Federal agency should regulate the workings of this insurance process (unlike Homeowners and Auto insurance which are done at state level) - Yes We can.

    Why should I be forced to carry mandatory health insurance when I never utilize allopathic pharmaceuticals? Will this insurance cover aromatherapy massages? Ayurvedic herbs? Homeopathic remedies? Goji berries? Marine phytoplanktins?

  39. 1) Preventive care isn’t hot and sexy!!!

    But vy not? I personally thought this sleeve sneeze campaign is brilliant and an exceptional use of our tax dollars. It’s simple and very effective IMO. Try it the next time you have to sneeze.

  40. Interesting discussion. I am a DBD and been here in the US for 21 years and been to the doctor only once, a few years back for a physical, upon the wife’s insistence when I turned 40. Don’t take any pills or vitamins or other health supplements either. If I can do it, I think at least 50% of the population can do it too. This is one way to cut health care costs.

  41. Many of you desis commented on preventive aspects of healthcare. I agree with you here. Here are some ideas that we could implement (but I still think that we need more medical doctors and all the other ideas that I made in this article): 1. Tax cigarettes even MORE. Here in MA, a pack of Parlis are ~$8.50! I love it! This more than anything will prevent the teens from starting this vile habit. 2.a. Tax soft-drink companies, fast food companies at the corporate/shareholder/retail level.
    2.b. Tax processed foods more – like Twinkies, either at the shareholder, corporate, or retail level. 3. Make physical education (PE) in school more effective. There was a study a few years ago stating that in PE, the kids, on average, only “exercise” for like 5-10 minutes. When I say “exercise”, I’m not referring to feverishly hiding that sweat pant hard-on. A real PE should involve running for at least 2-40 minutes about 3-5 times a week. Extend the school year as well. 4. Perhaps implement an idli-dosai/saambar mid-day meal scheme, since this is very healthy foods.

    I can’t think of other things. What do you think?

  42. Perhaps implement an idli-dosai/saambar mid-day meal scheme, since this is very healthy foods.

    What’s healthy about white rice?

    I remember back in my day, PE class was a hardcore workout. We had to run 1 mile daily, and that was just “warm up”. What happened?

  43. I can’t think of other things. What do you think?

    I am more for lifetsyle change. Here are some useful habits.

    A broccoli floret a day.

    An avacado a day

    A spoon of sesame oil (Idayam nallenna, not the Chinese version) a day.

    One beetroot dish a day

    10 almonds a day

    Just getting one of them a day would work. Plus:

    Avoid heavy dinners, and sleeping right after a meal

    Drink lots of water

  44. Doctors? No doctor has ever forced a test on me. Actually, I’ve had to request more tests.

    I am young and healthy, but I have cush insurance so hey, why not. An x-ray for a bruise? Eh, sure, I’ve never had an x-ray besides at the dentist, so it can’t hurt. Oh, and how about a biopsy of some kind, just to make sure my cells are in order. Oh, you need what for that? Would a fingernail work? Now, while we’re at it, I have this tiny mark on my arm. I don’t care if you don’t see it. I do. I know, it’s nothing compared to the door ding on my car, but getting this fixed is free and that’s not. Oh, what’s that? You prescribe drugs too? Hm, can I have some antimalarial meds incase I wake up in India tomorrow? And… are there any prescription allergy meds I can stock up on? I’m allergic to the cold virus.

    I can only imagine if I were an overweight smoking alcoholic with bad hygeine and diet and poor knowledge of nutrition living in a dangerous area and driving recklessly. Where’s the procedural shopping list? Let’s test that safety net.

  45. putting a finger on the scale against taking medicine amounts to nothing more than the BS of traditionalist and/or leftist anti-science know-nothings,

    rob, you are just throwing around names (leftist, blah blah etc). Let us stick to the issue.k? The fact is, the human body is a relatively strong self healing system. You can read books by MD’s who have done proper scientific medicine (John Sarno, Andrew Weil are some big names in Mind-body, Integrative healing respectively). These are the “modern day” scientists who are repeating a lot of carried down wisdom of the past. Unsustainable technology (without thorough research) is what led to: Lead use for antiknock in gasoline engines, Asbestos – the wonder roofing and insulation material. I never said technology is bad, the point is a) you dont know how to argue intelligently or b) you have met too many “leftist” people that now you instant start categorizing people. once you get off categorizing people instantly, let me know – i may come back to the discussion. I know sepia has a lot of those people, which is why I visit this site only on rare occasion – i came here to read about the Vienna attacks issue, but got sidetracked.

  46. @rob; I wanted to add that notwithstanding my advocacy of alternative medicine/healing, I am a practical person. Disclosure: Long GSK, HEB, BMY, NVAX (hedged) (speculative long) VPHM, PPHM, GNBT. Geez that’s an awful strong faith in modern medicines and even futuristic stuff (nvax). Go figure.

  47. 37 · Rupa on June 1, 2009 09:14 PM · I’m a 2nd year resident in a surgical subspecialty so I wanted to weigh in some things. First, can we ask who these costly tests and treatments are being ordered for? Are they for the healthy 55 year old who watched her weight, diet-controlled her diabetes and exercises her joints everyday? NO WAY. They’re for chronically ill end-of-lifers. And the ugly truth is many of these chronic illnesses (coronary artery disease requiring 4 vessel coronary artery bypass graft, end-stage renal failure secondary to diabetes requiring dialysis, diabetic retinopathy, chronic osteomyelitis from diabetic foot ulcers requiring perpetual antibiotics, cirrhosis related to Hepatitis C and/or alcohol, hemorrhagic stroke resulting in paralysis from your uncontrolled hypertension) could have been prevented with ongoing care and preventive medicine.

    I agree with the waste that this strategy has done for us all. I appreciate how you are shedding light on the other areas of inefficiency/waste that is adversely impacting our health care system.

    RUPA: Isn’t there some stat that 50% of Medicare dollars is utilized in the last 2 months of life? Can you imagine what that money could do had it been spent on preventive care and education of patients? But that will never happen…for 2 reasons: 1) Preventive care isn’t hot and sexy!!! People want to hear about their tax dollars going towards stem cell research and exciting new surgical advancements, not towards teaching adults that fast food is bad for you!! (Because well…DUH. A lot of preventive medicine is just common sense. Exercise=good. McDonalds=bad…and yet, so many chronic illnesses (diabetes, HTN, osteoarthritis, cardiovascular disease) are related to the pandemic of obesity.

    BOSTON_MAHESH: If you are this strident and passionate about preventive care medicine, then why aren’t you a nutritionist or personal trainer? Obviously there is some other motivational factor that has made you an aspiring MD VS being a nutritionist/trainer.

    RUPA: 2) It’s unappealing because the burden of healthcare then falls to the PATIENT, not to the physician. If our government organized a symptom (like the private insurance my hospital has purchased for its employees) where citizens could receive lowered-cost healthcare coverage IF they could show blood pressure control, a normal cholesterol panel, a balanced diet, and aerobic exercise 20 min/day 5d/week, how many people do you think would be eligible for such a thing? And for as much as this seems like common sense, its not. The truth of the matter is nobody likes to blame themselves…just think about it, some 60 year old grandfather suffers a major stroke, now has the R side of his body paralyzed, can’t talk and has to be fed with a G-tube because he can’t chew his food anymore. How can you tell him that it was his obesity that led to his hypertension, and if he would have taken his bp pills he wouldn’t have had a stroke, so..yeah, dude, welcome to your new room at the nursing room ps it’s all your own fault.

    BOSTON_MAHESH: I agree with some of this. After all, much of our health is inherited from our families. It’s not so much the Brahmin’s fault for having a heart-attack at 40 in spite of living a smoke-free, vegetarian, yoga-full lifestyle of prayer and meditation. It’s her/his genetics.

    RUPA: Additionally there’s no shortage of doctors. There’s a shortage of primary care docs…y’know, family practitioners, general internal medicine doctors, that type of thing. To be honest (I’m sure I’ll catch a lot of flak for this) the return’s not that good. You worked your ass off in college majoring in biomedical engineering while your friends majored in philosophy and econ. You then proceeded to sweat through 4 years of medical school (while your friends went to law school/did ibanking and laughed at you, while you would emerge from under a rock every 3-4 months after some set of exams to come get wasted with them), 3-9 years of residency, depending on what you’re going into, COUNTLESS board exams (general medical and then in your subspecialty), then 2-4 years of a fellowship. Nobody becomes a doctor to get rich (like HELLO don’t you think I would have gone to business school?)

    BOSTON_MAHESH: You must be kidding that there is no shortage of doctors. We are PULLING in MDs from India, and don’t tell us here on SM that there is MORE OF A NEED for MDs in India than in America. We are pulling and hustling MDs from India, and they need their MDs more than we do. This is how acute our MD shortage is.

    RUPA: but to be honest after spending at the VERY least 7 and at most >15 years of your life AFTER college getting paid peanuts, working “80″ hours (which…HA. HA. Dream on.) a week, being $200,000-$300,000 in debt by the time it’s all said and done (oh and if you’re a woman putting off your child-bearing til you’re “done with training” so now you’re 35 and your kid’s at increased risk for Down’s Syndrome – SUPER), you’re kind of ready for a little bit of a pay-off at the end.

    BOSTON_MAHESH: Of course people are doing it for the money and prestige (or prestige and money, in that order). The other aspects are tertiary reasons like challenge, stability of job, marriage prospects (after all, desi MD men have hot trophy wives all the time), altruism. Without a doubt money is a HUGE reason. Why would Indians from India come to America after all, when their debt levels are very smaller when compared to us? Moreover, there are MORE people to serve in India, so this rules out the altruism aspect of things.

    Also, I think as far as preventive medicine not being glamorous to taxpayers, it’s also less and less appealing to doctors…I mean, most people are drawn to the exciting cool stuff (there is TONS of cool stuff) about medicine, like cutting edge procedures and more advanced, exciting surgeries. The answer might be to hire more nurse practitioners, who can write Rx, and usually work with a doc to deal with straightforward primary care type stuff.

    Anywho, that’s just my 2 cents! Carry on.

  48. 37 · Rupa on June 1, 2009 09:14 PM · I’m a 2nd year resident in a surgical subspecialty so I wanted to weigh in some things. First, can we ask who these costly tests and treatments are being ordered for? Are they for the healthy 55 year old who watched her weight, diet-controlled her diabetes and exercises her joints everyday? NO WAY. They’re for chronically ill end-of-lifers. And the ugly truth is many of these chronic illnesses (coronary artery disease requiring 4 vessel coronary artery bypass graft, end-stage renal failure secondary to diabetes requiring dialysis, diabetic retinopathy, chronic osteomyelitis from diabetic foot ulcers requiring perpetual antibiotics, cirrhosis related to Hepatitis C and/or alcohol, hemorrhagic stroke resulting in paralysis from your uncontrolled hypertension) could have been prevented with ongoing care and preventive medicine.

    BOSTON_MAHESH: I agree with the waste that this strategy has done for us all. I appreciate how you are shedding light on the other areas of inefficiency/waste that is adversely impacting our health care system. Moreover, a problem this big has many reasons for being this bad, and it’s not simply the outcome of having too few doctors.

    RUPA: Isn’t there some stat that 50% of Medicare dollars is utilized in the last 2 months of life? Can you imagine what that money could do had it been spent on preventive care and education of patients? But that will never happen…for 2 reasons: 1) Preventive care isn’t hot and sexy!!! People want to hear about their tax dollars going towards stem cell research and exciting new surgical advancements, not towards teaching adults that fast food is bad for you!! (Because well…DUH. A lot of preventive medicine is just common sense. Exercise=good. McDonalds=bad…and yet, so many chronic illnesses (diabetes, HTN, osteoarthritis, cardiovascular disease) are related to the pandemic of obesity.

    BOSTON_MAHESH: If you are this strident and passionate about preventive care medicine, then why aren’t you a nutritionist or personal trainer? Obviously there is some other motivational factor that has made you an aspiring MD VS being a nutritionist/trainer.

    RUPA: 2) It’s unappealing because the burden of healthcare then falls to the PATIENT, not to the physician. If our government organized a symptom (like the private insurance my hospital has purchased for its employees) where citizens could receive lowered-cost healthcare coverage IF they could show blood pressure control, a normal cholesterol panel, a balanced diet, and aerobic exercise 20 min/day 5d/week, how many people do you think would be eligible for such a thing? And for as much as this seems like common sense, its not. The truth of the matter is nobody likes to blame themselves…just think about it, some 60 year old grandfather suffers a major stroke, now has the R side of his body paralyzed, can’t talk and has to be fed with a G-tube because he can’t chew his food anymore. How can you tell him that it was his obesity that led to his hypertension, and if he would have taken his bp pills he wouldn’t have had a stroke, so..yeah, dude, welcome to your new room at the nursing room ps it’s all your own fault.

    BOSTON_MAHESH: I agree with some of this. After all, much of our health is inherited from our families. It’s not so much the Brahmin’s fault for having a heart-attack at 40 in spite of living a smoke-free, vegetarian, yoga-full lifestyle of prayer and meditation. It’s her/his genetics.

    RUPA: Additionally there’s no shortage of doctors. There’s a shortage of primary care docs…y’know, family practitioners, general internal medicine doctors, that type of thing. To be honest (I’m sure I’ll catch a lot of flak for this) the return’s not that good. You worked your ass off in college majoring in biomedical engineering while your friends majored in philosophy and econ. You then proceeded to sweat through 4 years of medical school (while your friends went to law school/did ibanking and laughed at you, while you would emerge from under a rock every 3-4 months after some set of exams to come get wasted with them), 3-9 years of residency, depending on what you’re going into, COUNTLESS board exams (general medical and then in your subspecialty), then 2-4 years of a fellowship. Nobody becomes a doctor to get rich (like HELLO don’t you think I would have gone to business school?)

    BOSTON_MAHESH: You must be kidding that there is no shortage of doctors. We are PULLING in MDs from India, and don’t tell us here on SM that there is MORE OF A NEED for MDs in India than in America. We are pulling and hustling MDs from India, and they need their MDs more than we do. This is how acute our MD shortage is.

    RUPA: but to be honest after spending at the VERY least 7 and at most >15 years of your life AFTER college getting paid peanuts, working “80″ hours (which…HA. HA. Dream on.) a week, being $200,000-$300,000 in debt by the time it’s all said and done (oh and if you’re a woman putting off your child-bearing til you’re “done with training” so now you’re 35 and your kid’s at increased risk for Down’s Syndrome – SUPER), you’re kind of ready for a little bit of a pay-off at the end.

    BOSTON_MAHESH: Of course people are doing it for the money and prestige (or prestige and money, in that order). The other aspects are tertiary reasons like challenge, stability of job, marriage prospects (after all, desi MD men have hot trophy wives all the time), altruism. Without a doubt money is a HUGE reason. Why would Indians from India come to America after all, when their debt levels are very smaller when compared to us? Moreover, there are MORE people to serve in India, so this rules out the altruism aspect of things. After all, if it were about altruism, then why don’t YOU go and serve all the lepers of India, instead of some Christian missionary group, if you’re goal was to alleviate suffering in the world?

    RUPA: Also, I think as far as preventive medicine not being glamorous to taxpayers, it’s also less and less appealing to doctors…I mean, most people are drawn to the exciting cool stuff (there is TONS of cool stuff) about medicine, like cutting edge procedures and more advanced, exciting surgeries. The answer might be to hire more nurse practitioners, who can write Rx, and usually work with a doc to deal with straightforward primary care type stuff.

    BOSTON_MAHESH: Good point.

  49. If we want to talk about this specific article and McAllen TX-the answer is quite clear-Physician owned hospitals will ALWAYS drive up medical costs and CON (certificate of need) states will ALWAYS have lower costs for medical care. If a doctor has a personal financial stake in a hospital that he has the ability to admit patients to there is a conflict of interest-period. The history of Renaissance is pretty fascinating, how it was founded by a man that runs the place like the mafia and how he single handily was able to almost shut down the for-profit competitor hospital in town. Abhi thank you for posting this and bringing this issue to light to a larger group of people. I lived this issue daily when I lived in TX and it is nice to know it is getting more global coverage.