kottke.org posts about healthcare
Atul Gawande’s articles on healthcare for the New Yorker are all top-shelf, but his most recent piece on modern medicine’s difficulty in dealing with patients who are likely to die is a doozy and a must-read.
Almost all these patients had known, for some time, that they had a terminal condition. Yet they-along with their families and doctors-were unprepared for the final stage. “We are having more conversation now about what patients want for the end of their life, by far, than they have had in all their lives to this point,” my friend said. “The problem is that’s way too late.” In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or “I’m sorry” or “I love you.”
Warning: it’s good, but you’ll probably be crying by the end of this article.
Update: Shoshana Berger on How to Die in 5 Easy Steps.
My father didn’t die nearly so well. At 74, after a 50-year career as a professor of mechanical engineering, he lost his mind. At first he’d cover his mistakes with jokes-a forced punch line after slipping up on calculating the tip at dinner. Have you noticed how forgetful he’s getting? His second wife whispered to me in the kitchen after a family meal. I hadn’t. But it wasn’t long before his colleagues politely suggested that it was time for him to retire. He’d been spotted in the elevator, the doors opening and closing repeatedly, as he stood there incapable of deciding which button to push. He could no longer locate his car in the lot. The faculty feared he was a danger to himself. Not long after, my father left his office; it’s piles of professional journals and papers, and the poster hung on the back door, “I’M GOING TO BE AN ENGINEER LIKE MY MOM,” expecting to be back.
This clever graph by National Geographic shows the cost of healthcare compared to life expectancy in a number of countries. The way that the US healthcare expenditure is pictured entirely outside the confines of the graph’s scale and legend is a particularly effective design decision. (thx, jim)
In the early days of the United States (and even in the colonial days), there were struggles about how to handle healthcare. Was it the responsibility of the federal government, the state government, or the individual?
Health care in Colonial America looked nothing like what we’d consider medicine today, but the debates it triggered were similar. The danger of smallpox and the high cost of its prevention led to divisive questions about who should pay, whether everyone deserved equal access, and if responsibility lay at the feet of the individual, the state, or the nation. Epidemics forced the early republic to wrestle with the question of the federal government’s proper role in regulating the nation’s health.
A recent blog post by Roger Ebert shows that more than 200 years later, we’re still having this same basic argument.
I am told we cannot trust the government. I believe we must trust it, and work to make it trustworthy. We are told the free enterprise system will sort things out, but it has not. When insurance companies direct millions toward lobbying and advertising against a health care system, every dollar is being withheld from sick people. When it goes to salaries, executive jets, corporate edifices and legislative manipulation, it isn’t going to Amy Caudle.
Foreign Policy has a list of the worst healthcare reforms in the world…the list includes China, Russia, the United States, and Turkmenistan.
So, in a frankly insane healthcare reform effort, [Turkmenistan’s “President for Life” Saparmurat Niyazov] restricted the public’s access to care by replacing up to 15,000 doctors and nurses with unqualified military conscripts. The next year, he ordered hospitals and clinics outside of the capital, Ashgabat, to close — even though the vast proportion of Turkmenistan’s population lives in rural areas. The BBC quoted him as saying, “Why do we need such hospitals? If people are ill, they can come to Ashgabat.” He also implemented fees and created an “unofficial” ban on the diagnosis of certain communicable diseases, like hepatitis.
(via mr)
Atul Gawande and some colleagues searched the US for healthcare successes — hospitals and clinics where costs are relatively low and quality of care is high — and came up with a few lessons.
If the rest of America could achieve the performances of regions like these, our health care cost crisis would be over. Their quality scores are well above average. Yet they spend more than $1,500 (16 percent) less per Medicare patient than the national average and have a slower real annual growth rate (3 percent versus 3.5 percent nationwide).
I wanted this article to be much longer than it was with breakouts of each of the ten lessons with lengthy explanations.
Can you put a dollar value on a human life? Peter Singer writes that the US needs to do just that if we’re serious about making our healthcare system work.
You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?
If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man - and everyone else like him - with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.
I’ve got two follow-ups to share with you regarding Atul Gawande’s New Yorker piece about healthcare costs in the US (kottke.org post). In the Wall Street Journal, Abraham Verghese argues that in order for a healthcare reform plan to be successful, it has to include cost cutting.
I recently came on a phrase in an article in the journal “Annals of Internal Medicine” about an axiom of medical economics: a dollar spent on medical care is a dollar of income for someone. I have been reciting this as a mantra ever since. It may be the single most important fact about health care in America that you or I need to know. It means that all of us — doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others — are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not? — it’s hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman’s plan and scuttled Hillary Clinton’s proposal.
In Gawande’s example, what Verghese is saying is that you can’t just make McAllen’s healthcare system adopt an El Paso type of system without a whole lot of pain.
Gawande addressed some of the criticisms of his article on the New Yorker site. One of the major criticisms was that McAllen’s higher costs were associated with higher levels of poverty and unhealthiness:
As I noted in the piece, McAllen is indeed in the poorest county in the country, with a relatively unhealthy population and the problems of being a border city. They have a very low physician supply. The struggles the people and medical community face there are huge. But they are just as huge in El Paso — its residents are barely less poor or unhealthy or under-supplied with physicians than McAllen, and certainly not enough so to account for the enormous cost differences. The population in McAllen also has more hospital beds than four out of five American cities.
Taking a cue from auto insurance, Safeway has devised a healthcare insurance plan that emphasizes personal responsibility.
Safeway’s plan capitalizes on two key insights gained in 2005. The first is that 70% of all health-care costs are the direct result of behavior. The second insight, which is well understood by the providers of health care, is that 74% of all costs are confined to four chronic conditions (cardiovascular disease, cancer, diabetes and obesity). Furthermore, 80% of cardiovascular disease and diabetes is preventable, 60% of cancers are preventable, and more than 90% of obesity is preventable.
The result is that Safeway’s healthcare costs have held steady over the past four years while the costs at other American companies have increased almost 40%.
On Friday, Atul Gawande gave the commencement address at the University of Chicago Pritzker School of Medicine. The address touched on some of the same themes as his recent piece on the differing costs of healthcare across the US. He began with an anecdote about how observation of well-nourished children in poor Vietnamese villages led to village-wide improvments in curbing malnutrition.
The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways — feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to.
And I don’t know why, but I’ve always thought of surgery as primarily a cerebral pursuit; a great surgeon is so because he’s clever and smart. A short passage from Gawande’s address reveals that perhaps that’s not the case:
In surgery, for instance, I know that I have more I can learn in mastering the operations I do. So what does a surgeon like me do? We look to those who are unusually successful — the positive deviants. We watch them operate and learn their tricks, the moves they make that we can take home.
So surgeons learn surgery in the same way that kids learn Kobe Bryant’s post moves from SportsCenter highlights?
Obama read Atul Gawande’s article about the differences in healthcare costs in different parts of the US and was so taken by it that he had a meeting about it with his aides and mentioned the piece in a meeting with a group of Democratic senators.
As part of the larger effort to overhaul health care, lawmakers are trying to address the problem that intrigues Mr. Obama so much — the huge geographic variations in Medicare spending per beneficiary. Two decades of research suggests that the higher spending does not produce better results for patients but may be evidence of inefficiency.
Obama is indeed reading this guy’s stuff. (thx, cliff)
Atul Gawande discovered that McAllen, Texas spends more per person on healthcare than El Paso (which is demographically similar to McAllen) and set out to find out why. Along the way, he encounters a curious relationship between the amount spent on healthcare and the quality of that care: higher spending does not correlate with better care.
When you look across the spectrum from Grand Junction to McAllen — and the almost threefold difference in the costs of care — you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.
Obama, you’re reading this guy’s stuff, yes? Get him on the team.
Update: Dr. Peter Orszag is the Director of the Office of Management and Budget for the White House and is working on some of the problems that Gawande talks about in this article. Here’s a 40-minute video of Orszag speaking on “Health Care - Capturing the Opportunity in the Nation’s Core Fiscal Challenge”. (thx, todd)
I changed the bit in the first paragraph about El Paso and McAllen being “nearby”. Funny, I thought 800 miles in Texas *was* nearby. (thx, stephen)
I also changed “lower spending correlates with better care” to “higher spending does not correlate with better care”…those two statements are not the same. I misread the results of one of the studies that Gawande mentions. (thx, patrick)
From the New Yorker last week, Atul Gawande on how the US should nationalize healthcare. His answer: nationalize slowly, use what’s already in place, and don’t rebuild the whole system from scratch.
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.
As usual, Gawande makes a lot of sense. Whatever the solution, we should be doing all we can to avoid something like this from ever happening again:
“When I heard that I was losing my insurance, I was scared,” Darling told the Times. Her husband had been laid off from his job, too. “I remember that the bill for my son’s delivery in 2005 was about $9,000, and I knew I would never be able to pay that by myself.” So she prevailed on her midwife to induce labor while she still had insurance coverage. During labor, Darling began bleeding profusely, and needed a Cesarean section. Mother and baby pulled through. But the insurer denied Darling’s claim for coverage. The couple ended up owing more than seventeen thousand dollars.
In an effort to curtail healthcare spending, the Japanese government is requiring companies to cut the number of overweight workers (and their dependents!) by 25% as of 2015. Companies which fail to do so will have to pay into a fund for elderly care.
Reduced exercise, the adoption of western foods and an aging population have made Japanese men about 10 percent heavier than they were 30 years ago, ministry statistics show. Women are 6.4 percent fatter.
The ministry estimates that half of men over age 40 and 20 percent of women will be diagnosed with metabolic syndrome. For men, a key yardstick is whether they have a waistline wider than 85 centimeters (33.5 inches). Body mass, cholesterol, blood pressure, blood sugar and smoking will also be taken into account.
A group of federal researchers reports that there were 100,000 fewer deaths in 2004 among the overweight than would have been expected of people of normal weight.
Overweight people have a lower death rate because they are much less likely to die from a grab bag of diseases that includes Alzheimer’s and Parkinson’s, infections and lung disease. And that lower risk is not counteracted by increased risks of dying from any other disease, including cancer, diabetes or heart disease.
Related to the dentistry post from the other day, comes word from England that even with socialized medicine, six percent of people questioned in a survey “admitted they had resorted to self-treatment using pliers and glue”.
As dentists push their fees higher and make more money on high-end services like cosmetic dentistry, a growing number of people cannot afford treatment for even minor work like fillings. And even though the dentists won’t treat those patients who can’t pay, the ADA has “fought efforts to use dental hygienists and other non-dentists to provide basic care to people who do not have access to dentists”.
“Most dentists consider themselves to be in the business of dentistry rather than the practice of dentistry,” said Dr. David A. Nash, a professor of pediatric dentistry at the University of Kentucky. “I’m a cynic about my profession, but the data are there. It’s embarrassing.
When celebrities have heart attacks, they go to *two* hospitals.
Brown had severe chest pains Tuesday night and was taken to two hospitals.
I wish Mr. Brown a speedy recovery and hope he isn’t required to visit too many more hospitals before receiving the care he needs.
In order to minimize recovery time and scarring, doctors are attempting to make use of existing holes in the body for surgery instead of making new ones. “Much of the discomfort and recovery time after conventional surgery — even keyhole surgery — is due to the incisions made in the abdominal wall. However, because transgastric surgeons reach the abdominal cavity through the mouth, there is no need for an incision, so patients should be back up on their feet much faster.”
Atul Gawande on the state of health care for the elderly. “Mainstream doctors are turned off by geriatrics, and that’s because they do not have the faculties to cope with the Old Crock. The Old Crock is deaf. The Old Crock has poor vision. The Old Crock’s memory might be somewhat impaired. With the Old Crock, you have to slow down, because he asks you to repeat what you are saying or asking. And the Old Crock doesn’t just have a chief complaint — the Old Crock has fifteen chief complaints. How in the world are you going to cope with all of them? You’re overwhelmed.” This article depressed the hell out of me.
A personal experience with and a decision on the abortion issue. “I think about all those meddling politicians that would want to interject themselves into everything that just happened to me, interject themselves between me, my wife, and her doctors.”
Short profile of Atul Gawande, surgeon and writer, one of the few New Yorker contributers I make a point of reading every single time I see his byline. “I now feel like writing is the most important thing I do. In some ways, it’s harder than surgery. But I do think I’ve found a theme in trying to understand failure and what it means in the world we live in, and how we can improve at what we do.”
How doctors make their decisions is being studied in the hopes of making medical care better. “Doctors can also make mistakes when their judgments about a patient are unconsciously influenced by the symptoms and illnesses of patients they have just seen. Many common infections tend to occur in epidemics, afflicting large numbers of people in a single community at the same time; after a doctor sees six patients with, say, the flu, it is common to assume that the seventh patient who complains of similar symptoms is suffering from the same disease.”
Interview with Jill Youse, who started the International Breast Milk Project because she has excess breast milk that she wanted to donate to African babies in need. “Breast milk has this fascinating aspect to it. It’s not something you look at in your freezer and say, ‘Mmmm, boy, I’m hungry.’ It’s kind of gross, but it’s also kind of cool, and there’s this element of pride to it. It’s got this ick factor and this awe factor. So I had my baby and I had my breast milk, and I thought that donating seemed like an easy thing that I could do.”
Surprising factoid from an article on legalizing kidney sales: “America already lets people buy babies from surrogate mothers, and the risk of dying from renting out your womb is six times higher than from selling your kidney”. (via mr)
In his book, Urban Sprawl and Public Health, public-health advocate Richard Jackson says that “our car-dependent suburban environment is killing us”. “If that poor woman had collapsed from heat stroke, we docs would have written the cause of death as heat stroke and not lack of trees and public transportation, poor urban form, and heat-island effects. If she had been killed by a truck going by, the cause of death would have been ‘motor-vehicle trauma,’ and not lack of sidewalks and transit, poor urban planning, and failed political leadership.”
Notes from day 3 at PopTech:
Chris Anderson talked about, ba ba baba!, not the long tail. Well, not explicitly. Chris charted how the availability of a surplus in transistors (processors are cheap), storage (hard drives are cheap), and surplus in bandwidth (DSL is cheap) has resulted in so much opportunity for innovation and new technology. His thoughts reminded me of how surplus space in Silicon Valley (in the form of garages) allowed startup entrepreneurs to pursue new ideas without having to procure expensive commercial office space.
Quick thought re: the long tail…if the power law arises from scarcity as Matt Webb says, then it would make sense that the surplus that Anderson refers to would be flattening that curve out a bit.
Roger Brent crammed a 60 minute talk into 20 minutes. It was about genetic engineering and completely baffling…almost a series of non sequiturs. “Centripital glue engine” was my favorite phrase of the talk, but I’ve got no idea what Brent meant by it.
Homaro Cantu gave a puzzling presentation of a typical meal at his Chicago restaurant, Moto. I’ve seen this presentation twice before and eaten at Moto; all three experiences were clear and focused on the food. This time around, Cantu didn’t explain the food as well or why some of the inventions were so cool. His polymer box that cooks on the table is a genuinely fantastic idea, but I got the feeling that the rest of the audience didn’t understand what it was. Cantu also reiterated his position on copyrighting and patenting his food and inventions. Meg caught him saying that he was trying to solve the famine problem with his edible paper, which statement revealed two problems: a) famines are generally caused by political issues and therefore not solvable by new kinds of food, printed or otherwise, and b) he could do more good if he open sourced his inventions and let anyone produce food or improve the techniques in those famine cases where food would be useful.
Richard Dawkins gave part of his PopTech talk (the “queerer than we can suppose” part of it) at TED in 2005 (video).
Bob Metcalfe’s wrap-up of the conference was a lot less contentious than in past years; hardly any shouting and only one person stormed angrily out of the room. In reference to Hasan Elahi’s situation, Bob said that there’s a tension present in our privacy desires: “I want my privacy, but I need you to be transparent.” Not a bad way of putting it.
Serena Koenig spoke about her work in Haiti with Partners in Health. Koening spoke of a guideline that PIH follows in providing healthcare: act as though each patient is a member of your own family. That sentiment was echoed by Zinhle Thabethe, who talked about her experience as an HIV+ woman living in South Africa, an area with substandard HIV/AIDS-related healthcare. Thabethe’s powerful message: we need to treat everyone with HIV/AIDS the same, with great care. Sounds like the beginning of a new Golden Rule of Healthcare.
2.7 billion results for “blog” on Google. Blogs: bigger than Jesus.
I recently linked to a debate between Adam Gopnik and Malcolm Gladwell about health care that took place in 2000. Gladwell has recently updated his thinking on the issue here and here, saying that “I now agree with virtually everything Adam said and disagree with virtually everything I said”. (via lots of readers last week, when I forgot to post about it…was spurred into action this AM by this)
Debate between Malcolm Gladwell and Adam Gopnik on the health care systems in the US and Canada. “Adam Gopnik and Malcolm Gladwell have both lived in Canada and developed strong feelings about socialized health care — pro and con.”
Planned Parenthood in Southeastern Pennsylvania is running a unique pledge drive. The idea is that you pledge an amount of money for each anti-abortion protestor that shows up outside of the PP health center. “We will place a sign outside the health center that tracks pledges and makes protesters fully aware that their actions are benefiting PPSP”. That’s genius. (via freak)
March of the Penguins has become a favorite for conservative moviegoers, who cite it as making a good case for monogomy, intelligent design, and a pro-life stance on abortion. I wonder if liberals watch the film and come out advocating universal health care…all those dead penguin babies could have been saved with proper medical care.
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