Health care and education are IMO the next two major car wrecks coming for America. Both are like patients with similar symptoms (indicative of the general disease of America.)
- They treat the customers like replaceable widgets
- Costs are spiraling out of control. ($2-3000/day hospital, $3.4 TRILLION in total health spending [this equals the entire federal budget])
- Doctors / teachers often don't seem to communicate / care. (Friend's mother was recently in hospital, multiple doctors thru a single day, each one had to completely relearn what was going on.)
- The infrastructure systems are counter motivated (hospitals, drug companies, ect.. are profit not care motivated corps w/ "high" administrative overhead, schools are often public, yet view students as revenue and spend large amounts on noneducational costs to attract "talent". [$500k-$1.5M admin salaries])
No wonder many just want to self educate these days, and their health would be about as well served going to a shaman who cared about them.
It’s not relearning but making sure you get the facts from a primary source.
The ICU motto is ‘trust no bastard’ - if you rely on what is written down without asking the patient directly, can you be sure that it is correct? I have personally come across many instances where what has been recorded is inaccurate or misses important details that careful questioning elicits.
I will always take my own history from a patient, but I use the previous records as corroborating records - I know what the general gist has been, but what might they have missed/what might the patient have told them?
It is a critical part of good patient care, despite its inefficiencies
Can confirm that basic details frequently get misrecorded (here in Toronto). At a recent visit, the surgical staff received such a broken telephone version of my original reports and activity in the hospital, that when I overheard the surgeon discussing with the students prior to the procedure I literally burst out laughing (despite having an appendicitis waiting to be removed).
This is just how records like this work, frequently contextually or globally incorrect, I don't think it's really a matter of malpractice, at least not in relative terms; though I guess they could do better, like recording that staff had witnessed me collapse (!) two times (one in the waiting room, one in the halls) before they left me sitting in some random chair in a hallway for a couple hours, during which time I passed out a third time, scaring the bejesus out of the others waiting there, none of whom were patients.
Hospitals aren't really all that great at paying attention anywhere, as far as I can tell; the U.S. has the most discerning customers (and to some extent, some of the last remaining customers in the developed world). In the U.S. you might have some hope of complaining about service like I received, for example how the triage nurse spilled what looked like about 200ml of my blood all over my arm and the floor while drawing a sample at intake, or that when somebody finally called me to the the first room, she didn't even wait for me to get to the locked door (which I failed to do, because I collapsed half way there and needed to be wheeled in, mostly helped by random bystanders) before turning and walking back to sit down behind the desk (not at the desk), where I saw her playing on her phone.
I was at the hospital with a kidney infection last month. I get these regularly. I knew it was a kidney infection. I described my symptoms and the intake nurse agreed it sounded like a kidney infection. I told them my heart rate was faster than normal-- it's usually at 73, but it was now at 100. They took my vitals, which showed a fast heart rate (110) but I watched the nurse record a normal heart rate. Okay, whatever, maybe they think I'm anxious.
They take my urine, and three hours later they tell me my urine sample was "pristine". They were amazed at how clean it looked. Not even a single protein-- and as a female with a vagina that often discharges a proteinous substance, this was surprising! (And very good news! Doctor was astounded). The doctor concluded my kidney pain was "mechanical", that the muscle in that area had been bruised somehow I told her this was not the case, but she discharged me.
16 hours later (at home now) I'm running a fever of 104. My resting heart rate is an astounding 132 bpm. I'm scared of sepsis (infection of the blood) since I have experienced that before from kidney infections. I go to the hospital preparing for another 5 hour waiting time, but luckily they get me in an intake bed right away. I'm covering myself with a heavy blanket in my fever state-- something one shouldn't do, but nobody took it off me until I was about to be discharged. They come back with the results from another urine sample, and surprise, I have a kidney infection! I asked the doctor why my urine was "pristine" the day before and he said, "the lab tech probably didn't keep the dip stick in long enough" (which is why the test didn't register any protein in my urine whatsoever...) He acted like it was no big deal, like it happened all the time. They gave me 1/4 dose of morphine for the headache because I "look to be about 100 pounds" (I'm 5'10". That would put me at a BMI of 14.5-- ie. severely underweight, and cause for medical concern in and of itself! I'm 135 pounds, with a BMI of 19.4 Honestly, what the hell.) which doesn't help the pain at all, and I'm still wrapped in what amounts to a sweat lodge-- once again, nobody told me to take the blanket off. This is very common knowledge, but in my state of high fever and pain I did not think that it could be a bad idea. I would expect the doctors and nurses to be aware.
An hour later they suddenly tell me to get out of bed and they will move me to the waiting room with a chair and a goddamn television that I can already hear thumping through the walls, because this is an intake bed and "other patients need it". I'm sure they do, but I literally can't walk right now.
Long story short, the next time I get a kidney infection I'm staying home to die. The lack of care in that situation was astounding. To top it off, they treated me like a bad patient after I protested being moved to the waiting room.
edit: I also forgot to mention that they were going to give me pill antibiotics at discharge. I suggested they give me an IV instead, and set me up at an IV clinic. I'm not kidding, they said, "oh! That's actually a great idea". Ahhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
Yeah, despite this being the first serious thing requiring medical attention in my life, I knew it was appendicitis from literally the moment I felt it; it just took them seven hours to first, listen, and second, confirm the diagnosis. They spent hours sending me to tests that were ultimately pointless and inconclusive. Then when I collapsed spontaneously and went into a cold sweat for the third time since arriving, the people dealing with me seemed genuinely surprised that I had collapsed and went into a cold sweat!
They sent me home with like... "16 hours worth" of ultra-low-dose hydromorphone (I couldn't find any dosing guidelines which even reference 1mg tablets) and left me to choose which hours of pain I wanted them for; I missed my followup because the front desk folks couldn't send me where the surgeon's note said I should go.
The best part was the ambulance ride, which only cost me fifty bucks and was conducted excellently; the surgery itself also went well, as far as I can tell, though for an appendectomy that's nothing to write home about (not to downplay the work involved, but like flying in airplanes, it has become routine).
Likely not a coincidence, the ambulance ride is the one thing I had choice in as a patient, and the one thing I paid for out of pocket (although non-emergency rides somewhat subsidize emergency ones, by policy).
Do you know why she had a clean urine sample? Mistakes happen, but my experience as a whole in the hospital that night lends emphasis to the mistake. It is not just that the infection was missed accidentally, it was that the management of my diagnosis and my stay seemed so ill-informed and counter-intuitive to my needs.
She had been drinking a lot of cranberry juice -- the folk remedy for a UTI. That may have had something to do with her clean sample, though this is just speculation. Most of the times that she's had these infections, her samples have had detectable bacteria, so this was an unusual case even for her.
BTW, she had so many of these infections that her doctor eventually referred her to a urologist, who put her on a daily antibiotic (cephalexin, aka Keflex) as a preventative. She hasn't had another once since starting that, though there have been a couple of times that she felt like she might be getting one, and took an extra cephalexin, which was sufficient. I wish we had known about this option sooner.
Also: my pointing out that UTIs can sometimes fail to show up in the urine test was not intended as a defense of the way the hospital treated you. Quite the contrary: doctors should know that that can happen. My wife and I were not happy with the way she was treated on this occasion as well — it took hours to convince them to start the antibiotics, and she was in a lot of pain.
The cranberry juice thing is inconclusive, but I still drink a lot of it as well!
>Quite the contrary: doctors should know that that can happen.
Okay, thanks for clarifying. This is how I felt. It was silly to me that I could have all the symptoms of a UTI, only to have everything written off because of a clean urine sample. I think it was hopeful thinking on the doctor's part-- she just wanted me out of the bed so she could clear the waiting room.
How recurrent were your wife's UTIs, if you don't mind?
In fairness, I guess it really doesn't happen very often — the ER doc in my wife's situation commented that she had never seen it before. On the other hand, pulled muscles don't cause fever. I understand a little bit of reluctance to offer antibiotics, as they have been overused, but geez, you have a patient with a fever and in terrible pain, indeed with all the other symptoms of a kidney infection, what's really the downside to going ahead and starting the antibiotic to see what happens? That's how I see it, anyway; I'm not a doctor.
I think the best thing is to do another urine test. I'm also wary about antibiotics, but it doesn't hurt to keep the patient around for another hour or two to get a fresh sample and test it. But, the doctor assured me it was just a mechanical issue ¯\_(ツ)_/¯
This is from memory, but it seemed like there was the better part of a year when it wouldn't be more than two or three weeks after she was over one that she'd get another one.
Really, she should have been referred to the urologist a lot sooner.
That must have been hard, it's good she's on regular antibiotics now. Mine seem to be occurring once a year, almost to the day.
I had issues with bedwetting as a child and into my late teens. I went to sleep specialists, urologists, and psychologists but nobody could say anything about it. I think it's somehow related to what I've been experiencing lately but I don't know what to do about it. I was always getting infections as a kid too (ears, eyes, bladder, kidney) but not really flu or colds (despite not being vaccinated). Has your wife experienced any of these things in her youth?
This is a perfect example of the problem with uneducated opinions about healthcare. Everybody has them, has never even tried to confirm their assumptions with a doctor and will continue to propose all sorts of fixes (see sibling comments) that make zero practical sense and will actually drastically reduce the quality of care.
My SO is a doctor, even here in Europe there are many flaws, but what I have learned over the years is that this system is way, way more complex and effective than people think. If you want to improve it, great! Step one: go talk to a doctor about your ideas. If you haven't done that, don't spread your unfounded assumptions, it only leads to more demonization of staff and systems and doesn't help anybody.
Well, that's because the underlying approach needs an improvement. As an example, imagine that every doctor-patient communication is recorded with a camera. Now all you need to do to get facts from a primary source is to watch a video with another doctor talking to a patient. I'm not saying that this is the solution, but options do exist and they are worth exploration.
Say you're a gastroenterologist and in the video, your patient was interviewed by a pathologist. The pathologist would ask pathologist questions, but you need to know gastroenterologist answers. How do you get them from the video of a pathologist asking pathologist questions?
In this case gastroenterologist goes to a patient and asks questions he is interested in. The point is that a patient doesn't have to tell the same story over and over again. The problem is that gastroenterologist would now have to have its own video, which would probably be time-consuming for the third doc.
Patients report higher satisfaction with their medical care the longer that they spend engaging with clinicians. Even if this was a practical solution, by deploying cameras and ensuring that the resulting files were accessible and categorised simply and easily (no easy IT solution!) it doesn't change the fact that by reducing the amount of time a doctor (any doctor) spends with patients is going to worsen their outocmes, even if they are self-reported. Anyway, we already spend far too much time not with patients. And how is this any different from reading a 'transcript' of the last interaction a patient had with a Doctor
> Patients report higher satisfaction with their medical care the longer that they spend engaging with clinicians.
Agreed. But that is because doctors are not easily accessible. You can't simply call doctor's cell phone or text him a message. Instead, you call the office, leave a message and wait for God knows how long. Some doctors do not even bother to call you back if they're not in the office.
> And how is this any different from reading a 'transcript' of the last interaction a patient had with a Doctor
You don't want to cancel the transcript-based approach. I was talking about improving existing processes, not replacing them altogether. Knowing that you're being recorded makes you more responsible for every note you take, it improves the kind of information doctors write down.
I'm sure you are aware that there are a ton of things to improve in the healthcare industry. It's just a matter of wise execution, which is the most complicated part.
> And how is this any different from reading a 'transcript' of the last interaction a patient had with a Doctor
watching body language, pauses, etc vs just reading can give different information. and multiple people reviewing that over a spell will yield different/new/conflicting insights. but it's different than reading a transcript.
> Friend's mother was recently in hospital, multiple doctors thru a single day, each one had to completely relearn what was going on.
What's the alternative? 24 hour shifts for the doctor and the new doctor each day needs to relearn everything?
Having to relearn everything might be a problem, depending on what it actually means, but as long as we want a normal human being as a doctor, they will cycle over time as people start and end shifts, and they will need to learn what happened before their shift started (and they may receive patients from multiple doctors leaving over their shift, making 1-on-1 hand-off infeasible).
It's easy to call this out as a problem, the question is what's the alternative that's better?
In addition to this, many doctors want to re-take the history from the patients and re-examine them for themselves, rather than rely on a brief handover or potentially sub-optimal notes from another doctor. Clinical signs can be subtle, as can points in a patient's history that may point to a diagnosis. I see patients often frustrated at being asked the same questions by each doctor they see, but most of the time this is in their best interest.
I try to preempt the frustration by saying that we each take our own history for the purpose of making sure no details are missed, but rest assured, I’ve gotten the overview from your other docs. I then make sure to complete a sentence for them once in a while, to evidence that that is the case.
A good percentage still get frustrated. Can’t be helped. Patients reshape their narrative, remember new details, just plain open up more to some docs, etc. the repeated history taking really pays off in improving patient care.
Where I find patients get most frustrated is when docs come in for a specific job, and patients don’t have the health literacy to understand what that is or is not. “Doc, can I go home today?”
“ I’m just the consulting cardio here to check out your heart for your primary doc, Doc McStuffins, I have no say in that at all, you need to ask McStuffins.”
“Oh. But when do you think I can go home?”
There’s no good response to that. No one wants to cough up cash to pay for health professionals time to repeat themselves all day long. But the patient that’s asking? They want that answer. They don’t -feel- like they’re asking an inappropriate or stupid question.
I think this hits the nail on the head. There is a huge information gradient between most patients and the doctor and perfectly bridging that gap takes more [time|money] than any system is willing to support.
I think about this when it comes to providing a patient with "informed consent" for a particular treatment/operation. What does "informed" really mean in this case? A brief overview of the main risks and a couple of statistics? Or a thorough understanding of the pathophysiology of the disease and the trial data supporting the therapy? How long is a piece of string?
It's tough, and I get that. I also know that as a person with neurological trauma that makes speech difficult at best, having to recall what amounts now to 50+ pages of chart every 4 hours is... BS. You might as well be telling someone with a broken ankle to run up and down a flight of stairs every so often while they try to recover.
There is also an argument that, unless there is some sort of ongoing peer review (they did this during my Oncological Adventure(tm)), you're increasing the number of moving parts, and thus the chances of a breakdown. Charting errors are a significant source of medical mistakes.
The problem as I see it is not the intent of the procedure, it's the while (1) do x; mentality. There should be some "ifs" and mitigating functions instead of a hardcoded 1
Most patients get admitted under a DRG, which is a lump sum payment. It’s true that doesn’t apply to every patient, but enough of them that doctors habits aren’t going to be shaped by the minority.
For that matter, you can come in and see a patient without asking the same history as the guy before you, if you’re just checking a box for a billing.
And this certainly isn't the case in the NHS in the UK where doctors have no financial incentives interfering with their clinical decisions (barring saving the service money). What you describe is a pitfall of private medicine.
> And this certainly isn't the case in the NHS in the UK where doctors have no financial incentives interfering with their clinical decisions (barring saving the service money)
This meme really needs to die. The NHS has massive financial incentives that impact clinical decisions. In fact, you literally go on to mention as such in your next sentence.
It turns out that having an incentive to "save the system money" results in a different set of clinical decisions. And no, those don't always work out in favor of the patient. (They're particularly problematic for the patient in cases of long-term care, which is why the NHS does rather badly on complicated and chronic conditions like treating cancer compared to the US and other countries).
> which is why the NHS does rather badly on complicated and chronic conditions like treating cancer compared to the US and other countries).
It might be true that the NHS has poorer outcomes but I doubt that this is necessarily the cause. I live in Norway and have considerable recent first hand experience of the health system. I'm confident that they have incentives to save money too. In fact my wife's cancer nurse when explaining why there was a delay in starting the day's treatment said that preparations like Avastin would not be ordered from the pharmacy until the patient was both present and prepared for treatment because they could not afford to throw it away when the patient didn't turn up or turned out to be too ill for chemotherapy.
It is broadly speaking the same idea as the UK NHS but apparently has better outcomes for diseases like cancer. There are fees to pay, similar to an insurance excess or what the US calls co-pay; but those fees are affordable and capped to a couple of hundred pounds a year.
This meme really needs to die. The NHS has massive financial incentives that impact clinical decisions.
Not to mention that many if not most NHS-employed doctors run private practices on the side. Some only spend a day or two a week on their NHS duties. Others such as GPs are NHS-branded, but every GP practice is a private business that bills the NHS for time and materials.
In a discussion of NHS vs private practice, the fact that some (certainly not most) NHS-employed doctors also do private work, has no baring on the incentives placed upon them within their NHS employment.
I am certainly not saying the NHS system is perfect, and all private medicine is bad, so if that is the impression you got then perhaps I was unclear.
In almost every single clinical situations within an NHS hospital that I have seen or can think of, the clinicians treating you will not receive any extra money, bonus, promotion, etc. for the treatment they provide you or do not provide you.
I have lived in countries with more private systems, where there is a direct relationship between what treatment/investigations you receive and what money ends up in the doctors pocket. For example, a private doctor in HK referring for not-strictly-necessary-but-ultimatelhy-clinically-justifiable MRI scans at a private MRI clinic which, provides a percentage of the (expensive) scanning fee back to the referring clinician. Contrast that in the NHS, no one gets given money for sending a patient for an MRI scan, and in fact, if it isn't going to change the management of the patient, the request is likely to be refused to constrain resources. In the HK system, neither the doctor nor the MRI provider is incentivised to not do the scan, quite the opposite.
The NHS system is not perfect, but pointing out different the pros and cons of different incentivisation structures that do have an impact on patients is not something that is a "meme that needs to die"…
The NHS does worse in treating cancer than other countries, but many of those countries (Germany, France, etc) have public health care also. It's not clear that the difference in performance is because of public, vs privately, funded medicine.
> The NHS does worse in treating cancer than other countries, but many of those countries (Germany, France, etc) have public health care also. It's not clear that the difference in performance is because of public, vs privately, funded medicine.
Right, I'm saying that the difference isn't simply a matter of private vs. public funds, the way OP claims. You can really trivially create a private system that has the same bad incentives with respect to costs and care as the NHS does. You can also trivially create a public system that has the same bad incentives with respect to costs and care as the US does.
That said, Germany and France aren't really publicly-funded as well the way people think. Both rely on a private network for care delivery (unlike the NHS), so it's a bit of a stretch to say that they're "public health care" systems. Even if you're looking at funding, in those two countries, taxpayer funds only cover 75% and 70% of expenses, respectively.
We can start by treating this as an important problem and tasking ourselves with looking for and finding alternatives and putting political/financial pressure on these institutions to consider them.
Just asking "but what are the alternatives" isn't productive in itself, and doesn't really carry the conversation forward. It more likely shuts it down as a hopeless problem. We can do better. It's not hopeless and we're not powerless as a collective.
I'm sure there are alternatives but we're not looking for them very well. We could start there. I'm doing my part by bringing this up in conversation whenever it's relevant and getting to know my state representative and state senator. I also make noise towards the hospital's admins in the meanwhile.
---------------
Also, the article discusses possible alternatives. Here are a couple of paragraphs from it:
"This begins with our own training. Certainly doctors must understand disease, but medical education is overly skewed toward the biomedical sciences and minutiae about esoteric and rare disease processes. Doctors also need time to engage with the humanities, because they are the gateway to the human experience."
"To restore balance between the art and the science of medicine, we should curtail initial coursework in topics like genetics, developmental biology and biochemistry, making room for training in communication, interpersonal dynamics and leadership."
So I took my dad to the hospital a couple times in his last year or so, and I think the main thing every patient needs but doesn’t necessarily have is someone to do the top-level coordination. There might be a surgeon and a hospitalist and a cardiologist and a neurologist and whoever, but no one is actually in charge. Most hospitalized patients mentally check out—humans don’t do well in captivity—so unless you have a family member advocating for you, you’re kind of fucked. Doctors come and go, but none of them take responsibility for the patient’s overall well-being.
It doesn’t require 24-hour shifts or even a medical degree to do this kind of coordination. I did it and I have no medical training whatsoever. But it was pretty important work, and my dad would have been lost without it.
Methodologies such as Kepner-Tregoe explicitly make handovers very easy, used very effectively in manufacturing, energy, and other industries. But God forbid that almighty doctors should ever take any advice from outside their profession.
My spouse is an MD and she spends a minimum of 45 minutes before her shift reviewing her patients' charts. After work, at home she tidies up patient notes to ensure the next person gets an efficient summary of the patient. Then after dinner she's answering a bunch of instant messages from patients on the hospital's patient portal and doing any prep necessary for the next day.
Programmers would be collectively rending our garments if we had to do anywhere near the amount of unpaid / off-the-clock work as doctors do.
This was the desired behavior. Its not that they reviewed existing info to check for changes, its that they knew nothing. Like the last 30 minutes of questions and chart didn't exist. On the side of the patient, this does not inspire confidence. It projects a sense of confusion and disorganization.
Twenty years ago when I did tech support for a living, I had a series of questions worded in very specific ways I would ask at the start of a call. Sometimes the content of the answer was the useful part of the response, sometimes how the answer was said.
More often than not, if I got someone on the other line that seemed to know a bit, skipping the questions ended up being counterproductive, as I would assume some knowledge about a specific item from the other end that didn't exist (but other knowledge did). I learned to trust the process, and glean the extra bits of information that weren't what the other side was trying to convey, but did nonetheless.
I think it's a mistake to assume that just because the doctor asks you questions and doesn't always seem to take into account a prior answer the doctor is not listing. I think it's more likely that they have learned that the small percentage of time that asking similar questions in different ways has led to new, important information has led them to be careful and methodical, even at the expense of patients thinking they aren't listening.
When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other.
His very countenance rippled like the sea, and the sound of my own voice came back to me, distorted. ... it was how I affected his sounds and how she affected mine that transmitted the message. - SMAC
I don't disagree with what I interpret as the intent of your message - that there is real value in process, question repetition, and not jumping to conclusions.
I do think it implies a false choice at the end though. A doctor can imply they care / listen / are familiar with your case, while still asking insightful questions and probing for relevant changes.
[Analogy] As there are many engineers here, consider this contracting example: how would most companies respond if, for a project, at each meeting, the contractor sent a new representative, who asked all the same questions as the first meeting, could provide no status updates, and many reps suggested apparently different solutions, platforms, or approaches?
> When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other.
This is an important point but I feel you're approaching it from a very short term view. Look at Pakistan, for example: after the CIA used a vaccination program as cover for a genetic testing scheme meant to find Bin Laden [1], there was (and still is) a significant impact on the Pakistani and other population's trust in their domestic healthcare industry [2]. Even if it was a real Polio vaccination program that saved thousands of lives in a purely utilitarian short term calculation, the damage that distrust causes long term can far outweigh the benefits. Worst of all, due to the nature of that distrust, measuring that damage becomes so much harder.
The point is, doctors don't just need their patients to trust them, but to trust the institution of modern medicine and healthcare as a whole. They need the patients to trust their nurses, pharmacists, specialists, and technicians just as much as the primary doctor. Given how critical patient cooperation/honesty and preventative care are to clinical outcomes, I don't see any convincing evidence that patient perception isn't just as important as the rest of the process.
That does sound rather concerning if that's the case!
As a medical student about to sit my final exams, I have shadowed hundreds of doctors of different grades and specialties in many different hospitals and family practices, and I don't recall ever seeing a doctor not review the notes before seeing a patient. Often here in the UK at least there is a large amount of time pressure and it would certainly be desirable to have more time to review further back, in more detail, etc. but given in general practice there is a 10 minute slot per patient, there are systemic limits on this (that would be nice to address).
On the other side, trying to figure out what is going on with patients is much more complex than catching up on notes and trying to get a "delta" update from them about what has changed in the shortest space of time/words as possible. The number of times I have taken a history from a patient and then less than half an hour later observed them add hugely important extra details that were omitted previously is pretty large. Often, it is far more helpful and illuminating to ask a patient to tell you what has been going on in their own words, even if you think you have read it all in the notes. I have often seen more senior clinicians pick up subtle clues that were missed by more junior clinicians, or ask a pertinent question that was not asked before.
And finally, on a more pragmatic basis, doctors take a lot of risk on board whenever they treat a patient. Patient's get tired of people asking them if they have any allergies for example, but when it's your name on the prescription, and your ability to sleep and your license on the line, you may well decide to ask the patient again rather than rely on what some previous clinician in some previous setting has written down on the patient's file. In a similar vein, a lot of practice is not black and white. If a junior with limited experience writes that a particular clinical sign is positive in the notes, you may well want to repeat that examination to re-assure yourself before you allow it to guide your treatment.
None of this is excusing unpreparedness or poor practice, but hopefully shines a little light on some reasons why it seems like there is so much needless repetition.
You bring up good points and your last is particularly relevant in this case, as the patient arrived with what were termed simple problems, was expelled due to lack of finances, died suddenly a week later apparently due to MRSA contracted at the care facility, and the family is now considering malpractice. Your name on the line is a very real risk.
Unfortunately, I expect this may create a lawyer averse culture where process is as repeatable as possible, because in the event of a suit, systematic process is a solid defense.
To play devil's advocate, patient handoffs are incredibly risky and one of the biggest causes of medical error. Retaking patient history is one of the best ways to reduce that risk.
Think of it like talking to a project's stakeholders yourself rather than relying on requirements gathered by somebody else.
5 minutes lol. From a surgery perspective: Getting a consult as an intern on a patient with a big case file is like (at least) 30 minutes of reading notes, then you talk with the patient, then you talk with your senior, then you and the senior go talk to the patient, then the senior talks to the attending (depending). Sign out (patient hand off) can take a while depending on the size of the list but I don't know any other interns that don't stalk the charts before they are about to come in so it's usually just a quick brief on each patient and what therapies are going on. Did I mention you do sign out (on trauma) after having been at the hospital for 24+ (sometimes 30 depending on attending) hours? Things can and do still get missed.
Part of this can be solved by having better care managers associated with each patient (primary care doctors), who can share relevant information with different parties. Works mainly for chronic care. In the case of acute cases, information needs to be readily accessible in a format that is interpretable by doctors when they go through the process of assessing differential diagnoses. That information is not captured well right now, hence the ask for patient's history with each new physician. Personal health records with smart annotation of key pieces of information can play a part in solving this problem, but are only part of the answer. One of the most dangerous periods in the emergency room is the transition of one care team shift to another. It takes forever, and often leads to key information loss.
I don't really understand is this concern about having to "relearn" everything when doctors change shifts, because that's not how it works. Maybe that's how patients perceive it, but generally before each shift ends, in order to be relieved of your shift, you have to sign your patients out. This is basically an hour long phone call with the next doctor, where you tell them everything that happened for all their patients.
Is there really a need for 24 hour doctor visits most of the time?
No. Doctors can have mostly normal 8-hour workdays, 5 times per week. Nurses administer drugs and monitor the patients. If a problem arise, they can call the doctor in charge of the patient or bring the doctor doing the night —or weekend— shift.
In the last few years I've spent almost a triple number of days in hospitals (not as a patient). I can tell you from first-hand experience that most patients that are hospitalized —except in the ICU— do not need multiple doctor visits per single day. Maybe they need a couple different specialties, but certainly they do not need multiple doctors of the same specialty in the same day or more than a few specialties.
As has been pointed out in many submissions on HN about USA's medical practices, the main reason you get many visits is to inflate your bill. I think someone even wrote that he was charged $600 per 1-minute visit during his stay in the hospital.
The alternative? How about not artificially restricting the number of doctors in the system so the ones in it don't play musical chairs and ones aspiring to don't do 28-hour shifts?
Artificially restricting? Could you elaborate? I was under the impression that the only restriction on the number of doctors is the ability for people to get through med school.
There's a fixed number of seats in medical schools and a fixed number of residency slots. When you add foreign doctors that would like to practice in the US to medical school graduates, there's less residency slots than doctors that would like to take them.
Most residencies are paid for by Medicare. Big hospital systems just can't seem to find the funds to train doctors on their own.
This sounds like first world problems. You have a doctor you trust to go off script? You trust that when your kids' teachers treat them differently they aren't just stereotyping and limiting them? Lucky you. While you work to unshackle your providers from the mediocrity of "best practices" (and I say that as someone for whom "best practices" is a bane in my own work) keep in mind there are a lot of people for whom competent cookie-cutter care is a wish, not a disappointment. In technology we can let a thousand flowers bloom and we all get to choose and enjoy the most beautiful ones, but in education and health care there's no natural elimination of the worst and amplification of the best. Everyone just lives (or dies) with whoever they randomly end up with, so worst-case performance matters just as much as best-case, and average-case matters a whole lot more.
The problem is MBA administrators looking at their little accounting tables and deciding that not letting patients actually see a doctor is their purpose in life, just so they can pay everyone at a hospital as little as possible. This of course leads to global cost blowups and worse care.
Of course, by now there is no turning back, and the government has decided that actually training doctors must be prevented at all costs.
VERY short term vision, constantly sacrificing the future for a quick buck, leads over the span of decades, to spiraling costs and worse outcomes. Who knew ? Well, everybody knew.
I'm talking about teachers with master's degrees and MD doctors, which means many years of education. We've made it standard to have access to these people (unless you have a scratch???) but it's not a panacea. Just got word that my father is seeing the same doctor that has fucked up his care multiple times, not out of creativity or being too smart but because of not guessing the simplest and most common explanation of common symptoms. I'm very angry, but can't convince my father to move out of the home & town I grew up in so he doesn't have to deal with this incompetence.
If you live in a town where smart and educated people like to live, you get the cream of the crop of doctors. It's very different from living in a backwater where ambitious young people aspire not to live. And most of the world lives in backwaters, with unexceptional doctors who make simple but deadly mistakes when they go off script.
To add to this anecdote, I lived in the suburbs of a major city for quite some time. My primary care doctor's practice was in the city at a prestigious hospital.
The care I received at that hospital was a night and day difference compared to what I received in the suburbs.
My favorite experience was the time I was very sick, went to a doctor in the suburbs and was told I was absolutely fine, despite the coughing, difficulty breathing, looking like I was dying, chest pain and X-ray results. I was sent on my way without even a script for antibiotics.
The next day, I went to see my PCP who demanded the names of the doctors responsible for letting a patient with severe pneumonia leave their care without proper treatment. Said if I waited another day, I'd have to be hospitalized.
Maybe at some hospitals but not mine. I have tried scheduling for example sleep apnea tests at my hospital and I have go through a doctor. I had a second one with in a year and they required me to still see a doctor for some reason. No exceptions. You would think a test like this wouldn't require an initial visit, an actual overnight stay and a follow up reading of the results with the doctor but it does.
Was charged $70k for a procedure that should have cost 5k max even with nurses and doctors and materials. I also was under the impression it was covered by my insurance because the front desk said she would call me if it wasn't. I was also given wrong information about what type of treatment I was going to get and when I requested to check with the doctor, I was given the option of "do you want the procedure or am ai going to just cancel it" and if it was cancelled, the next available appointment with the doctor was in 5 months.
I payed just $3k, but that was ridiculous to be surprised by and I'm still confused what the treatment plan is because front desk didn't schedule me until July. The doctor is great but support staff has become so beuracratic...
No, I looked at how much the exact same procedure using the exact same equipment would cost by a doctor in another state who made the pricing relatively transparent.
> Doctors / teachers often don't seem to communicate / care.
You really don't have much contact with teachers if you believe this.
The education system runs in spite of its systemic horribleness precisely because there are enough teachers who do care and fight/ignore the system when necessary.
If you want to actually fix the educational system, we have models for doing so in several different countries. However, they all tend to share the same characteristics.
You have to raise standards for both admission and completion; you test to those standards; you raise salaries to match those standards; and you give respect, autonomy and authority to the people now adhering to those standards.
HOWEVER, that is going to cost money. Quite a lot of money. And, really, nobody is actually interested in doing that in the US. They're really only interested looking like they are concerned rather than actually fixing the problem.
> HOWEVER, that is going to cost money. Quite a lot of money. And, really, nobody is actually interested in doing that in the US.
This seems to imply that the US doesn’t spend enough money on education, even though it is (one of?) the highest spender(s) on education in the world (just from a quick Google search). I believe the real change needed is better management of how the existing money is spent.
There is not some magic bank of "misused" money waiting to be tapped.
The US also has a lot of students who fall into the education assistance category (free breakfasts, lunches) who would fall into a "social safety net" in countries like Sweden and Norway. A lot of the poorest students eat up the largest chunks of funding.
Finally, the Gates Foundation, whom I don't necessarily like, has shown time and again two fundamental things about education attainment:
1) any SUSTAINED focused resource improves educational outcomes
2) resource allocation is strongly sub-linear--it takes FAR more than 10% more resource to cause 10% improvement in outcome from our current system
Not trying to be antagonistic, but aren’t you kind of proving the point? You've shown the US funding for education is good, it’s comparable with other countries that have good education systems, but the results seem to be poorer. (I guess that’s what people are saying but I haven’t verified that myself.) Thus there seems to be inefficiency in how that funding is allocated/used compared to other countries. So increasing funding doesn’t seem necessary. But improving the system that uses that funding through the measures you’ve rightly identified seems... well obvious at this point. (And those points you've identified IMO are key to improving a lot of the broken systems we talk about.)
As anecdata about this misallocation in US education funding: I come from another part of the world (a first world country), and something that I have not, for the life of me, been able to reconcile with the funding arguments is the stupendous sports facilities that most schools have. High schools in the US have sports stadiums bigger than many cities where I come from. If there were a real funding problem in an education system, sports should be the first thing to downsize in order to protect the core mission. But the priorities are just not aligned right for education.
If food for poor kid in Netherlands goes from different fund while in US education funding, then funding inUS should be higher to cover that up.
Also, schools in US are not funded equally and sports have special status in society. You have art teachers paying supplies out of pocket in one district and expensive stadium in another district. You have well funded schools and badly funded schools.
I just worked 10 years at a public state University. The inefficiency, cronyism, and often blatant corruption is staggering. At least with respect to universities, there is some magic bank of "misused" money waiting to be tapped. But it is in no one's interests - not the high paid administrators, not the powerful local real estate developers and other businesses, and not the state and national politicians who generally work out a way to personally benefit from those big expensive projects.
Fun example of inefficiency,
- 2 units at university using same enterprise software package
- I propose consolidating to one license, 1 server, both departments split cost.
- Both department heads agree, both IT depts agree, campus IT agrees
- cancelled last minute
- that was 7 years ago, by now both departments combined (not each) would have saved $250k
1) any SUSTAINED focused resource improves educational outcomes
2) resource allocation is strongly sub-linear--it takes FAR more than 10% more resource to cause 10% improvement in outcome from our current system
I’d like to learn more about these 2 points, particularly the first (how it’s measured, etc). Is there any specific work of the Gates foundation you could point to?
Page 16-17 talks about known effective programs and their costs. Note that the more expensive programs (almost all exceeding $15K per student--sometimes dramatically) are almost always more effective. Under $10K is almost uniformly not helpful and the further you get from 10K the less helpful they get. You can have effective programs for $10K, but it's really hard. Money really does make things easier.
From Page 21: "At the highest level, this “doing many things well” requirement results in a high degree of difficulty and is a key reason why high-quality early learning that sticks is so infrequently seen."
From Page 22: "ESSENTIAL ELEMENTS OF HIGH-QUALITY PRE-K THAT STICKS"
"3. Teachers delivering high-quality instruction is a key differentiator between early learning that sticks and early learning that, more than likely, will not stick. ...
4. All exemplar programs have two adults in the classroom—one lead teacher and one paraprofessional/aide— at all times. ...
5. All exemplar programs have maximum class size of 22 children or fewer and adult-to-child ratios ranging from 2:15 to 2:22. Adult-to-child ratios at the lower end of the range are particularly advantageous for classrooms where a significant number of English language learners (ELLs) are present and/or where a significant number of children with special needs are present.
6. Lead teachers with a B.A. plus suitable early learning credential, paid at same level as K-3 teachers. ...
7. Dosage. Three of the four exemplars offer pre-K that runs 6-6.5 hours/day, for 180-205 days/year. The other (Maryland) offers full-day (6.5 hours/day, 180 days/year) and part-day (3 hours/day, 180 days/year) options. It is clear from the exemplars and consistent with research findings that within high-quality pre-K programs the dosage required is related to the size of the achievement gap that must be closed for each low-income child.
For low-income children who enter pre-K already on a trajectory to be kindergarten-ready, a high-quality part- day option may be sufficient. For most low-income children, at least one year in full-day, high-quality pre-K is needed to be kindergarten-ready.
For low-income children for whom English is not spoken at home, children with special needs, and children who are significantly below age-level competency in one or more domains, it is likely that two years of high- quality, full-day pre-K is ideal and, in fact, may be necessary for most of these children to be kindergarten- ready on time.
"
It goes on to other things as well.
And these exemplars are at the $10K-$12K per student mark, roughly. And even successful ones still can't get funding--"New Jersey was poised to expand the Abbott Pre-K Program in 2013, but budget pressures have delayed that expansion.".
And the Gates foundation is VERY gently suggesting that all the mediocre, non-useful programs should be shut down in preference to spending ALL that money on the most underperforming students. While this is likely the best use of resource, it is going to be a politically unviable one.
The upshot is that teaching properly is expensive, and money really DOES have an impact. And the effectiveness "breakpoint" is somewhere around $12K with some adjustmemts for cost of living. And your primary expense is the teacher vs class size--see page 17. The cost per student with a teacher at BA I qualification ranges from $10K with a 15 student class size to $8K with a 20 student class size. Of course, teaching effectiveness is inversely related to class size--pick your optimization point.
I don't always like the Gates foundation because I think they sometimes helicopter in, muck things up, leave, and then other people have to clean up the mess. However, they have been quite forthright with publishing their information and do acknowledge when they have NOT succeeded even when it goes against their agenda. That I applaud.
The US spends double the OECD average on tertiary education (university, etc), but we're just somewhat above average in spending on primary and secondary education [1].
In the US at least, you can't read too much into the averages, because there are so many additional factors that vary by state and between cities. Some states spend far more per pupil than others, although different states can have very different cost-of-living, so comparing absolute numbers in that case doesn't make much sense.
Even within a state, different areas have very different cost of living, and very different hyper-local conditions like concentrations wealth or poverty, that have a big affect on how far each dollar spent goes.
All I want out of a physician is an expert consultant. I have goals for where I want my health to be, and I could use advice on how to get there that doesn't require me to spend so much time separating the wheat from the chaff of google results. This could be handled over email most of the time. But most doctors I've met don't seem to see themselves in this role. They seem to think their job is to take measurements and tell me how far out of spec I am. Worse yet, most of them believe they are infallible. Its fine if you're making educated guesses doc, just don't act so damn confident about them and dismiss the negative results.
Maybe I've had bad luck in doctors. It's not like I get a choice in them, the way the US system works. Three times in my life I have had severe chronic problems that were ultimately solved by my own inexpert research and experimentation or by the inexpert observations of a casual observer. These days I only bother to go to a doctor after I have a good suspicion of what's wrong already, like if I broke a bone or something.
Much better for each doctor to directly interview patient than to rely on previous histories that may have omitted crucial info or asked questions in a way that led patient to not realize what was being asked.
The underlying problems in these industries are because they are labor intensive. Partly this is due to the difficulty of automating those jobs, and partly it is due to political arrangements that protect incumbents.
Technological innovations that reduce costs will be the most lasting ways to reform these sectors.
Yeah, but when tech innovation becomes the only way out of a shitty situation, you incentivize tech innovation! I guess some smart folk figured out that in order to maintain superpower status at all costs you need to maintain the lead at hard-to-replicate tech-innovation, and paying the cost of this with your people's quality of life, and sometimes with their lives, is worth it. For some people at the top it's a big difference between being at the top of "just some random first world country", and being at the top of "practically the world".
Regular people can change the countries they are living in if they don't like the tradeoffs their government is doing, you know... Or vote to change them, but don't be surprised when improving lives comes at the cost of losing "top dog" status.
(Note: I'm not an American, but I see the tradefoffs the U.S. made, and I understand they make sense to some.)
Consider who and how benefits. The incentive in for-profit medicine in the US is to spend as much time and treatment as possible per patient. If each Doctor has to order the same tests as the patient is passed around - that is efficient from the perspective of maximising profit.
The government is also involved in lots of other things without exploding costs. I’d say the common thread is the combination of these factors: 1) the service is considered essential by consumers and 2) payments are deferred (by insurance or student loans). So consumers never say no due to rising prices.
To be more specific, the US government. Other governments seem to figure this stuff out, from time to time, but there's something about the FPTP, federal/state split or other such details that's sabotaged efforts here.
We should realize that it isn't a fundamental property of government, just the one we have and we have mechanisms for making changes that we haven't yet tried.
The problem in the present US system, is that it's a bad mixture of private and government involvement. We have the negatives from both acting simultaneously.
5% of patients are half of all costs in the US healthcare system; 1% of patients are 22% of the cost. People over the age of 65 are a greater share of cost in the US system than in universal healthcare systems, because the US doesn't have a big lever for rationing care.
The healthiest half, is 3% of the cost in the system.
A market healthcare system, which is widely considered immoral, will drop many of the most expensive and poorest patients from the system. That's how you can dramatically lower costs in the US system, if you want to go the market route. A market system would particularly focus on the 50% that are only 3% of cost, with costs being far higher for everyone else (resulting in lack of access to expensive treatment for many, and many millions of people would get denied healthcare coverage due to pre-existing conditions).
A universal healthcare system smashes costs by rationing care, and tightly controlling everything from drug prices to healthcare worker salaries.
The US today has neither of those approaches widely implemented. We have a lot of government and private healthcare without enough of the tight cost checks. The obvious outcome, is a perpetual cost spiral until it can't spiral anymore (which is about where we're at now).
Specifically, the government's mostly laissez-faire approach to handling both and, for education at least, its inability to prioritize it above other priorities like declaring war on vague concepts (drugs, crime, terrorism, etc)
Gee I wonder why I used the exact phrase organized as non profits.
But hundreds of millions in executive salaries at companies that pay billions in insurance claims isn't the thing driving health care costs. It barely registers.
And further to that point, the admin side of US healthcare costs have massively expanded - similar to what has occured in education - over the last 30 years.
That 25% share, is about double what it is in Canada (although a few are equally high, the Netherlands is at 20%).
Is there one that shows dollar amounts instead of growth?
If a dollar amount chart showed the same effect it would do a better job of making the point that chart is intended to make. But I think it is pretty likely that the 1970 administrative baseline is tiny (because in 1970 there were lots of small hospitals run by 1 doctor).
It needs to be inflation adjusted, and then you have to agree about which inflation measure (there are several, and the differences over 50 years are significant)
But you could sidestep all of that by comparing to other countries, non of which ever had a significant number of “small hospitals run by 1 doctor”; their expenditure as a percentage is mostly consistent through the years and about half as high as the US, with similar trends in education.
Presumably the underlying data for the linked chart is already adjusted for inflation. And the index used doesn't matter all that much, it will be applied to both data series and various inflation measures aren't that different anyway.
The higher administrative costs at US hospitals account for something like 3% or 4% of total US healthcare spending. A huge win if you take it all back and not any sort of solution to the cost problem.
Different inflation measures can diverge up to 1%/year, so at 50 years, the choice matters a lot. Also, things like "core CPI" get redefined through the years (in a way that almost always makes them lower) and other "hedonistic" adjustments are not universally accepted.
While I see your point, "CEO/Executive Pay" is a poor indicator of waste in these organizations. Fundamentally, Non-profits need to operate like businesses, in the sense that their balance sheets need to remain stable and their income needs to cover their costs. The difference between a non-profit and a corporation of course exists, in their respective names imply, in who they're beholden to. Non-profits exist to not make a profit, where "for-profit" corporations exist to deliver a profit to their shareholders. For-profit corporations pay their CEOs exorbitant amounts as well, and for non-profits to recruit talent, they have to do the same.
Let's be careful about nostalgia for the "good old days" of medical practice. Keep in mind that standardizing medical care process has done more to get physicians to WASH THEIR HANDS than all kinds of exhortations about relationships, partnerships, and healing. And washing hands has, since Semmelweis's discoveries 150 years ago, been known as the easiest way to promote healing that medical people don't do.
Why do the overnight shift of nurses take vital signs every four hours? So they catch rapid unexpected changes in patient conditions more quickly. Put more crudely, so they don't accidentally leave a corpse in a bed for the next shift. Having to write, or type, the patient's blood pressure into a log is a way to help the overnight nursing shift remember to pay detailed attention to each patient, at least for a few moments. If their instructions were "stop at each door and listen for the patient breathing" those nurses might well miss important changes.
Hospital care these days is not only about the towering figure of the heroic superhuman doctor, Harvard Medical School lore to the contrary notwithstanding. It's about all the folks who look after patients, from the community primary care doctor to the RN, to the chaplain, to the "hospitalist" physician, to the person who cleans up, to the person who maintains all the electronic gear. The challenge is getting all these people to cooperate with the patient and for the patient's benefit.
The superhuman healer approach to medicine demands superhuman people to be doctors. They aren't, any more than the rest of us are. They have to sleep, and to eat, and to see many patients. So, a good hospital needs to be organized like a good company: where each person's skills and passion complement the others, and gets an extraordinary result from a collection of ordinary people. The buzzword for that is "synergy." Good discipline--good and predictable process--is part of synergy.
And, at the end of all that excellent care on our behalf, each and every one of us will become a corpse. A nineteen-year-old with a broken leg can be cured. A 90-year-old with cancer and pneumonia, not so much. It doesn't matter how towering a figure the doctor is, or how kind the nurse is.
A radical move in medicine would be to come to terms with death as a natural part of life rather than as a failure of the system.
That may be true, but one aspect of the "good old days" (at least in the common cultural imagining of the "good old days") is that you could get more attention from doctors outside of a hospital setting, even at home, and that doctors had more time overall to spend with each patient
All the procedures you describe seem like very important improvements in quality of hospital care, but there is (or should be) more to the healthcare conversation than what happens in the hospital
Sigh, so true. My first job out of college here in Seattle was by a major company that provided 100% coverage for all healthcare, $0 copay; at the time, that included doctors straight to your home, anytime. It was only after we were pushed to HSA plans that I started learning about billing, and that apparently it's basically unheard of to have physicians come to the home. Still feel whiplashed by the change...
>Why do the overnight shift of nurses take vital signs every four hours? So they catch rapid unexpected changes in patient conditions more quickly.
The first sentence of the second paragraph of the article you seemed to have avoided reading says:
“Checking things like temperature, blood pressure and respiratory rate every four hours on hospitalized patients has been the standard of care since the 1890s, yet scant data indicates that it helps.”
But this is not the case. In the UK, these observations are entered into a proforma by the nursing staff which allows them to calculate a "National Early Warning Score". Based on the patients score, the nurse has to escalate to an appropriate team and the doctor on the appropriate team has to take the referral.
Not only does this help identify deteriorating patients, but it helps to fight human factors like "I don't want to call such and such a doctor because they are always rude on the phone so I'll just leave it and hope it gets better"
In terms of actual data, we have a national body (NICE) that provides guidelines and recommendations based on appraising the available data and research. For NEWS scores, see:
If a patient is stable enough that the taking of regular vital signs is nothing but a nuisance, maybe it's time for the patient to leave the acute care hospital and go home or to a rehabilitation facility. Nobody wants patients who don't need acute care services in acute care hospitals.
Maybe DNR / palliative-care patients should get a break on the four-hour vital sign gathering. But people start yelling "death panels" when this sort of thing comes up in hospital policy.
> ... gets an extraordinary result from a collection of ordinary people
Of course doctors are ordinary people. The ones that become doctors these days aren't even the brightest in school -- those go into STEM or, god forbid, finance.
But if they are ordinary people why are they paid like the superhuman healers that they aren't and still hold themselves as such?
> But if they are ordinary people why are they paid like the superhuman healers that they aren't and still hold themselves as such?
They're not. The lifetime after-tax expected earnings of a person entering medical school today, after work and operating expenses are taken into account, is probably a lot less than the equivalent figure for the average Hacker News reader.
Doctors make nowhere near as much money as people think they do, and that incorrect perception is based on stereotypes that haven't been true for decades.
I speak of labor cost, so don't include student debt, delayed employment due to training, and taxes as they are kind of irrelevant. Malpractice insurance counts, not sure what other "work and operating expenses" are unique to doctors.
Many doctors I know opt to work for a practice association and draw a salary, typically in the very low six figures. Why? Their association handles all the huge pain in the neck CYA stuff like electronic medical records, triage, insurance and Medicare billing, malpractice risk management, scheduling.
From the practioners' point of view, especially for those who care for people over 65, socialized medicine has already arrived in the US. The rules around care and reimbursement are rigid.
You'll get an occasional congresscritter who used to be an obstetrician or dentist claiming it isn't so. But those specialties don't have to try to get paid by Medicare.
This. Every healthcare system in the world needs to choose.
We simply cannot have healthcare for everything, including rare, expensive and/or hopeless diseases (or all 3 at the same time). As long as that's what we demand, healthcare will go wrong.
And let's please just stop pretending that this is somehow an America-only problem, caused by whatever (democrats: by not being public conservatives: by public largesse. And yes, despite how it sounds I do think both arguments have merit). True, America has it bad, but healthcare is failing, financially or otherwise everywhere in the developed world [1]. And healthcare in the non-developed world ... well, this was in the newspaper 2 days ago [2].
Healthcare is failing in the developed world for economic reasons. Those are not about to change, so it will get worse unless we figure this thing out with major changes (which ARE going to include limiting treatment).
Why does [2] have anything to do with this conversation? Maybe google translate missed how it was related to the doctor missing something or the healthcare system not paying for treatment? Can you explain more?
Well, there was a hospital in India, that when a patient came in feeling unwell in his abdomen and then ...
a) somehow this patient developed a ruptured liver and severe trauma to the skull (given that he survived the flight and was conscious we can easily conclude that neither injury was present before the hospital got involved)
b) missed that someone at the hospital has removed the heart and kidneys from the patient
c) signed off on a "natural causes" death certificate, no mention of what happened to the organs
(note that organs for transplant need to be taken out before death occurs, so it's not like they removed them with the family's permission after clinical death)
d) refuses to investigate how this happened
e) got the government to concur, and actually the government is helping them with d)
That's something that got reported last week, and this was a hospital in India, so third world healthcare.
Hospitals should post prices of their procedures in the lobby. A surgeon gets $500 to repair a hernia and the hospital pulls in $5k for the ancillary services. The surgeon has to see the patient,make the diagnosis, provide the treatment, provide the aftercare and be the 'face'. The hospital-insurance complex has managed to create this fantasy world with complicated rules and somehow have sequestered themselves from the free market. They set their own prices and by virtue of being of local monopolies thwart the ability of the individual to choose. Hospitals have become like cable companies.
It's not like hospitals are wildly profitable to run though? I think the inflated costs are due to the little understood phenomenon of "cost disease" rather than owners of hospitals extracting outrageous rent for themselves as I think you are implying.
You're correct about the spread of cost disease, it has essentially reached every corner of US healthcare. The part that hospitals are particularly guilty of, is unnecessary admin expense inflation. The US education system has seen an almost identical problem. Building buildings that aren't needed, hiring 10x the admin staff that the system had 30 or 40 years ago, etc. It's the system rewarding itself, bureaucrats hiring more bureaucrats, playing lords as they go on building sprees that aren't needed. There are very few readily available levers in the US healthcare system, that can be used to properly pull back against such cost spirals and spending behavior.
Last time I was out the hospital they had robots running around to just to pick up towels. Robots are great and all, but that's a symptom of not managing costs.
thank you all for your input. The hospital you linked in Asia. It seems that SE Asia has leapfrogged us in the concept of capitalism and the free market. Indeed, it is a 'free-for-all' in terms of lack of regulation, but certainly it is not 'free care for all'. Here in the US, The medical-industrial complex has seen how other industrial complexes deal with our government and are trying to mimic that gravy train. I still remember articles about the $500 hammer, and $2000 toilet the Navy had purchased in the thousands.
We need to get back to our roots. A free market where people can buy what they want when they want it. Health care insurance is an oxymoron. Everyone gets sick. There is no probability of someone NOT using the system. The minute you try to amortize the costs over time or large populations to provide services, there is infinite demand.
Insurance would make sense for events that are RARE. House fires, automobile accidents, gun accidents, etc. (BTW, why isnt gun insurance mandatory? That way everyone could be happy- you could still buy a gun as long as you paid your $5000 premium. The insurance companies could make more money, there would more 'gun control', and the money could go to the emergency rooms that take care of shooting victims. But OH NO! Hospitals would figure out a way to spend that money too and it would never be enough!! Maybe the gun insurance premiums could be given to the victims !)
Anyway, there is no easy fix until we start to force our politicians to GET OFF THEIR ASSES. It particularly annoys me that they offer 'thoughts and prayers' after each mass murder and do nothing else. They should be in Florida digging the graves. Representing their constituents properly.
> Hospitals should post prices of their procedures in the lobby. A surgeon gets $500 to repair a hernia and the hospital pulls in $5k for the ancillary services
Cost for repairing hernia is not exactly the same for every patient though. Depends on the severity, general health of the patient and a million other things.
Not sure if its even possible to put an upfront price. Even if they did, how do patients know beforehand what exactly they need to figure how much they are going to pay. Maybe that works for simple things like a flu shot but seems impossible to for anything even slightly more involved.
The same reasons would apply elsewhere, they're not USA-specific, so they don't explain why it's not possible to do the same thing that's successfully done elsewhere.
Sure, there's some inherent variance always - the same thing happens in many industries and doesn't prevent them from offering fixed quotes; the service provider is the one best qualified to estimate the expected variance in their costs and offer appropriate pricing.
Sure, there may be special requirements that justify charging extra for a particular case; that's not an obstacle from telling the customer about that beforehand. Well, not in ER, but most care is not ER.
> The same reasons would apply elsewhere, they're not USA-specific, so they don't explain why it's not possible to do the same thing that's successfully done elsewhere.
I 've never seen a chart with prices for hernia in the lobby , anywhere that I've lived( I am not from USA).
Well, it's not literally placed in the lobby (since the price chart is big and different locations/types/severities of e.g. hernia mean different types of operations, and the choice of which type of operation should be chosen is generally not made by you but by the consulting doctor) but it's conceptually the same in that the price list is publicly available and you know beforehand about what exactly you're going to be charged.
E.g. a link to a random local (to me) hospital's pricelist (not in English, sorry) https://www.aslimnica.lv/lv/content/neirokirurgijas-operacij... starts with two different procedures for herniated spinal disc repair. That's it, if your doctor recommends to do this operation, then if it's not covered by your insurance this is what you'll pay for the procedure followed by a standard per-day inpatient fee for however you're required to stay during recovery. It's up to the hospital how to split the amount among all the involved specialists labor, equipment, drugs and supplies required.
As far as I've seen when traveling, the same (i.e. once it's clear what you want to be done, there's a price known beforehand) applies in most European and Asian countries, but it's hard to provide online examples as you must look for the local non-english (the english-speaking market, USA+UK+UK dominions, seems quite different from the rest of the world) services since English websites tend to be oriented for "medical tourism" services which is different from how the locals handle their healthcare, and there's a significant language barrier.
How does pricing of elective surgeries work in your area?
> That's it, if your doctor recommends to do this operation, then if it's not covered by your insurance this is what you'll pay for the procedure followed by a standard per-day inpatient fee for however you're required to stay during recovery. It's up to the hospital how to split the amount among all the involved specialists labor, equipment, drugs and supplies required.
But this exactly the same in USA too. I got shoulder surgery in USA. Doctors office took my insurance information and called my insurance provider and told me how much my insurance covered and how much I am going to pay for it. I paid exactly that amount out of pocket post surgery.
As far as I understand, the insurance-negotiated system works more or less fine in USA, the major problems seem to be with uninsured rates; I have no first-hand experience from USA but the discussion about the health system claims that often they're either not able to obtain such information (especially if they'd be shopping to obtain a quote from multiple providers) or, alternatively, get hit with significant "surprise" extra bills from different additional providers. Of course, the issue may be exaggerated, but that's the impression I've got from media.
no it doesnt work. the insurance companies restrict reimbursement even for those people who pay premiums. I have seen deductibles now in the $5000 to $10000 range. The costs and fees have been inflated beyond reality to facilitate their profit numbers for their EPS ratios.
>Despite his reputation, Dr. Lown was treated like just another widget on the hospital’s conveyor belt. “Each day, one person on the medical team would say one thing in the morning, and by the afternoon the plan had changed,” he later told me. “I always was the last to know what exactly was going on, and my opinion hardly mattered.”
yes, this is what it is like to be a patient at a hospital these days. And good luck if the patient wants to speak to a physician. and don't ever go to a teaching hospital if you have the choice. some intern will have the brilliant idea to adjust every medication you are taking.
Oh, the old ones where too - the stories just never circulated.
Someone i know worked as a surgery nurse - by now almost 40 years ago. The surgeon was quite choleric - and once, when a cotton -wad was unaccounted for threw a sewn off hip joint twoards those who dared to assist him.
The health sector is the Afghanistan of the tech business. It's entire history is of empires arriving to solve its problems, and after a decade and massive losses, they leave, mystified at how something so contained could be so intractable. The only people who survive there are the ones who don't try to change it.
When you can send your diagnostic images to get a consult from 2 clinics in India and an expert system for less than the price of a three block ambulance trip in the US, prices for domestic care will come down.
not sure where your confidence comes from, though i hope you are correct. i don't see it yet though.
in the US healthcare market the payment model will have to change before Indian healthcare market prices have an impact.
in other words, US legislation that takes money away from the current system of providers would need to be passed. (i mean, why doesn't the US medicare/medicaid system take advantage of the lower costs you're describing by flying US patients to hospitals in other countries for major, expensive procedures and other treatments? they could save a lot of money, but US law does not currently allow payment to providers all over the world.)
US hospitals, doctors, pharma, etc have created a closed system wherein they are the only service and product providers. i think they like that aspect of the current system. they've built themselves a moat and globalization cannot enter.
Tell me more of your impregnable fortresses and unsinkable ships.
I agree that the barriers you mention are real, but those are in the domain or class of solvable problems. Apps like Figure1 are a good example of how doctors are moving around this.
To borrow from Nial Ferguson's new book, the big CMS/EHR players (nightingale and another one here) control the integration points and hierarchical relationships, but I think they are vulnerable to networks.
>The medical team was concerned that because Dr. Lown was having trouble swallowing, he was at risk for recurrent pneumonias. So we restricted his diet to purées. Soon the speech therapist recommended that we forbid him to ingest anything by mouth. Then the conversation spiraled into ideas for alternative feeding methods — a temporary tube through the nose followed, perhaps, by a feeding tube in the stomach.
Maybe not the main point of this article, but there are numerous occasions where I’ve encountered just this. Allied health professionals, all of whom are very well intentioned, making recommendations that physicians readily follow without taking into consideration the needs or desires of the patient and family. If as a physician you are being advised to declare a patient NPO or to send them off to a skilled nursing facility instead of home - please remember that this is just a recommendation and that it’s your job to look at the patient as a whole, including their general medical condition, likelihood of their family supporting them, etc. before following through.
Going to a doctor in America, for whatever reason, the first thing that happens is that a nurse comes and takes your blood pressure. I wonder why? Never happened to me in Europe.
In the UK (not an insurance-based system), many GPs ("family doctors") will aim to take a BP reading if there is time. This is partly because there is a system called the Quality Outcome Framework that incentivises practices to do so, but the route of it is that those incentives are in place because high blood pressure is extremely common, under-diagnosed, and has huge health consequences if left untreated, which in turn is extremely expensive for a national health service. A BP check is quick, simple, and cheap, and can help to identify problems early on when simpler interventions can stave off bad outcomes.
When I asked, they said the insurance company forces them to collect two metrics or the insurance will reject the claim. That's why a nurse always gets your weight, temperature, and/or blood pressure regardless of the reason you're seeing a doctor.
Two reasons. First, it's a clinical quality measure that needs to be collected by law. The government mandates that you collect certain data about X% of patients you are in contact with and transmit that data to relevant parties or else you will be penalized financially by Medicare.
Also, BP, weight, and temperature are important diagnostic indicators
"Checking things like temperature, blood pressure and respiratory rate every four hours on hospitalized patients has been the standard of care since the 1890s, yet scant data indicates that it helps."
Someone didn't read the parent comment. The article talks about re-taking of history and vitals during care transitions, after the patient has been admitted. The parent comment asked about taking those measures during admission / triage and checkups when the healthcare team doesn't have any data yet. Those are two different things.
In the UK, they do. In my GP's surgery there's even an automated machine in the lobby that will print out your BP and a sign advising to take your BP if you haven't "recently" and bring the printed slip with you to show the doctor or nurse.
For better or for worse, everything in America is a business -- healthcare is no exception. Helpful to keep in mind when you think about potential improvements or solutions.
If by "business" you mean a public/private hybrid in which profits are privatized while losses are socialized, then you are correct, in so far as health care goes. And that seems to be the model that is now being adopted in more and more areas of economic activity.
I don’t like that wording because it implies that hospitals somehow benefit from government involvement; in reality, it just sucks for everyone. In general, I agree - very few medical institutions in the US actually get to be private.
I will say that truly private medicine is, in my reasonably broad experience, excellent. I use a private subscription-only medical service in the US which is excellent (and procedures are generally cheaper than they would be in a public hospital, whether I’m paying with insurance or out of pocket), and my experiences with private medicine in SE Asia and Mexico have been excellent (and affordable) as well (to a greater degree than can be explained by labor cost differences).
> it implies that hospitals somehow benefit from government involvement
But they very clearly do. A huge proportion of their income comes from government sources (Medicare/Medicaid/VA), they are subsidized by tax exemption for health spending, and government grants them the power to deny competitive entrants into their markets via "certificates of need."
> But they very clearly do. A huge proportion of their income comes from government sources (Medicare/Medicaid/VA)
Hospitals lose money on Medicare and Medicaid patients on the margin. They have to overcharge private insurers to make up the difference.
It's so bad that Medicare has not one but multiple programs to compensate hospitals that don't see enough private patients to make up the difference, because otherwise they wouldn't be able to sustain themselves on Medicare reimbursement rates.
I don't know why you're even mentioning the VA; it's not relevant here at all.
> Hospitals are obviously capable of accounting such that Medicare patients are money-losers on the margin, but they keep taking them for some reason.
You seem to be under the impression that there's some deception going on here. There's not, and it's pretty plainly evident. Medicare's reimbursement rates are below COGS. Hospitals control neither of those two things (Medicare sets rates by fiat, and if hospitals could lower COGS by paying vendors less, they would).
As for why they keep taking them - they oftentimes have no choice, legally. Though, incidentally, in recent years, we've started to see hospitals find more creative ways to close their doors to Medicare patients for this exact reason.
> Normal non-VA hospitals accept VA patients and are reimbursed for them.
The number of VA patients hospitals see is negligible. The amount of revenue they receive, proportional to the number of patients they see, is even less.
Stories like this are not uncommon in so-called developed countries. Makes you realise why medical tourism industry does so well. From my own experience i would prefer to return to Guangzhou or Shanghai for procedures rather than anywhere else. Not really that much cheaper but at least i can determine up front the size of the bill. Added to that is that in spite of factory-scale medical care in China(remember there are basically no private medical practices - all doctors are linked with hospitals), they are actual (in my personal experience) quite caring and dont charge unnecessarily.
Healthcare in the US has left the era of the small business and is entering the era of the nameless corporation. What wal-mart did to all of the mom-and-pop shops is happening to healthcare. Except that instead of lowering prices, it is raising them
Physicians have gone from small business owners to rank and file employees of large corporations. The burnout that is increasingly common among physicians is not unlike that of american office workers in the 1990s.
I'd love for the next stage of the evolution of healthcare to see physicians as customer focused, tech savvy entrepreneurs
> To restore balance between the art and the science of medicine, we should ... make room for training in communication, interpersonal dynamics and leadership.
How would this help solve the problem the article started with, that patients don't heal because they're deprived of sleep by being woken up every 4 hours? It's a problem everyone knows about (I saw complaints about it online years ago) -- so it's not directly a communications problem. Leadership I can see: it seems needed to dig the system out of an inadequate equilibrium (https://equilibriabook.com/molochs-toolbox/) but that's pretty different from college courses in leadership.
As a survivor of stage IV cancer, I can say my experience strongly mirrors that. I would go further to say that the assembly/widget mentality in a health care setting made it difficult for some of the staff to see me as a human. Abuse or care-full neglect (is that a thing? working on the words) is, in my experience at least, common.
It's not to say I don't appreciate being alive, but we can do better for those suffering.
It is a nice coincidence that a video by an educational YouTube channel Kurzgesagt discusses homeopathy and why it still remains popular—hypothesizing that one reason may be that their practicioners pay good attention and affection to their patients. https://m.youtube.com/watch?v=8HslUzw35mc
This article and the comments here combine to illustrate for me the difficulty of making healthcare work in all the different ways it has to. I read the article, and I think, "Yeah! That's the kind of healthcare I want!" I read the comments with contrary opinions, and I think, "Those are great points — these counter-intuitive practices make sense when you need healthcare to scale." I talk to my wife, a physician, and I hear about what results in the rare cases when these protocols and consultations don't happen, and I think it's a wonder that hospitals function at all.
I think it's not a matter of finding the solution to the problem, but a maximization problem, where we have:
- patients who need to be cared for as human beings and allowed to make their own informed decisions, but who are generally not experts in medicine
- physicians who have more patients than they can keep in their minds at once, and who are reliant on nurses and computerized systems to keep patients breathing and not get sued, but who are also skilled, highly-educated professionals whose human judgment is frequently superior to any algorithm
- nurses who are both underpaid and responsible for more than their training considered
- hospitals that need to pay the bills, pay salaries, attract new physicians, etc.
There are so many conflicting aspects of this problem that any simple solution is probably unrealistic.
"[W]e should curtail initial coursework in topics like genetics, developmental biology and biochemistry, making room for training in communication, interpersonal dynamics and leadership. Such skills would [...] strengthen our ability to advocate for health care as a human right and begin to rectify the broken economics and perverse incentives of the system."
In other words, train doctors to be social justice activists rather than scientists? No thanks.
Article does not address the problem why the doctors' behave this way: insurance companies.
Unfortunately, treating makes more money than curing and the United States is scared to death of what shall they do with all that free time if they actually do cure, while other countries do not work themselves to death because they do not have an artificially controlled supply of Doctors...
This is an absurd and oft-repeated claim that taps into variations of the conspiracy thinking around 'doctors keeping the cure for cancer (or insert other condition here) secret' because powerful lobby groups insist that there is more money to be made in 'treating' than 'curing'.
It is patently untrue.
Firstly, it assumes that neither doctors, nor the scientists and researchers working in the companies and universities that drive medical progress forward, have an ounce of self-respect for either themselves, their family members or members of the community - because if true, either family members and themselves would never get cancer or other chronic diseases that we 'treat', or if they are somehow as vulnerable as the rest of the population to these conditions, that maybe there is a secret stash of 'cure' somewhere that they allow out to the people in the know. The conspiracy goes deep...
Secondly, it throws out the window all the evidence around what we can actually cure and what health policy seeks to do. We have an entire field of medicine called preventative medicine that aims to stop conditions before they happen, by lobbying governments to ie. Ban or decrease rates of Smoking and alcoholism, to provide safe needle exchange so IV Drug Users don't get bloodborne diseases, to improve exercise rates, to provide vaccination programs - all of which stop disease from happening.
The fact of modern life in a western country is that most of the burden of disease is related to lifestyle factors or age related - Osteoarthritis (Age and Obesity), Cancers (Lifestyle risks and age), Diabetes (Diet, exercise, genetics) Cardiovascular disease (Exercise, Age, Lifestyle risks, diet).
It also ignores the tremendous advances that are still occuring.
When I was in my final year of Medical school, 5 years ago, Metastatic Melanoma was a condition with an average survival of 6 months. It is now (thanks to some incredible, and incredibly expensive drugs - don't get into a debate about cost here, I live and practice in Australia and the cost for a patient is capped at $46.60 per year as it is on the PBS) more of a chronic disease with average survival in the 4-5 year range. Incredible, and this progress occured in 5 years.
Similarly, Hepatitis C, a condition that in it's chronic form invariably results in liver cirrhosis and failure, can now be cured - this was unthinkable 5 years ago, and is now a fact, with a 12 week course of medicine.
Please inform yourself and don't just trumpet that which you hear on the internet. Your ignorance is not as valid as my knowledge and to assume that in your version of this myth that insurance companies (but in the more common version of this myth, Doctors, Pharmaceutical Companies etc) are primarially interested in keeping the population teetering on the edge to milk them dry is disingenuous.
> Your ignorance is not as valid as my knowledge and to assume that in your version of this myth that insurance companies (but in the more common version of this myth, Doctors, Pharmaceutical Companies etc) are primarially interested in keeping the population teetering on the edge to milk them dry is disingenuous.
You really know how to talk to people haha. It seems like you were triggered by something I said even though it did not apply to you.Take a breath. It is okay for other people to have different viewpoints on the medical industry in the United States.
>This is an absurd and oft-repeated claim that taps into variations of the conspiracy thinking around 'doctors keeping the cure for cancer (or insert other condition here) secret' because powerful lobby groups insist that there is more money to be made in 'treating' than 'curing'. It is patently untrue.
Where are your sources? I never stated that they are hiding the cure for cancer? It is a fact that treating vs curing is a business model in the United States. The U.S outspends everyone yet gets them same results
>https://www.npr.org/sections/goatsandsoda/2017/04/20/5247741...
I never mentioned anything about Australia, I was talking about the United States. I cannot speak for Australia.
>Please inform yourself and don't just trumpet that which you hear on the internet.
The fact that medical records are not electronic being a standard is laughable. I cannot speak for anyone else but the United States. HIPA laws are one of the reasons which makes it harder for researchers and doctors to actually get data they need to develop cures because of the need an individual signature for everyone.
Regarding Supply of Doctors
>In the United States, the supply of doctors is tightly controlled by the number of medical school slots, and more importantly, the number of medical residencies. Those are both set by the Accreditation Council for Graduate Medical Education, a body dominated by physicians’ organizations. The United States, unlike other countries, requires physicians to complete a U.S. residency program to practice. (Since 2011, graduates of Canadian programs have also been allowed to practice in the U.S., although there are still substantial obstacles.) This means that U.S. doctors get to legally limit their competition. As a result, U.S. doctors receive higher pay, and like anyone in a position to exploit a cartel, they also get patients to buy services (i.e., from specialists) that they don’t really need.
(https://www.politico.com/agenda/story/2017/10/25/doctors-sal...)
Business Model Point
>Imagine a portable, low-intensity X-ray machine that can be wheeled between offices on a small cart. It creates images of such clarity that pediatricians, internists, and nurses can detect cracks in bones or lumps in tissue in their offices, not in a hospital. It works through a patented “nanocrystal” process, which uses night-vision technology borrowed from the military. At 10% of the cost of a conventional X-ray machine, it could save patients, their employers, and insurance companies hundreds of thousands of dollars every year. Great innovation, right? Guess again. When the entrepreneur who developed the machine tried to license the technology to established health care companies, he couldn’t even get his foot in the door. Large-scale X-ray equipment suppliers wanted no part of it. Why? Because it threatened their business models.
(https://hbr.org/2000/09/will-disruptive-innovations-cure-hea...)
> The fact that medical records are not electronic being a standard is laughable. I cannot speak for anyone else but the United States. HIPA laws are one of the reasons which makes it harder for researchers and doctors to actually get data they need to develop cures because of the need an individual signature for everyone.
In the US it is a standard that Medical Records are digitised. Unfortunately the existing eMRs are so awful that they decrease efficiency, so much so that many american clinics are removing them - [0, 1, 2]. If you think that the limiting factor on advances in medical research are access to digital records, you are severely misguided.
We have the same control on medical school spots in Australia. We train 1 per 6,285 people per year. You train 1 per 16,150 (roughly). However you also have Nurse Practitioners and a range of other allied health professionals and are a huge importer of overseas Doctors. It's not an ideal solution for the country. In Australia the medical colleges can limit training positions and this cartel behaviour has been the focus of the ACCC a number of times. On the other hand, How can you ensure that people are appropriately trained in the field they are representing, and going to be a net positive to patient safety? I have some ideas that I will be trying if I get to Series B.
I can't speak to your inventor of the X-Ray machine but would suggest that if in the last 18 years he has still been unable to get a market for it, or to launch it himself, than probably the technology has other problems than having a distributor. Disruptive technologies always find a way.
Let's be very clear: there are a lot of problems with healthcare, particularly in the United States. One of the biggest problems worldwide is that healthcare is a demand-inelastic good. When someone needs it, they will pay whatever they can to get it. In my opinion the US model is so completely fucked that the only way I see it being fixed is by transitioning to a post-scarcity economy. An illustrative example: When I was undergoing my medical school elective in Boston in 2013, which under Romney introduced State-wide access to insurance, I observed people accessing their care inefficiently. For example, Tram Drivers coming to Beth Israel Deaconess to have their Lipoma operated on by the Professor of Plastic Surgery at Harvard, because they had insurance. Normally this patient would have presented to the County Hospital, which in the US is the most efficient provider of care, but because they were able to access insurance, they wanted gold-plated healthcare. This is an example of 'universal care' twisting the market forces even more, as the most efficient providers of care are put under more pressure.
The manufacturing operations-ization of hospitals is both good and bad. Good because that means we have standard care (as desired by regulators and single-payer advocates) but bad because doctors lose the ability to perform customized care solutions.
I’m in favor of single-payer but we have to guard against turning healthcare into a manufacturing operation while also bouncing out bad actors and poo-quality physicians.
The issue with hospitals controlling healthcare is that they are the group with the least incentive to lower the cost of care
Hospitals account for the largest chunk of healthcare spend (30%). Hospitals make money by increasing inpatient admissions, particularly for profitable surgeries. The standardization of care in hospitals is intended to maximize profit under the constraints of various regulations around readmissions penalties, reimbursement limited length of stay, etc. If you look at the financials of public hospital companies like HCA and Community Health and Tenet, their major metrics are growth in admissions and surgeries. Even non profit hospitals are driven by this
The expansion of hospitals into owning tons of formerly independent specialist and generalist physicians is scary. Once in a hospital's system, these physicians act as loss leaders funneling patients into the hospitals profit center
Having hospitals in charge of the healthcare system is like having a fox in charge of the proverbial chicken coop
- They treat the customers like replaceable widgets
- Costs are spiraling out of control. ($2-3000/day hospital, $3.4 TRILLION in total health spending [this equals the entire federal budget])
- Doctors / teachers often don't seem to communicate / care. (Friend's mother was recently in hospital, multiple doctors thru a single day, each one had to completely relearn what was going on.)
- The infrastructure systems are counter motivated (hospitals, drug companies, ect.. are profit not care motivated corps w/ "high" administrative overhead, schools are often public, yet view students as revenue and spend large amounts on noneducational costs to attract "talent". [$500k-$1.5M admin salaries])
No wonder many just want to self educate these days, and their health would be about as well served going to a shaman who cared about them.
I will always take my own history from a patient, but I use the previous records as corroborating records - I know what the general gist has been, but what might they have missed/what might the patient have told them?
It is a critical part of good patient care, despite its inefficiencies
This is just how records like this work, frequently contextually or globally incorrect, I don't think it's really a matter of malpractice, at least not in relative terms; though I guess they could do better, like recording that staff had witnessed me collapse (!) two times (one in the waiting room, one in the halls) before they left me sitting in some random chair in a hallway for a couple hours, during which time I passed out a third time, scaring the bejesus out of the others waiting there, none of whom were patients.
Hospitals aren't really all that great at paying attention anywhere, as far as I can tell; the U.S. has the most discerning customers (and to some extent, some of the last remaining customers in the developed world). In the U.S. you might have some hope of complaining about service like I received, for example how the triage nurse spilled what looked like about 200ml of my blood all over my arm and the floor while drawing a sample at intake, or that when somebody finally called me to the the first room, she didn't even wait for me to get to the locked door (which I failed to do, because I collapsed half way there and needed to be wheeled in, mostly helped by random bystanders) before turning and walking back to sit down behind the desk (not at the desk), where I saw her playing on her phone.
They take my urine, and three hours later they tell me my urine sample was "pristine". They were amazed at how clean it looked. Not even a single protein-- and as a female with a vagina that often discharges a proteinous substance, this was surprising! (And very good news! Doctor was astounded). The doctor concluded my kidney pain was "mechanical", that the muscle in that area had been bruised somehow I told her this was not the case, but she discharged me.
16 hours later (at home now) I'm running a fever of 104. My resting heart rate is an astounding 132 bpm. I'm scared of sepsis (infection of the blood) since I have experienced that before from kidney infections. I go to the hospital preparing for another 5 hour waiting time, but luckily they get me in an intake bed right away. I'm covering myself with a heavy blanket in my fever state-- something one shouldn't do, but nobody took it off me until I was about to be discharged. They come back with the results from another urine sample, and surprise, I have a kidney infection! I asked the doctor why my urine was "pristine" the day before and he said, "the lab tech probably didn't keep the dip stick in long enough" (which is why the test didn't register any protein in my urine whatsoever...) He acted like it was no big deal, like it happened all the time. They gave me 1/4 dose of morphine for the headache because I "look to be about 100 pounds" (I'm 5'10". That would put me at a BMI of 14.5-- ie. severely underweight, and cause for medical concern in and of itself! I'm 135 pounds, with a BMI of 19.4 Honestly, what the hell.) which doesn't help the pain at all, and I'm still wrapped in what amounts to a sweat lodge-- once again, nobody told me to take the blanket off. This is very common knowledge, but in my state of high fever and pain I did not think that it could be a bad idea. I would expect the doctors and nurses to be aware.
An hour later they suddenly tell me to get out of bed and they will move me to the waiting room with a chair and a goddamn television that I can already hear thumping through the walls, because this is an intake bed and "other patients need it". I'm sure they do, but I literally can't walk right now.
Long story short, the next time I get a kidney infection I'm staying home to die. The lack of care in that situation was astounding. To top it off, they treated me like a bad patient after I protested being moved to the waiting room.
edit: I also forgot to mention that they were going to give me pill antibiotics at discharge. I suggested they give me an IV instead, and set me up at an IV clinic. I'm not kidding, they said, "oh! That's actually a great idea". Ahhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh
They sent me home with like... "16 hours worth" of ultra-low-dose hydromorphone (I couldn't find any dosing guidelines which even reference 1mg tablets) and left me to choose which hours of pain I wanted them for; I missed my followup because the front desk folks couldn't send me where the surgeon's note said I should go.
The best part was the ambulance ride, which only cost me fifty bucks and was conducted excellently; the surgery itself also went well, as far as I can tell, though for an appendectomy that's nothing to write home about (not to downplay the work involved, but like flying in airplanes, it has become routine).
Likely not a coincidence, the ambulance ride is the one thing I had choice in as a patient, and the one thing I paid for out of pocket (although non-emergency rides somewhat subsidize emergency ones, by policy).
BTW, she had so many of these infections that her doctor eventually referred her to a urologist, who put her on a daily antibiotic (cephalexin, aka Keflex) as a preventative. She hasn't had another once since starting that, though there have been a couple of times that she felt like she might be getting one, and took an extra cephalexin, which was sufficient. I wish we had known about this option sooner.
Also: my pointing out that UTIs can sometimes fail to show up in the urine test was not intended as a defense of the way the hospital treated you. Quite the contrary: doctors should know that that can happen. My wife and I were not happy with the way she was treated on this occasion as well — it took hours to convince them to start the antibiotics, and she was in a lot of pain.
>Quite the contrary: doctors should know that that can happen.
Okay, thanks for clarifying. This is how I felt. It was silly to me that I could have all the symptoms of a UTI, only to have everything written off because of a clean urine sample. I think it was hopeful thinking on the doctor's part-- she just wanted me out of the bed so she could clear the waiting room.
How recurrent were your wife's UTIs, if you don't mind?
In fairness, I guess it really doesn't happen very often — the ER doc in my wife's situation commented that she had never seen it before. On the other hand, pulled muscles don't cause fever. I understand a little bit of reluctance to offer antibiotics, as they have been overused, but geez, you have a patient with a fever and in terrible pain, indeed with all the other symptoms of a kidney infection, what's really the downside to going ahead and starting the antibiotic to see what happens? That's how I see it, anyway; I'm not a doctor.
Really, she should have been referred to the urologist a lot sooner.
I had issues with bedwetting as a child and into my late teens. I went to sleep specialists, urologists, and psychologists but nobody could say anything about it. I think it's somehow related to what I've been experiencing lately but I don't know what to do about it. I was always getting infections as a kid too (ears, eyes, bladder, kidney) but not really flu or colds (despite not being vaccinated). Has your wife experienced any of these things in her youth?
My SO is a doctor, even here in Europe there are many flaws, but what I have learned over the years is that this system is way, way more complex and effective than people think. If you want to improve it, great! Step one: go talk to a doctor about your ideas. If you haven't done that, don't spread your unfounded assumptions, it only leads to more demonization of staff and systems and doesn't help anybody.
They asked me what happend and wrote down "was drunk" so everyone I met at the hospital was like "uhuu was drunk at the uni... one of those guys..."
[0] https://www.fiercehealthcare.com/it/study-docs-spend-more-ti...
Agreed. But that is because doctors are not easily accessible. You can't simply call doctor's cell phone or text him a message. Instead, you call the office, leave a message and wait for God knows how long. Some doctors do not even bother to call you back if they're not in the office.
> And how is this any different from reading a 'transcript' of the last interaction a patient had with a Doctor
You don't want to cancel the transcript-based approach. I was talking about improving existing processes, not replacing them altogether. Knowing that you're being recorded makes you more responsible for every note you take, it improves the kind of information doctors write down.
I'm sure you are aware that there are a ton of things to improve in the healthcare industry. It's just a matter of wise execution, which is the most complicated part.
watching body language, pauses, etc vs just reading can give different information. and multiple people reviewing that over a spell will yield different/new/conflicting insights. but it's different than reading a transcript.
What's the alternative? 24 hour shifts for the doctor and the new doctor each day needs to relearn everything?
Having to relearn everything might be a problem, depending on what it actually means, but as long as we want a normal human being as a doctor, they will cycle over time as people start and end shifts, and they will need to learn what happened before their shift started (and they may receive patients from multiple doctors leaving over their shift, making 1-on-1 hand-off infeasible).
It's easy to call this out as a problem, the question is what's the alternative that's better?
A good percentage still get frustrated. Can’t be helped. Patients reshape their narrative, remember new details, just plain open up more to some docs, etc. the repeated history taking really pays off in improving patient care.
Where I find patients get most frustrated is when docs come in for a specific job, and patients don’t have the health literacy to understand what that is or is not. “Doc, can I go home today?”
“Oh. But when do you think I can go home?”There’s no good response to that. No one wants to cough up cash to pay for health professionals time to repeat themselves all day long. But the patient that’s asking? They want that answer. They don’t -feel- like they’re asking an inappropriate or stupid question.
I think about this when it comes to providing a patient with "informed consent" for a particular treatment/operation. What does "informed" really mean in this case? A brief overview of the main risks and a couple of statistics? Or a thorough understanding of the pathophysiology of the disease and the trial data supporting the therapy? How long is a piece of string?
There is also an argument that, unless there is some sort of ongoing peer review (they did this during my Oncological Adventure(tm)), you're increasing the number of moving parts, and thus the chances of a breakdown. Charting errors are a significant source of medical mistakes.
The problem as I see it is not the intent of the procedure, it's the while (1) do x; mentality. There should be some "ifs" and mitigating functions instead of a hardcoded 1
Most patients get admitted under a DRG, which is a lump sum payment. It’s true that doesn’t apply to every patient, but enough of them that doctors habits aren’t going to be shaped by the minority.
For that matter, you can come in and see a patient without asking the same history as the guy before you, if you’re just checking a box for a billing.
This meme really needs to die. The NHS has massive financial incentives that impact clinical decisions. In fact, you literally go on to mention as such in your next sentence.
It turns out that having an incentive to "save the system money" results in a different set of clinical decisions. And no, those don't always work out in favor of the patient. (They're particularly problematic for the patient in cases of long-term care, which is why the NHS does rather badly on complicated and chronic conditions like treating cancer compared to the US and other countries).
It might be true that the NHS has poorer outcomes but I doubt that this is necessarily the cause. I live in Norway and have considerable recent first hand experience of the health system. I'm confident that they have incentives to save money too. In fact my wife's cancer nurse when explaining why there was a delay in starting the day's treatment said that preparations like Avastin would not be ordered from the pharmacy until the patient was both present and prepared for treatment because they could not afford to throw it away when the patient didn't turn up or turned out to be too ill for chemotherapy.
It is broadly speaking the same idea as the UK NHS but apparently has better outcomes for diseases like cancer. There are fees to pay, similar to an insurance excess or what the US calls co-pay; but those fees are affordable and capped to a couple of hundred pounds a year.
Not to mention that many if not most NHS-employed doctors run private practices on the side. Some only spend a day or two a week on their NHS duties. Others such as GPs are NHS-branded, but every GP practice is a private business that bills the NHS for time and materials.
I am certainly not saying the NHS system is perfect, and all private medicine is bad, so if that is the impression you got then perhaps I was unclear.
In almost every single clinical situations within an NHS hospital that I have seen or can think of, the clinicians treating you will not receive any extra money, bonus, promotion, etc. for the treatment they provide you or do not provide you.
I have lived in countries with more private systems, where there is a direct relationship between what treatment/investigations you receive and what money ends up in the doctors pocket. For example, a private doctor in HK referring for not-strictly-necessary-but-ultimatelhy-clinically-justifiable MRI scans at a private MRI clinic which, provides a percentage of the (expensive) scanning fee back to the referring clinician. Contrast that in the NHS, no one gets given money for sending a patient for an MRI scan, and in fact, if it isn't going to change the management of the patient, the request is likely to be refused to constrain resources. In the HK system, neither the doctor nor the MRI provider is incentivised to not do the scan, quite the opposite.
The NHS system is not perfect, but pointing out different the pros and cons of different incentivisation structures that do have an impact on patients is not something that is a "meme that needs to die"…
Right, I'm saying that the difference isn't simply a matter of private vs. public funds, the way OP claims. You can really trivially create a private system that has the same bad incentives with respect to costs and care as the NHS does. You can also trivially create a public system that has the same bad incentives with respect to costs and care as the US does.
That said, Germany and France aren't really publicly-funded as well the way people think. Both rely on a private network for care delivery (unlike the NHS), so it's a bit of a stretch to say that they're "public health care" systems. Even if you're looking at funding, in those two countries, taxpayer funds only cover 75% and 70% of expenses, respectively.
Just asking "but what are the alternatives" isn't productive in itself, and doesn't really carry the conversation forward. It more likely shuts it down as a hopeless problem. We can do better. It's not hopeless and we're not powerless as a collective.
I'm sure there are alternatives but we're not looking for them very well. We could start there. I'm doing my part by bringing this up in conversation whenever it's relevant and getting to know my state representative and state senator. I also make noise towards the hospital's admins in the meanwhile.
---------------
Also, the article discusses possible alternatives. Here are a couple of paragraphs from it:
"This begins with our own training. Certainly doctors must understand disease, but medical education is overly skewed toward the biomedical sciences and minutiae about esoteric and rare disease processes. Doctors also need time to engage with the humanities, because they are the gateway to the human experience."
"To restore balance between the art and the science of medicine, we should curtail initial coursework in topics like genetics, developmental biology and biochemistry, making room for training in communication, interpersonal dynamics and leadership."
It doesn’t require 24-hour shifts or even a medical degree to do this kind of coordination. I did it and I have no medical training whatsoever. But it was pretty important work, and my dad would have been lost without it.
Methodologies such as Kepner-Tregoe explicitly make handovers very easy, used very effectively in manufacturing, energy, and other industries. But God forbid that almighty doctors should ever take any advice from outside their profession.
That's not modern reality and its shameful.
My spouse is an MD and she spends a minimum of 45 minutes before her shift reviewing her patients' charts. After work, at home she tidies up patient notes to ensure the next person gets an efficient summary of the patient. Then after dinner she's answering a bunch of instant messages from patients on the hospital's patient portal and doing any prep necessary for the next day.
Programmers would be collectively rending our garments if we had to do anywhere near the amount of unpaid / off-the-clock work as doctors do.
More often than not, if I got someone on the other line that seemed to know a bit, skipping the questions ended up being counterproductive, as I would assume some knowledge about a specific item from the other end that didn't exist (but other knowledge did). I learned to trust the process, and glean the extra bits of information that weren't what the other side was trying to convey, but did nonetheless.
I think it's a mistake to assume that just because the doctor asks you questions and doesn't always seem to take into account a prior answer the doctor is not listing. I think it's more likely that they have learned that the small percentage of time that asking similar questions in different ways has led to new, important information has led them to be careful and methodical, even at the expense of patients thinking they aren't listening.
When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other.
I don't disagree with what I interpret as the intent of your message - that there is real value in process, question repetition, and not jumping to conclusions.
I do think it implies a false choice at the end though. A doctor can imply they care / listen / are familiar with your case, while still asking insightful questions and probing for relevant changes.
[Analogy] As there are many engineers here, consider this contracting example: how would most companies respond if, for a project, at each meeting, the contractor sent a new representative, who asked all the same questions as the first meeting, could provide no status updates, and many reps suggested apparently different solutions, platforms, or approaches?
This is an important point but I feel you're approaching it from a very short term view. Look at Pakistan, for example: after the CIA used a vaccination program as cover for a genetic testing scheme meant to find Bin Laden [1], there was (and still is) a significant impact on the Pakistani and other population's trust in their domestic healthcare industry [2]. Even if it was a real Polio vaccination program that saved thousands of lives in a purely utilitarian short term calculation, the damage that distrust causes long term can far outweigh the benefits. Worst of all, due to the nature of that distrust, measuring that damage becomes so much harder.
The point is, doctors don't just need their patients to trust them, but to trust the institution of modern medicine and healthcare as a whole. They need the patients to trust their nurses, pharmacists, specialists, and technicians just as much as the primary doctor. Given how critical patient cooperation/honesty and preventative care are to clinical outcomes, I don't see any convincing evidence that patient perception isn't just as important as the rest of the process.
[1] https://www.theguardian.com/world/2011/jul/11/cia-fake-vacci...
[2] https://www.scientificamerican.com/article/how-cia-fake-vacc...
That does sound rather concerning if that's the case!
As a medical student about to sit my final exams, I have shadowed hundreds of doctors of different grades and specialties in many different hospitals and family practices, and I don't recall ever seeing a doctor not review the notes before seeing a patient. Often here in the UK at least there is a large amount of time pressure and it would certainly be desirable to have more time to review further back, in more detail, etc. but given in general practice there is a 10 minute slot per patient, there are systemic limits on this (that would be nice to address).
On the other side, trying to figure out what is going on with patients is much more complex than catching up on notes and trying to get a "delta" update from them about what has changed in the shortest space of time/words as possible. The number of times I have taken a history from a patient and then less than half an hour later observed them add hugely important extra details that were omitted previously is pretty large. Often, it is far more helpful and illuminating to ask a patient to tell you what has been going on in their own words, even if you think you have read it all in the notes. I have often seen more senior clinicians pick up subtle clues that were missed by more junior clinicians, or ask a pertinent question that was not asked before.
And finally, on a more pragmatic basis, doctors take a lot of risk on board whenever they treat a patient. Patient's get tired of people asking them if they have any allergies for example, but when it's your name on the prescription, and your ability to sleep and your license on the line, you may well decide to ask the patient again rather than rely on what some previous clinician in some previous setting has written down on the patient's file. In a similar vein, a lot of practice is not black and white. If a junior with limited experience writes that a particular clinical sign is positive in the notes, you may well want to repeat that examination to re-assure yourself before you allow it to guide your treatment.
None of this is excusing unpreparedness or poor practice, but hopefully shines a little light on some reasons why it seems like there is so much needless repetition.
Unfortunately, I expect this may create a lawyer averse culture where process is as repeatable as possible, because in the event of a suit, systematic process is a solid defense.
Think of it like talking to a project's stakeholders yourself rather than relying on requirements gathered by somebody else.
No. Doctors can have mostly normal 8-hour workdays, 5 times per week. Nurses administer drugs and monitor the patients. If a problem arise, they can call the doctor in charge of the patient or bring the doctor doing the night —or weekend— shift.
>> Friend's mother was recently in hospital, multiple doctors thru a single day, each one had to completely relearn what was going on.
> What's the alternative? 24 hour shifts for the doctor and the new doctor each day needs to relearn everything?
This is from your response:
> Is there really a need for 24 hour doctor visits most of the time?
The exact situation described is hospitalization. Pointing out that most treatment may not be on a 24h basis is not relevant here.
As has been pointed out in many submissions on HN about USA's medical practices, the main reason you get many visits is to inflate your bill. I think someone even wrote that he was charged $600 per 1-minute visit during his stay in the hospital.
Most residencies are paid for by Medicare. Big hospital systems just can't seem to find the funds to train doctors on their own.
This sounds like first world problems. You have a doctor you trust to go off script? You trust that when your kids' teachers treat them differently they aren't just stereotyping and limiting them? Lucky you. While you work to unshackle your providers from the mediocrity of "best practices" (and I say that as someone for whom "best practices" is a bane in my own work) keep in mind there are a lot of people for whom competent cookie-cutter care is a wish, not a disappointment. In technology we can let a thousand flowers bloom and we all get to choose and enjoy the most beautiful ones, but in education and health care there's no natural elimination of the worst and amplification of the best. Everyone just lives (or dies) with whoever they randomly end up with, so worst-case performance matters just as much as best-case, and average-case matters a whole lot more.
Of course, by now there is no turning back, and the government has decided that actually training doctors must be prevented at all costs.
VERY short term vision, constantly sacrificing the future for a quick buck, leads over the span of decades, to spiraling costs and worse outcomes. Who knew ? Well, everybody knew.
If you live in a town where smart and educated people like to live, you get the cream of the crop of doctors. It's very different from living in a backwater where ambitious young people aspire not to live. And most of the world lives in backwaters, with unexceptional doctors who make simple but deadly mistakes when they go off script.
The care I received at that hospital was a night and day difference compared to what I received in the suburbs.
My favorite experience was the time I was very sick, went to a doctor in the suburbs and was told I was absolutely fine, despite the coughing, difficulty breathing, looking like I was dying, chest pain and X-ray results. I was sent on my way without even a script for antibiotics.
The next day, I went to see my PCP who demanded the names of the doctors responsible for letting a patient with severe pneumonia leave their care without proper treatment. Said if I waited another day, I'd have to be hospitalized.
I payed just $3k, but that was ridiculous to be surprised by and I'm still confused what the treatment plan is because front desk didn't schedule me until July. The doctor is great but support staff has become so beuracratic...
You really don't have much contact with teachers if you believe this.
The education system runs in spite of its systemic horribleness precisely because there are enough teachers who do care and fight/ignore the system when necessary.
If you want to actually fix the educational system, we have models for doing so in several different countries. However, they all tend to share the same characteristics.
You have to raise standards for both admission and completion; you test to those standards; you raise salaries to match those standards; and you give respect, autonomy and authority to the people now adhering to those standards.
HOWEVER, that is going to cost money. Quite a lot of money. And, really, nobody is actually interested in doing that in the US. They're really only interested looking like they are concerned rather than actually fixing the problem.
This seems to imply that the US doesn’t spend enough money on education, even though it is (one of?) the highest spender(s) on education in the world (just from a quick Google search). I believe the real change needed is better management of how the existing money is spent.
The US isn't that out of line with spending:
US is $15,171 per student while Switzerland is $14,922 per student. US is 7.3% of GDP while Denmark is 8% of GDP.
Source: https://www.cbsnews.com/news/us-education-spending-tops-glob...
There is not some magic bank of "misused" money waiting to be tapped.
The US also has a lot of students who fall into the education assistance category (free breakfasts, lunches) who would fall into a "social safety net" in countries like Sweden and Norway. A lot of the poorest students eat up the largest chunks of funding.
Finally, the Gates Foundation, whom I don't necessarily like, has shown time and again two fundamental things about education attainment:
1) any SUSTAINED focused resource improves educational outcomes
2) resource allocation is strongly sub-linear--it takes FAR more than 10% more resource to cause 10% improvement in outcome from our current system
As anecdata about this misallocation in US education funding: I come from another part of the world (a first world country), and something that I have not, for the life of me, been able to reconcile with the funding arguments is the stupendous sports facilities that most schools have. High schools in the US have sports stadiums bigger than many cities where I come from. If there were a real funding problem in an education system, sports should be the first thing to downsize in order to protect the core mission. But the priorities are just not aligned right for education.
Also, schools in US are not funded equally and sports have special status in society. You have art teachers paying supplies out of pocket in one district and expensive stadium in another district. You have well funded schools and badly funded schools.
Fun example of inefficiency, - 2 units at university using same enterprise software package - I propose consolidating to one license, 1 server, both departments split cost. - Both department heads agree, both IT depts agree, campus IT agrees - cancelled last minute - that was 7 years ago, by now both departments combined (not each) would have saved $250k
I’d like to learn more about these 2 points, particularly the first (how it’s measured, etc). Is there any specific work of the Gates foundation you could point to?
https://docs.gatesfoundation.org/documents/Lessons%20from%20...
Page 16-17 talks about known effective programs and their costs. Note that the more expensive programs (almost all exceeding $15K per student--sometimes dramatically) are almost always more effective. Under $10K is almost uniformly not helpful and the further you get from 10K the less helpful they get. You can have effective programs for $10K, but it's really hard. Money really does make things easier.
From Page 21: "At the highest level, this “doing many things well” requirement results in a high degree of difficulty and is a key reason why high-quality early learning that sticks is so infrequently seen."
From Page 22: "ESSENTIAL ELEMENTS OF HIGH-QUALITY PRE-K THAT STICKS"
"3. Teachers delivering high-quality instruction is a key differentiator between early learning that sticks and early learning that, more than likely, will not stick. ...
4. All exemplar programs have two adults in the classroom—one lead teacher and one paraprofessional/aide— at all times. ...
5. All exemplar programs have maximum class size of 22 children or fewer and adult-to-child ratios ranging from 2:15 to 2:22. Adult-to-child ratios at the lower end of the range are particularly advantageous for classrooms where a significant number of English language learners (ELLs) are present and/or where a significant number of children with special needs are present.
6. Lead teachers with a B.A. plus suitable early learning credential, paid at same level as K-3 teachers. ...
7. Dosage. Three of the four exemplars offer pre-K that runs 6-6.5 hours/day, for 180-205 days/year. The other (Maryland) offers full-day (6.5 hours/day, 180 days/year) and part-day (3 hours/day, 180 days/year) options. It is clear from the exemplars and consistent with research findings that within high-quality pre-K programs the dosage required is related to the size of the achievement gap that must be closed for each low-income child. For low-income children who enter pre-K already on a trajectory to be kindergarten-ready, a high-quality part- day option may be sufficient. For most low-income children, at least one year in full-day, high-quality pre-K is needed to be kindergarten-ready. For low-income children for whom English is not spoken at home, children with special needs, and children who are significantly below age-level competency in one or more domains, it is likely that two years of high- quality, full-day pre-K is ideal and, in fact, may be necessary for most of these children to be kindergarten- ready on time. "
It goes on to other things as well.
And these exemplars are at the $10K-$12K per student mark, roughly. And even successful ones still can't get funding--"New Jersey was poised to expand the Abbott Pre-K Program in 2013, but budget pressures have delayed that expansion.".
And the Gates foundation is VERY gently suggesting that all the mediocre, non-useful programs should be shut down in preference to spending ALL that money on the most underperforming students. While this is likely the best use of resource, it is going to be a politically unviable one.
The upshot is that teaching properly is expensive, and money really DOES have an impact. And the effectiveness "breakpoint" is somewhere around $12K with some adjustmemts for cost of living. And your primary expense is the teacher vs class size--see page 17. The cost per student with a teacher at BA I qualification ranges from $10K with a 15 student class size to $8K with a 20 student class size. Of course, teaching effectiveness is inversely related to class size--pick your optimization point.
I don't always like the Gates foundation because I think they sometimes helicopter in, muck things up, leave, and then other people have to clean up the mess. However, they have been quite forthright with publishing their information and do acknowledge when they have NOT succeeded even when it goes against their agenda. That I applaud.
In the US at least, you can't read too much into the averages, because there are so many additional factors that vary by state and between cities. Some states spend far more per pupil than others, although different states can have very different cost-of-living, so comparing absolute numbers in that case doesn't make much sense.
Even within a state, different areas have very different cost of living, and very different hyper-local conditions like concentrations wealth or poverty, that have a big affect on how far each dollar spent goes.
[1] http://www.oecd.org/education/EAG2014-Indicator%20B1%20(eng)...
Maybe I've had bad luck in doctors. It's not like I get a choice in them, the way the US system works. Three times in my life I have had severe chronic problems that were ultimately solved by my own inexpert research and experimentation or by the inexpert observations of a casual observer. These days I only bother to go to a doctor after I have a good suspicion of what's wrong already, like if I broke a bone or something.
Technological innovations that reduce costs will be the most lasting ways to reform these sectors.
Regular people can change the countries they are living in if they don't like the tradeoffs their government is doing, you know... Or vote to change them, but don't be surprised when improving lives comes at the cost of losing "top dog" status.
(Note: I'm not an American, but I see the tradefoffs the U.S. made, and I understand they make sense to some.)
We should realize that it isn't a fundamental property of government, just the one we have and we have mechanisms for making changes that we haven't yet tried.
5% of patients are half of all costs in the US healthcare system; 1% of patients are 22% of the cost. People over the age of 65 are a greater share of cost in the US system than in universal healthcare systems, because the US doesn't have a big lever for rationing care.
The healthiest half, is 3% of the cost in the system.
A market healthcare system, which is widely considered immoral, will drop many of the most expensive and poorest patients from the system. That's how you can dramatically lower costs in the US system, if you want to go the market route. A market system would particularly focus on the 50% that are only 3% of cost, with costs being far higher for everyone else (resulting in lack of access to expensive treatment for many, and many millions of people would get denied healthcare coverage due to pre-existing conditions).
A universal healthcare system smashes costs by rationing care, and tightly controlling everything from drug prices to healthcare worker salaries.
The US today has neither of those approaches widely implemented. We have a lot of government and private healthcare without enough of the tight cost checks. The obvious outcome, is a perpetual cost spiral until it can't spiral anymore (which is about where we're at now).
Is that including the entire population or just those on Medicare?
> government's mostly laissez-faire approach to handling both
actually those are among the most heavily regulated and subsidized industries in the us.
Spending goes up because a majority of politically engaged people have good access to care that they don't directly see the cost of.
Yep, and they all have administrators that make a ton of money.
I worked for a Blue Cross Blue Shield franchise a decade ago. It is/was a "non-profit", the CEO made 2.1 million dollars per year.
Non-profit != Money well spent
But hundreds of millions in executive salaries at companies that pay billions in insurance claims isn't the thing driving health care costs. It barely registers.
http://www.commonwealthfund.org/publications/in-the-literatu...
Overall the administrative overhead is 8% for healthcare in the US, more than double global average (3%)
http://money.cnn.com/2017/01/11/news/economy/healthcare-admi...
That 25% share, is about double what it is in Canada (although a few are equally high, the Netherlands is at 20%).
The famous chart showing the US growth in admin vs physicians since 1970: https://i.imgur.com/lnIcjo2.jpg
If a dollar amount chart showed the same effect it would do a better job of making the point that chart is intended to make. But I think it is pretty likely that the 1970 administrative baseline is tiny (because in 1970 there were lots of small hospitals run by 1 doctor).
But you could sidestep all of that by comparing to other countries, non of which ever had a significant number of “small hospitals run by 1 doctor”; their expenditure as a percentage is mostly consistent through the years and about half as high as the US, with similar trends in education.
The higher administrative costs at US hospitals account for something like 3% or 4% of total US healthcare spending. A huge win if you take it all back and not any sort of solution to the cost problem.
Why do the overnight shift of nurses take vital signs every four hours? So they catch rapid unexpected changes in patient conditions more quickly. Put more crudely, so they don't accidentally leave a corpse in a bed for the next shift. Having to write, or type, the patient's blood pressure into a log is a way to help the overnight nursing shift remember to pay detailed attention to each patient, at least for a few moments. If their instructions were "stop at each door and listen for the patient breathing" those nurses might well miss important changes.
Hospital care these days is not only about the towering figure of the heroic superhuman doctor, Harvard Medical School lore to the contrary notwithstanding. It's about all the folks who look after patients, from the community primary care doctor to the RN, to the chaplain, to the "hospitalist" physician, to the person who cleans up, to the person who maintains all the electronic gear. The challenge is getting all these people to cooperate with the patient and for the patient's benefit.
The superhuman healer approach to medicine demands superhuman people to be doctors. They aren't, any more than the rest of us are. They have to sleep, and to eat, and to see many patients. So, a good hospital needs to be organized like a good company: where each person's skills and passion complement the others, and gets an extraordinary result from a collection of ordinary people. The buzzword for that is "synergy." Good discipline--good and predictable process--is part of synergy.
And, at the end of all that excellent care on our behalf, each and every one of us will become a corpse. A nineteen-year-old with a broken leg can be cured. A 90-year-old with cancer and pneumonia, not so much. It doesn't matter how towering a figure the doctor is, or how kind the nurse is.
A radical move in medicine would be to come to terms with death as a natural part of life rather than as a failure of the system.
All the procedures you describe seem like very important improvements in quality of hospital care, but there is (or should be) more to the healthcare conversation than what happens in the hospital
The first sentence of the second paragraph of the article you seemed to have avoided reading says:
“Checking things like temperature, blood pressure and respiratory rate every four hours on hospitalized patients has been the standard of care since the 1890s, yet scant data indicates that it helps.”
But this is not the case. In the UK, these observations are entered into a proforma by the nursing staff which allows them to calculate a "National Early Warning Score". Based on the patients score, the nurse has to escalate to an appropriate team and the doctor on the appropriate team has to take the referral.
Not only does this help identify deteriorating patients, but it helps to fight human factors like "I don't want to call such and such a doctor because they are always rude on the phone so I'll just leave it and hope it gets better"
In terms of actual data, we have a national body (NICE) that provides guidelines and recommendations based on appraising the available data and research. For NEWS scores, see:
For an overview: https://www.nice.org.uk/guidance/cg50/chapter/1-Guidance#phy...
For the full report and evidence used to compile the guideline: https://www.nice.org.uk/guidance/cg50/evidence/full-guidelin...
Maybe DNR / palliative-care patients should get a break on the four-hour vital sign gathering. But people start yelling "death panels" when this sort of thing comes up in hospital policy.
Of course doctors are ordinary people. The ones that become doctors these days aren't even the brightest in school -- those go into STEM or, god forbid, finance.
But if they are ordinary people why are they paid like the superhuman healers that they aren't and still hold themselves as such?
They're not. The lifetime after-tax expected earnings of a person entering medical school today, after work and operating expenses are taken into account, is probably a lot less than the equivalent figure for the average Hacker News reader.
Doctors make nowhere near as much money as people think they do, and that incorrect perception is based on stereotypes that haven't been true for decades.
From the practioners' point of view, especially for those who care for people over 65, socialized medicine has already arrived in the US. The rules around care and reimbursement are rigid.
You'll get an occasional congresscritter who used to be an obstetrician or dentist claiming it isn't so. But those specialties don't have to try to get paid by Medicare.
We simply cannot have healthcare for everything, including rare, expensive and/or hopeless diseases (or all 3 at the same time). As long as that's what we demand, healthcare will go wrong.
And let's please just stop pretending that this is somehow an America-only problem, caused by whatever (democrats: by not being public conservatives: by public largesse. And yes, despite how it sounds I do think both arguments have merit). True, America has it bad, but healthcare is failing, financially or otherwise everywhere in the developed world [1]. And healthcare in the non-developed world ... well, this was in the newspaper 2 days ago [2].
Healthcare is failing in the developed world for economic reasons. Those are not about to change, so it will get worse unless we figure this thing out with major changes (which ARE going to include limiting treatment).
[1] https://www.politico.eu/article/europe-health-care-systems-o... or more specific https://www.theguardian.com/society/2016/aug/16/nhs-cancels-... https://www.bloomberg.com/news/articles/2013-01-03/frances-h... and let's just not mention Spain or Greece's health care system.
[2] http://deredactie.be/cm/vrtnieuws.francais/Soci%25C3%25A9t%2...
a) somehow this patient developed a ruptured liver and severe trauma to the skull (given that he survived the flight and was conscious we can easily conclude that neither injury was present before the hospital got involved)
b) missed that someone at the hospital has removed the heart and kidneys from the patient
c) signed off on a "natural causes" death certificate, no mention of what happened to the organs
(note that organs for transplant need to be taken out before death occurs, so it's not like they removed them with the family's permission after clinical death)
d) refuses to investigate how this happened
e) got the government to concur, and actually the government is helping them with d)
That's something that got reported last week, and this was a hospital in India, so third world healthcare.
We need to get back to our roots. A free market where people can buy what they want when they want it. Health care insurance is an oxymoron. Everyone gets sick. There is no probability of someone NOT using the system. The minute you try to amortize the costs over time or large populations to provide services, there is infinite demand.
Insurance would make sense for events that are RARE. House fires, automobile accidents, gun accidents, etc. (BTW, why isnt gun insurance mandatory? That way everyone could be happy- you could still buy a gun as long as you paid your $5000 premium. The insurance companies could make more money, there would more 'gun control', and the money could go to the emergency rooms that take care of shooting victims. But OH NO! Hospitals would figure out a way to spend that money too and it would never be enough!! Maybe the gun insurance premiums could be given to the victims !)
Anyway, there is no easy fix until we start to force our politicians to GET OFF THEIR ASSES. It particularly annoys me that they offer 'thoughts and prayers' after each mass murder and do nothing else. They should be in Florida digging the graves. Representing their constituents properly.
Cost for repairing hernia is not exactly the same for every patient though. Depends on the severity, general health of the patient and a million other things.
Not sure if its even possible to put an upfront price. Even if they did, how do patients know beforehand what exactly they need to figure how much they are going to pay. Maybe that works for simple things like a flu shot but seems impossible to for anything even slightly more involved.
Sure, there's some inherent variance always - the same thing happens in many industries and doesn't prevent them from offering fixed quotes; the service provider is the one best qualified to estimate the expected variance in their costs and offer appropriate pricing.
Sure, there may be special requirements that justify charging extra for a particular case; that's not an obstacle from telling the customer about that beforehand. Well, not in ER, but most care is not ER.
I 've never seen a chart with prices for hernia in the lobby , anywhere that I've lived( I am not from USA).
Where has it been successfully done?
E.g. a link to a random local (to me) hospital's pricelist (not in English, sorry) https://www.aslimnica.lv/lv/content/neirokirurgijas-operacij... starts with two different procedures for herniated spinal disc repair. That's it, if your doctor recommends to do this operation, then if it's not covered by your insurance this is what you'll pay for the procedure followed by a standard per-day inpatient fee for however you're required to stay during recovery. It's up to the hospital how to split the amount among all the involved specialists labor, equipment, drugs and supplies required.
As far as I've seen when traveling, the same (i.e. once it's clear what you want to be done, there's a price known beforehand) applies in most European and Asian countries, but it's hard to provide online examples as you must look for the local non-english (the english-speaking market, USA+UK+UK dominions, seems quite different from the rest of the world) services since English websites tend to be oriented for "medical tourism" services which is different from how the locals handle their healthcare, and there's a significant language barrier.
How does pricing of elective surgeries work in your area?
But this exactly the same in USA too. I got shoulder surgery in USA. Doctors office took my insurance information and called my insurance provider and told me how much my insurance covered and how much I am going to pay for it. I paid exactly that amount out of pocket post surgery.
yes, this is what it is like to be a patient at a hospital these days. And good luck if the patient wants to speak to a physician. and don't ever go to a teaching hospital if you have the choice. some intern will have the brilliant idea to adjust every medication you are taking.
A modern hospital is a zero trust environment.
Someone i know worked as a surgery nurse - by now almost 40 years ago. The surgeon was quite choleric - and once, when a cotton -wad was unaccounted for threw a sewn off hip joint twoards those who dared to assist him.
All praise be upon the anaesthetist.
When you can send your diagnostic images to get a consult from 2 clinics in India and an expert system for less than the price of a three block ambulance trip in the US, prices for domestic care will come down.
in the US healthcare market the payment model will have to change before Indian healthcare market prices have an impact.
in other words, US legislation that takes money away from the current system of providers would need to be passed. (i mean, why doesn't the US medicare/medicaid system take advantage of the lower costs you're describing by flying US patients to hospitals in other countries for major, expensive procedures and other treatments? they could save a lot of money, but US law does not currently allow payment to providers all over the world.)
US hospitals, doctors, pharma, etc have created a closed system wherein they are the only service and product providers. i think they like that aspect of the current system. they've built themselves a moat and globalization cannot enter.
I agree that the barriers you mention are real, but those are in the domain or class of solvable problems. Apps like Figure1 are a good example of how doctors are moving around this.
To borrow from Nial Ferguson's new book, the big CMS/EHR players (nightingale and another one here) control the integration points and hierarchical relationships, but I think they are vulnerable to networks.
Maybe not the main point of this article, but there are numerous occasions where I’ve encountered just this. Allied health professionals, all of whom are very well intentioned, making recommendations that physicians readily follow without taking into consideration the needs or desires of the patient and family. If as a physician you are being advised to declare a patient NPO or to send them off to a skilled nursing facility instead of home - please remember that this is just a recommendation and that it’s your job to look at the patient as a whole, including their general medical condition, likelihood of their family supporting them, etc. before following through.
Also, BP, weight, and temperature are important diagnostic indicators
"Checking things like temperature, blood pressure and respiratory rate every four hours on hospitalized patients has been the standard of care since the 1890s, yet scant data indicates that it helps."
If by "business" you mean a public/private hybrid in which profits are privatized while losses are socialized, then you are correct, in so far as health care goes. And that seems to be the model that is now being adopted in more and more areas of economic activity.
I will say that truly private medicine is, in my reasonably broad experience, excellent. I use a private subscription-only medical service in the US which is excellent (and procedures are generally cheaper than they would be in a public hospital, whether I’m paying with insurance or out of pocket), and my experiences with private medicine in SE Asia and Mexico have been excellent (and affordable) as well (to a greater degree than can be explained by labor cost differences).
But they very clearly do. A huge proportion of their income comes from government sources (Medicare/Medicaid/VA), they are subsidized by tax exemption for health spending, and government grants them the power to deny competitive entrants into their markets via "certificates of need."
Hospitals lose money on Medicare and Medicaid patients on the margin. They have to overcharge private insurers to make up the difference.
It's so bad that Medicare has not one but multiple programs to compensate hospitals that don't see enough private patients to make up the difference, because otherwise they wouldn't be able to sustain themselves on Medicare reimbursement rates.
I don't know why you're even mentioning the VA; it's not relevant here at all.
> I don't know why you're even mentioning the VA; it's not relevant here at all.
Normal non-VA hospitals accept VA patients and are reimbursed for them.
You seem to be under the impression that there's some deception going on here. There's not, and it's pretty plainly evident. Medicare's reimbursement rates are below COGS. Hospitals control neither of those two things (Medicare sets rates by fiat, and if hospitals could lower COGS by paying vendors less, they would).
As for why they keep taking them - they oftentimes have no choice, legally. Though, incidentally, in recent years, we've started to see hospitals find more creative ways to close their doors to Medicare patients for this exact reason.
> Normal non-VA hospitals accept VA patients and are reimbursed for them.
The number of VA patients hospitals see is negligible. The amount of revenue they receive, proportional to the number of patients they see, is even less.
But as with all things YMMV.
Physicians have gone from small business owners to rank and file employees of large corporations. The burnout that is increasingly common among physicians is not unlike that of american office workers in the 1990s.
I'd love for the next stage of the evolution of healthcare to see physicians as customer focused, tech savvy entrepreneurs
How would this help solve the problem the article started with, that patients don't heal because they're deprived of sleep by being woken up every 4 hours? It's a problem everyone knows about (I saw complaints about it online years ago) -- so it's not directly a communications problem. Leadership I can see: it seems needed to dig the system out of an inadequate equilibrium (https://equilibriabook.com/molochs-toolbox/) but that's pretty different from college courses in leadership.
It's not to say I don't appreciate being alive, but we can do better for those suffering.
I think it's not a matter of finding the solution to the problem, but a maximization problem, where we have:
- patients who need to be cared for as human beings and allowed to make their own informed decisions, but who are generally not experts in medicine
- physicians who have more patients than they can keep in their minds at once, and who are reliant on nurses and computerized systems to keep patients breathing and not get sued, but who are also skilled, highly-educated professionals whose human judgment is frequently superior to any algorithm
- nurses who are both underpaid and responsible for more than their training considered
- hospitals that need to pay the bills, pay salaries, attract new physicians, etc.
There are so many conflicting aspects of this problem that any simple solution is probably unrealistic.
In other words, train doctors to be social justice activists rather than scientists? No thanks.
Unfortunately, treating makes more money than curing and the United States is scared to death of what shall they do with all that free time if they actually do cure, while other countries do not work themselves to death because they do not have an artificially controlled supply of Doctors...
Firstly, it assumes that neither doctors, nor the scientists and researchers working in the companies and universities that drive medical progress forward, have an ounce of self-respect for either themselves, their family members or members of the community - because if true, either family members and themselves would never get cancer or other chronic diseases that we 'treat', or if they are somehow as vulnerable as the rest of the population to these conditions, that maybe there is a secret stash of 'cure' somewhere that they allow out to the people in the know. The conspiracy goes deep...
Secondly, it throws out the window all the evidence around what we can actually cure and what health policy seeks to do. We have an entire field of medicine called preventative medicine that aims to stop conditions before they happen, by lobbying governments to ie. Ban or decrease rates of Smoking and alcoholism, to provide safe needle exchange so IV Drug Users don't get bloodborne diseases, to improve exercise rates, to provide vaccination programs - all of which stop disease from happening. The fact of modern life in a western country is that most of the burden of disease is related to lifestyle factors or age related - Osteoarthritis (Age and Obesity), Cancers (Lifestyle risks and age), Diabetes (Diet, exercise, genetics) Cardiovascular disease (Exercise, Age, Lifestyle risks, diet).
It also ignores the tremendous advances that are still occuring. When I was in my final year of Medical school, 5 years ago, Metastatic Melanoma was a condition with an average survival of 6 months. It is now (thanks to some incredible, and incredibly expensive drugs - don't get into a debate about cost here, I live and practice in Australia and the cost for a patient is capped at $46.60 per year as it is on the PBS) more of a chronic disease with average survival in the 4-5 year range. Incredible, and this progress occured in 5 years. Similarly, Hepatitis C, a condition that in it's chronic form invariably results in liver cirrhosis and failure, can now be cured - this was unthinkable 5 years ago, and is now a fact, with a 12 week course of medicine.
Please inform yourself and don't just trumpet that which you hear on the internet. Your ignorance is not as valid as my knowledge and to assume that in your version of this myth that insurance companies (but in the more common version of this myth, Doctors, Pharmaceutical Companies etc) are primarially interested in keeping the population teetering on the edge to milk them dry is disingenuous.
>This is an absurd and oft-repeated claim that taps into variations of the conspiracy thinking around 'doctors keeping the cure for cancer (or insert other condition here) secret' because powerful lobby groups insist that there is more money to be made in 'treating' than 'curing'. It is patently untrue.
Where are your sources? I never stated that they are hiding the cure for cancer? It is a fact that treating vs curing is a business model in the United States. The U.S outspends everyone yet gets them same results >https://www.npr.org/sections/goatsandsoda/2017/04/20/5247741...
It is also true that privacy data laws and business models are impeding the impact of disruption in healthcare where technology is disrupting every other field. (https://www.bloomberg.com/news/articles/2017-11-28/alphabet-...)
I never mentioned anything about Australia, I was talking about the United States. I cannot speak for Australia.
>Please inform yourself and don't just trumpet that which you hear on the internet.
The fact that medical records are not electronic being a standard is laughable. I cannot speak for anyone else but the United States. HIPA laws are one of the reasons which makes it harder for researchers and doctors to actually get data they need to develop cures because of the need an individual signature for everyone.
Regarding Supply of Doctors >In the United States, the supply of doctors is tightly controlled by the number of medical school slots, and more importantly, the number of medical residencies. Those are both set by the Accreditation Council for Graduate Medical Education, a body dominated by physicians’ organizations. The United States, unlike other countries, requires physicians to complete a U.S. residency program to practice. (Since 2011, graduates of Canadian programs have also been allowed to practice in the U.S., although there are still substantial obstacles.) This means that U.S. doctors get to legally limit their competition. As a result, U.S. doctors receive higher pay, and like anyone in a position to exploit a cartel, they also get patients to buy services (i.e., from specialists) that they don’t really need. (https://www.politico.com/agenda/story/2017/10/25/doctors-sal...)
Limits on the supply of doctors a conspiracy? >https://mises.org/library/how-government-helped-create-comin... >https://skeptics.stackexchange.com/questions/4561/does-the-a... >https://www.quora.com/Who-or-what-controls-the-number-of-med...
It is also a fact that insurance companies are the most powerful lobby in the United States. >https://www.cbsnews.com/news/ex-dea-agent-opioid-crisis-fuel...
Business Model Point >Imagine a portable, low-intensity X-ray machine that can be wheeled between offices on a small cart. It creates images of such clarity that pediatricians, internists, and nurses can detect cracks in bones or lumps in tissue in their offices, not in a hospital. It works through a patented “nanocrystal” process, which uses night-vision technology borrowed from the military. At 10% of the cost of a conventional X-ray machine, it could save patients, their employers, and insurance companies hundreds of thousands of dollars every year. Great innovation, right? Guess again. When the entrepreneur who developed the machine tried to license the technology to established health care companies, he couldn’t even get his foot in the door. Large-scale X-ray equipment suppliers wanted no part of it. Why? Because it threatened their business models. (https://hbr.org/2000/09/will-disruptive-innovations-cure-hea...)
In the US it is a standard that Medical Records are digitised. Unfortunately the existing eMRs are so awful that they decrease efficiency, so much so that many american clinics are removing them - [0, 1, 2]. If you think that the limiting factor on advances in medical research are access to digital records, you are severely misguided.
We have the same control on medical school spots in Australia. We train 1 per 6,285 people per year. You train 1 per 16,150 (roughly). However you also have Nurse Practitioners and a range of other allied health professionals and are a huge importer of overseas Doctors. It's not an ideal solution for the country. In Australia the medical colleges can limit training positions and this cartel behaviour has been the focus of the ACCC a number of times. On the other hand, How can you ensure that people are appropriately trained in the field they are representing, and going to be a net positive to patient safety? I have some ideas that I will be trying if I get to Series B.
I can't speak to your inventor of the X-Ray machine but would suggest that if in the last 18 years he has still been unable to get a market for it, or to launch it himself, than probably the technology has other problems than having a distributor. Disruptive technologies always find a way.
Let's be very clear: there are a lot of problems with healthcare, particularly in the United States. One of the biggest problems worldwide is that healthcare is a demand-inelastic good. When someone needs it, they will pay whatever they can to get it. In my opinion the US model is so completely fucked that the only way I see it being fixed is by transitioning to a post-scarcity economy. An illustrative example: When I was undergoing my medical school elective in Boston in 2013, which under Romney introduced State-wide access to insurance, I observed people accessing their care inefficiently. For example, Tram Drivers coming to Beth Israel Deaconess to have their Lipoma operated on by the Professor of Plastic Surgery at Harvard, because they had insurance. Normally this patient would have presented to the County Hospital, which in the US is the most efficient provider of care, but because they were able to access insurance, they wanted gold-plated healthcare. This is an example of 'universal care' twisting the market forces even more, as the most efficient providers of care are put under more pressure.
[0] https://www.fiercehealthcare.com/it/study-docs-spend-more-ti... [1] https://www.fiercehealthcare.com/practices/unhappy-ehr-one-p... [2] https://twitter.com/gphymel/status/952559168975769600
The manufacturing operations-ization of hospitals is both good and bad. Good because that means we have standard care (as desired by regulators and single-payer advocates) but bad because doctors lose the ability to perform customized care solutions.
I’m in favor of single-payer but we have to guard against turning healthcare into a manufacturing operation while also bouncing out bad actors and poo-quality physicians.
Hospitals account for the largest chunk of healthcare spend (30%). Hospitals make money by increasing inpatient admissions, particularly for profitable surgeries. The standardization of care in hospitals is intended to maximize profit under the constraints of various regulations around readmissions penalties, reimbursement limited length of stay, etc. If you look at the financials of public hospital companies like HCA and Community Health and Tenet, their major metrics are growth in admissions and surgeries. Even non profit hospitals are driven by this
The expansion of hospitals into owning tons of formerly independent specialist and generalist physicians is scary. Once in a hospital's system, these physicians act as loss leaders funneling patients into the hospitals profit center
Having hospitals in charge of the healthcare system is like having a fox in charge of the proverbial chicken coop
https://news.ycombinator.com/newsguidelines.html