Posts Tagged ‘United States’

The ultimate challenge in controlling healthcare costs: reducing needless care

October 8, 2014  |  General  |  No Comments

Efforts to reduce overuse of health care services run counter to the dominant financial incentives in our fee-for-service system, challenge the cultural assumption that more is better, and raise concerns about stinting on necessary care.

That quotation is from a recent editorial in the New England Journal of Medicine. It points out the often quoted estimate that 25-35% of all medical care either doesn’t do any good or is actually potentially harmful, what the editorialist calls low-value care. That is a huge problem, one that will prove very difficult to solve.

The fundamental issue as I see it is that, although founded on science, medicine is very imperfect as a science. It’s a mixture of science, near-science, intuition, guesswork, and blind luck. Depending upon the disease or condition, the more uncertain portions of medical practice figure much more prominently than the certain ones. Over the past several decades we have tried more and more to use evidence-based medicine, that is, doing only things and using only treatments that hard evidence has shown to be beneficial. Unfortunately, rigorous studies of what works and what doesn’t work are difficult and expensive to do. More than that, a great deal of what we do doesn’t even lend itself to that kind of research. We’re often stuck with what committees of experts recommend based upon weaker studies or just opinions.

The other huge problem is with how fee-for-service medical practice works: doctors are generally paid  much more for doing things than for not doing things. Low benefit or even useless treatments represent somebody’s revenue stream; limiting or even eliminating them takes money out of practitioners’ pockets, creating a strong impetus to keep going as we are. But the enormous cost may finally be convincing the public that something has to change:

Public acceptance of a role for policy in reducing the use of low-value care in the United States is tenuous but increasing with growing awareness of the burden that health care spending places on federal and state budgets and with patients’ increasing exposure to health care costs.

I have no doubt that ultimately physicians will be told what they can and cannot do, most likely through the mechanism of what insurance payers will pay for. We’ve been seeing various forms of that kind of limitation for years and the process will accelerate. The mechanism of high co-pays was hoped to help by giving patients a financial incentive to avoid needless medical care. But there is a problem with that, too.

Demand-side interventions — targeting patients — principally include financial incentives and education. Increasing patient cost sharing is a blunt instrument: research shows that it can reduce use of both low- and high-value care, which suggests that patients do not have the information or skill required to differentiate between the two.

Many people outside the medical field think that applying simple market principles would help. If things cost so much, why not just increase the number of physicians and let them compete with each other on cost. Surely the result would be, as with other supply and demand commodities, that costs will come down. It doesn’t happen that way. In medical care, supply drives demand rather than the other way around. Adding more physicians who do things results in more things being done, something known for 50 years.

I don’t know what will happen with all this, but something will. But this will be the general direction:

To address overuse, we now need to work against the current of culture and payment models that still largely reward volume over value.

In vitro fertilization and the business of making babies: hype vs. hope

July 17, 2013  |  General  |  No Comments

(Guest Post: What follows is a fascinating and enlightening essay and book review by Maggie Mahar, who blogs on healthcare policy issues at her excellent blog Healthbeat, posted here with her permission.)

Miriam Zoll’s  Cracked Open:  Liberty, Fertility and the Pursuit of High Tech Babies is in part a moving memoir, in part a troubling expose of yet another unregulated corner of our healthcare system. In this case it is an industry that offers women everything from in-vitro fertilization (IVF) to another women’s eggs-for-sale.

Zoll titles her first chapter “One Egg, Please and Make it Easy.” If only it were that simple. She begins by acknowledging how naïve she was:

“I am an official member of the Late Boomer Generation. We grew up . . . . in the 1970s and ‘80s, watching with wide eyes while millions of American women—some with children and some not—infiltrated formerly closed-to-females professions like medicine, law, and politics. This exodus from the kitchen into the boardroom created a thrilling, radical shift in home and office politics, in the economy, and in relations between the sexes. ‘Shoot for the stars,’ some of the more thoughtful women advised us, ‘but don’t forget about the kids.’”

Zoll herself became one of the trailblazers. She is the founding co-producer of the original “Take Our Daughters to Work” Day, and on the board of “Our Bodies Ourselves.” In 2005, she became a Research Fellow at MIT’s Center for International Studies. There, her widely –published research addressed gender inequity and poverty in HIV/AIDS-affected households in sub-Saharan Africa.

At 35, Zoll married. At 40 she reports, she looked in the mirror, and decided: “It’s time to have a baby.” Finally, she felt confident that she would be a good mother. It didn’t occur to her that she might have trouble conceiving.

“We are the generation that . . . came of age at a time of burgeoning reproductive technologies,” she explains. “We grew up with dazzling front-page stories heralding the marvels of test-tube babies, frozen sperm, surrogates and egg donors; stories that helped paint the illusion that we could forget about our biological clocks and have a happy family life after—not necessarily before or during—the workplace promotions.”

Zoll goes on to chronicle her own long trek through our multi-billion-dollar fertility industry. At the beginning, she and he husband were as innocent as most couples who believe what the media had told them: “Science and technology have finally outsmarted Mother Nature. Just because you’re over 40, this does not mean that you can’t conceive.”

That final line is absolutely true. Each year in-vitro fertilization and other forms of Assisted Reproductive Technology (ART) produce miracles. The extraordinary joy that parents who thought that they could never have a child feel when holding their baby should never be discounted. When the right patient receives the right therapy at the right time, these technologies can heal broken hearts.

ART is still a medical experiment. Or, as Zoll puts it: “ART is a crap shoot.” In many cases, physicians don’t know why some couples succeed and others do not. No one keeps tabs on who wins and who loses. We have a National Joint Replacement Registry, a database of information that surgeons can consult as they learn why certain procedures work for certain patients while others go awry. But there is no official registry for in vitro fertilization—despite the fact it is an infant science shot through with uncertainties.

As Minnesota law professor Michele Goodwin and Judy Norsigian, Executive Director of Our Bodies Ourselves, warn in the Foreword to Cracked Open: “While the ‘better’ fertility centers now claim live birth rates of 50 percent or more, the national average remains at about one-third. It is easy to misinterpret pregnancy rates—which are high but often end in miscarriage—as live birth rates, which are much lower in comparison.”

Here are the facts: The most recent data from the CDC reveal IVF failure rates as high as 68 to 78% in women ages 35 to 40, and 88 to 95% among women 40-44. Meanwhile the “baby business” is a for-profit business. The industry’s mission statement is also a marketing statement: “It just takes one good egg.” Little wonder that so many would-be parents are seduced. They want to believe that their doctor is a fairy-godfather/mother who has just one desire: to make sure that they become parents.

“As a business, what makes the fertility industry unique is the combination of supply-side virtuousness and demand-side desperation,” writes Michael Cook, editor of Mercatornet. “The doctors and scientists who run the clinics can do no wrong. The women who want the babies will pay them whatever they charge.” But fertility clinics are run by human beings. Some are more truthful than others. Zoll describes her first visit to one.

“Michael and I were nervous and excited. The clinic literature cited studies claiming that well over two-thirds of all couples seeking treatment for fertility-related problems become parents. It didn’t occur to us then to ask if this statistic meant that two-thirds of parents birthed their own babies or a donor egg or embryo baby, or if they became parents through adoption or surrogacy. We were as green as could be about what to expect and what to ask, and we were eager to hear how the doctors thought they might help us.”

“That first day, my husband and I met with two health care professionals, one who examined my female interior and another who walked us through the ins and outs of the medical aspects of fertility treatments. A marble egg sat on a little pedestal on both staff members’ desks, and at one point during our meetings they each held it between their thumb and index fingers. . . .They smiled and said, verbatim: ‘Like we say here at the clinic, it only takes one good egg to make a baby.’ It was obviously the clinic’s mission statement.”

“I immediately thought that, if all we had to do was find one good egg, we were certainly the right candidates for the job. How hard could that be, really? . . . . I was in great mental and physical health. I exercised and practiced yoga regularly. I ate well. What more could a doctor ask from a patient? Little did I know that the process of finding one good egg would be a bit like panning for gold in a mine that had already been stripped of much of its bullion.”                  

A few weeks later, Zoll and her husband met with a veteran physician she would dub the “Silver Fox.” After reading the couple’s medical records, he looked Zoll straight in the eye: “‘The first thing I want to say is that you’re old.’”

“I winced as his words cut through me like a razor-sharp sword,” she remembers, “and then within a split second I found myself in a serious state of denial, fighting back the urge to tell him that he was the one with the white hair, not me. He was the old geezer in the room, not me. No sir, not me. All my life I had to convince people that I wasn’t as young as I appeared. I knew I was teetering on the brink of officially entering middle age, but I didn’t think I was there—yet. ‘Women your age have a harder time conceiving, especially if they have endometriosis, like you,’ he continued. ‘You should have come to see me when you were thirty.’ This veteran fertility specialist was horribly blunt. But he was right.”

Endometriosis is an often painful disorder involving tissue that normally lines the uterus growing outside the uterus. While it can be treated, endometriosis can lower a woman’s chances of conceiving. The first doctor should have told her this. This doesn’t mean that a woman diagnosed with endometriosis shouldn’t try ART. That is a personal decision. But a woman needs to know the truth about her chances so that she can make an informed choice.

When Zoll saw the Silver Fox, she harbored high hopes. “I was confident that, since my mother had birthed me later in life, I would have no trouble doing the same thing. During that first meeting with the Silver Fox, I proudly told him that my mother had been thirty-nine years old when I was born. ‘Just because your mother did it doesn’t mean you will too,’ he replied. ‘Do you think there’s a gene for birthing in middle age that your mother passed onto you?'”

“In response to that question, I distinctly remember that I blinked three times,” she writes. “Um, yes, think me an idiot, but actually I did believe that since mom had done it I could do it. Why would I think otherwise? For decades, the Sunday New York Times and People magazine had reported that it was possible to birth a baby later in life, and American pop culture is loaded with messages telling women that they can become pregnant when they are older. In the movie Parenthood, Mary Steenburgen and Dianne Wiest both play the role of older women who have no trouble birthing babies, and in Father of the Bride, a middle-aged Diane Keaton delivers a baby on the same day her 21-year-old daughter does. . . .Year after year, the headlines and cultural messages screamed out: ‘Relax and sit back. You’ve got science on your side.”

“But now this doctor was telling me that I might not have science on my side, after all. He was telling me that I had deluded myself with misinformation and false hopes about my own biology—and, according to global research, I am not alone . . . . In a survey of undergraduates in the United States conducted in 2012, two-thirds of women and 81 percent of men believed that female fertility did not markedly decline until after the age of 40. One-third of women and nearly half of men believed this marked decline occurred after the age of 44—an age at which IVF is least effective. A full 64 percent of men and 53 percent of women surveyed overestimated the chances of couples conceiving a child following only one IVF treatment. The study concluded: “The discrepancy between participant’s perceived knowledge and what is known regarding the science of reproduction is alarming and could lead to involuntary childlessness.”

Ultimately, Zoll would meet a doctor who advised: “In a situation like yours, where your hormones are not stimulating the kind of egg production needed for pregnancy, we like to recommend that couples think about egg donation or adoption.” This was honest advice.

Reluctantly, Zoll explored the idea of finding a donor: “I first entertained the possibility of working with a donor egg agency after the second IVF cycle failed. The very idea of Michael’s sperm fertilizing a stranger’s eggs and then having those embryos inserted into my uterus made me wince. But, given what the doctors had told us about the quality of my eggs early on, I wanted to be open to the idea of a donor—just in case. While some of the literature said there was great success with older women using younger women’s eggs, other data suggested just the opposite. Once again, it was a crapshoot: you either win or you lose, but the big question was, do you want to play the game?”                        

Zoll confides that “The first donor egg website I happened to stumble upon was a California agency where the majority of potential donors looked like contestants for the Miss California pageant. They were all slender, blonde, and buxom and their price tags were high, ranging from $8,000 to $10,000. Why did they call them donors, I wondered? I spent only five minutes on the site before I hastily clicked off.”

I felt like an eggless sociopath for even considering asking one of these young women to risk her health so that I might purchase her eggs.

“The vast majority of donors on this site and elsewhere in the United Staes were in their twenties. How and why do they decide to sell their eggs to someone like me? How do the donor agencies and these young women determine that their eggs are worth $8,000 while someone else’s eggs are worth only $5,000? Were blonde, blue-eyed donors always more expensive than brown-eyed, overweight donors? . . . . We were told on more than one occasion that it is not unheard of for infertile Ivy League alums to post a classified ad in campus publications offering up to $100,000 for an egg donor with high SAT scores, 36-24-36 body measurements, and a penchant for Mozart.”

Capitalism sets a price for eggs, depending upon a woman’s bloodline.

“One thing this boom in fertility medicine has done is to help us apply an economic value to women’s reproductive labor,” Zoll writes. “This may or may not be a good thing, depending on how you look at it. In today’s U.S. marketplace, a woman’s egg is valued at anywhere between $5,000 to $100,000 or more, depending on her bloodline. On average, though, let’s say an egg is worth between $5,000 and $10,000. Some people think it is immoral to put a price tag on genetic material and women’s reproductive hardware and capabilities. But, considering that the global fertility industry generates billions of dollars a year, why not calculate women’s economic contributions, too?”

Zoll makes a reasonable point. Pharmaceutical companies are paid a fortune for fertility drugs. Why shouldn’t the women who donate their eggs cash in too? Like Zoll, I, personally, am appalled by the idea of commerce that traffic in womens’ eggs. But men regularly sell their sperm. Shouldn’t women be able peddle their eggs? Here’s the difference: when men donate sperm they take no risk. By contrast harvesting eggs from a woman’s body is an invasive procedure and can affect her health. The drugs the donor must take are potent. Particularly when researchers are paying for the eggs, poor women may be exploited.                         

After Miriam’s second IVF cycle failed, she and Michael bravely advanced to a third. And finally, she became pregnant. Then the silver fox gave her the news: “The heartbeat is weak. . . You’ll miscarry within a week, most likely.’’ He told her this as he was leaving the office.

Inconsolable, Miriam and Michael embarked on a fourth IVF cycle, using “new super-drugs.” This time, they chose a young fertility doctor who leveled with them, explaining that “a female baby is born with millions of egg follicles that dwindle to about 400,000 by the time she reaches puberty.” But by the time she is 40, “’what remains are the eggs that were never very healthy in the first place. ‘The strong ones leave the roost early,’ he explained. “The robust eggs want to move out. They want to meet the sperm. The weaker ones stay behind.” Nevertheless, Zoll writes, “he was unable to resist the temptation of his clinic’s mantra.” And so he continued: ” Of course, that’s not to say that you don’t have some good eggs left.”

After 10 days of shots, vitamins and suppositories, Miriam went for her first ultrasound appointment. She remembers what the technicians said as she greased the probe and slid it into her vagina: “Well let’s see what’s happening in there.” The examination didn’t take long: “Okay, that’s it.”

“That was fast,” Zoll said as she stood up.

“There’s nothing there,” she said. “The doctor will call you.”

Finally, Zoll overcame her reservations and decided to look for an egg donor. She and Michael picked two. When doctors screened the first one, it turned out that she was infertile. That cost Miriam and Michael $4,000. Then the clinic explained that it couldn’t screen the second donor until it received another $4,000.

“But that’s ridiculous,” Zoll told the nurse. “The second donor just completed a cycle at a reputable hospital clinic that produced a pregnancy. Why can’t you use their tests?”

“Well, we have to run our own tests,” the nurse replied. Finally, she explained “you have to realize that we have to make money somehow. These tests can’t be free.”

Because Zoll put up a fight, the clinic eventually waived the fee. The donor was screened, and the doctor retrieved 12 eggs that were fertilized with Michael’s sperm.

Then they got the news that crushed them, once again. None of the 12 eggs fertilized.

Zoll recalls her conversation with the doctor: “’It’s really quite shocking to us,’ he said in that tone we had heard before. It was the tone that implied that the clinic was not responsible for the outcome, and I suppose that in many ways, they weren’t. Doctors could try to control nature, but they couldn’t manipulate it completely. Still, the clinic has approved the donor. Now, the doctor was saying ‘there is likely something wrong with the donor’s eggs. . . . . . I do hope you will try another donor cycle, but I don’t recommend that you use this woman again .. . Given the drugs she was taking, she should have produced many more eggs than she did.’”

“I didn’t say a word, I just sat there listening,” Zoll recalls. “Our donor had helped another couple become pregnant only a few months earlier. Maybe she should have taken more time off between cycles before working with us. Why hadn’t the doctors flagged the possibility that her reproductive system was oversaturated with drugs that were likely wreaking havoc on her ovaries?”

At this point Zoll realizes that “We had spent thousands of dollars on IVF and even more on the donor egg process, and through it all, no one was accountable for the outcomes. The clnics were not accountable. The pharmaceutical companies that made the drugs the donor and I ingested were not accountable. . . . . Thousands of dollars earlier this same doctor had told us that Donor #2 was a fine candidate . . . . Now. . . he was encouraging us to spend more money and select a different donor, perhaps a younger donor, or a donor with purple eyes and blue hair , who might give us a better yield. What kind of wishy-washy medicine was this?”

Still, Zoll admits: “We had willingly and under no duress paid ridiculous amounts of money for access to medical technologies that we were sure would work and did not. We paid for the chance to hope. We paid for the chance to try.

We were the only ones who are accountable.

Of course, Zoll is right. But still, the question of accountability haunts medicine. When a patient submits to medical treatment, there are no guarantees and no warrantees. If he is unhappy with the results of an operation, he cannot return it. If the patient dies, the surgeon and the hospital still must be paid. This is because most of medicine is still such an uncertain science, fraught with unknowns. If hospitals and physicians were paid only when they were successful many, if not most, would only take the easiest cases. But this is all the more reason why patients need to be fully informed about risks and the odds of success before they choose a course of treatment.

Instead, silence reinforces the fairy-tales

When treatments fail, Zoll writes, “most couples never want to talk about it. And who could blame them.”

There was a cultural taboo — reinforced by the clinics themselves, that we shouldn’t talk about our infertility or our miscarriages or the inability of science to solve our reproductive health challenges. It was that absence of truth-telling that made the success stories sensationalized in the media so dangerously misleading.

It is terribly important that couples tell the truth about their experiences. At the end of her book, Zoll explains: “By sharing my experience, I’m hoping that others will begin to speak out and share theirs, whether treatments were successful or not. For those still recovering, I invite you to cast off your silence and contribute to expanding an open and honest consumer-driven discussion about these life-altering technologies. Men and women contemplating fertility treatments need to hear your perspective . . . By sharing your experiences you can help create a more balanced perspective.”

Best of all, Zoll points readers to a place where “if you would like to share information about your experience, please visit the voluntary registry at Dartmouth-Hitchcock Medical Center.” (I am far from suprised that Dartmouth has taken on this task. It remains one of the most patient-centered institutions in the nation.)

How Does the Story End?  A Postscript

I won’t disclose whether a child ever found Miriam and Michael. It is their story, and I don’t want to spoil the ending. Cracked Open is available in paperback and it’s an excellent read.

If you pick up the book, you will find out, among other things, how they met, and, perhaps most importantly, why they didn’t marry in their 20s.

Here, I would like to add a postscript.

Cracked Open is meant as a cautionary tale for women who may think that they should first become successful in their careers, then plan to have a child when they turn 40. Both media and market hype have convinced many that they can plan a pregnancy when they choose. The CDC’s numbers reveal that his just isn’t true.

I should add that the story of Michael and Miriam’s roller-coaster relationship when they were in their 20s convinces me that if they had married then, they would have divorced within a few years.

Miriam acknowledges that she wasn’t ready for marriage: “This kind of ‘push-me-pull-me’ love eventually ended our relationship and helped motivate me to begin therapy. Difficulties from childhood were now spilling over into my life. I needed to make sense of it all. This was an excellent reason to delay marriage and children. A great many twenty-somethings—women as well as men—are not ready for marriage and parenthood.”

When writing about Cracked Open, I worried that this tale could send a 33-year-old single woman (or her mother) into a panic –though I know this is not Zoll’s intention. Cracked Open is not urging women to let the “tick-tock” of their biological clocks rush them into marriage.

Delaying motherhood because you’re caught on a fast-track and just don’t know how to get off is one thing. Postponing children until you and the right person find each other at the right time is another.

Not everyone would agree with me. Zoll reports that “an article published a few years ago in the British Medical Journal, advised women to start having children before they turn 30: ‘Surveys of older mothers show that half say they delayed because they had not yet met a suitable partner. Maybe instead of waiting for Mr. Right they ought to wait for Mr. Good-Enough, if they want children.’ If Mr. Good-Enough means ‘he doesn’t earn as much as my sister’s husband– but we have such a good time together, and I know he’ll be a great father,’ that’s fine. But if it means that when you think about spending 30 or 40 years with him, you sigh . . . all I can say is “don’t do it.”

I have known so many women who found the right husband after 35. Out of nowhere, he appears. When that happens, it’s not a difficult decision. You recognize each other.

At that point, women have many options including in vitro fertilization, finding an egg donor, and adoption. Not long ago, a friend who met her husband in her late 30s told me: “When I turned 40, I realized I could take $20,000 and go to a fertility clinic. Or I could take the same $20,000, go to Russia and adopt a child.” She has never regretted her decision.

Those are not a woman’s only options. Some will decide that rather than struggling to become the perfect 40-something mother, they would prefer to become the perfect aunt. It’s a personal choice, not a medical decision.

(Thanks, Maggie — and thanks Ms. Zoll for writing this excellent and heartfelt book.) 

Injuries from bottles, pacifiers, and sippy cups: silly fear or a real risk?

July 7, 2012  |  General  |  No Comments

There is a somewhat interesting article in the  most recent issue of the journal Pediatrics; at least the title is interesting. It’s called “Injuries associated with bottles, pacifiers, and sippy cups in the United States, 1991-2010. I occasionally have wondered how common it is, for example, for a toddler running around with a pacifier in her mouth to fall and have the plastic of the pacifier cause significant injury. Is it a reasonable thing to worry about? Or is it akin to worrying about your child being struck by lightning?

It turns out that such injuries are not common, but they’re not especially rare, either. The authors found 45,398 of them appeared in America’s emergency departments over the past 20 years, averaging 2,270 cases per year. Most injuries involved bottles (66%), with pacifiers coming in at 20% and sippy cups at 14%. Unsurprisingly, most of the injuries were to the mouth and most occurred as the result of the fall. Also unsurprisingly, the peak incidence was at one year of age, a time when a child’s natural exuberance exceeds her coordination. Interestingly, even though sippy cups represented the lowest number, they were associated with more severe injuries, but only a handful of children from any group required admission to the hospital.

Bottom line — don’t let your toddler run around with a substantial plastic object  in her mouth. Obviously. Sometimes you run across a research paper that quantifies the obvious, screaming loudly: “I need to publish a research paper!” This is such an example.

Safe transport for critically ill and injured children

May 12, 2011  |  General  |  No Comments

Critically ill or injured children often develop their problems far from where they need to be in order to get the care they need. A common scenario is for a child to be brought initially to a facility such as a general community hospital, where they are stabilized and receive initial therapy. Following this, however, they often need transport to a larger facility with specialized resources, such as a children’s hospital. To get there they need to ride in an ambulance, an airplane, or a helicopter. Are there risks to that? Unfortunately, although the risks are small, they are real, as you can read about here. As with everything we do in medicine, the risks of the transport needs to be weighed against the benefit of getting the child to facility that can better care for the child.

How common are accidents with pediatric transports? The last data I saw are from 2002, in which a survey of all pediatric transport teams in the United States asked if they had suffered any accidents in the preceding five years — 42% of the teams answering the survey had. These included 9 aircraft crashes and 57 ambulance accidents. To judge transport risk, of course, we need to know a key piece of information — the total number of transports — and this number is unknown. We do know that there were about 150 pediatric transport teams in the country at the time, and a typical team does around 100-200 transports each year. That’s a pretty broad range, but it would estimate the accident risk to be somewhere around 0.05-0.1%. This isn’t a big number, but 5 to 10 mishaps of some kind for every 1,000 trips does indicate a real risk. Many of the ambulance accidents were minor, but, as you can read in the link above, some of the air transport accidents were not. Overall, there were 8 deaths and 10 serious injuries to patients or transport personnel during the 5 year period.

Fifteen years ago I founded and subsequently ran for nearly a decade a pediatric transport program, during which time I made quite a few flights in both fixed-wing aircraft and in helicopters. I quickly learned how difficult that work environment can be for the medical team. Our team suffered one accident, the result of engine malfunction with our helicopter; fortunately, no one was injured, but the incident underscored for all of us the risks of the process. (I don’t do that any more, but I continue to be a member of the Transport Section of the American Academy of Pediatrics.)

From a patient-care perspective, the main advantage of helicopter transport versus ground ambulance is speed (fixed-wing aircraft transports are a bit separate, being typically used for long-range transports over hundreds of miles). Speed is especially important for severe trauma cases. The principal disadvantage of a helicopter, compared to an ambulance, is that the former is a very difficult environment in which to work; it is noisy, cramped, and often buffeted about in the air.

In spite of the risks of transport, specially-trained pediatric transport teams are an important component of all regionalized pediatric critical care systems. If your child’s doctor recommends this for your child, the slight risk of the trip is far outweighed by the benefits of getting your child to the people best equipped to care for her. Do ask about the members of the transport team — if they are specially trained to do pediatric transports and, overall, give the best results.

How are doctors trained anyway? (Part 1: the historical background)

April 24, 2011  |  General  |  No Comments

A couple of conversations I’ve had with patients’ families over the past month have made me realize that many folks don’t know how our system produces a pediatrician, a radiologist, or a surgeon. And a lot of what people know is wrong. Physicians are so immersed in what we do that we forget that the process is a pretty arcane one. Just what are the mechanics of how doctors are trained? Understanding your physician’s educational journey should help you understand what makes him or her tick. As it turns out, a lot of standard physician behavior makes more sense when you know were we came from. This post concerns some important history about that.

Most physicians in the nineteenth century received their medical educations in what were called proprietary medical schools. These were schools started as a business enterprise, often, but not necessarily, by doctors. Anyone could start one, since there were no standards of any sort. The success of the school was not a matter of how good the school was, since that quality was then impossible to define anyway, but of how good those who ran it were at attracting paying students.

There were dozens of proprietary medical schools across America. Chicago alone, for example, had fourteen of them at the beginning of the twentieth century. Since these schools were the private property of their owners, who were usually physicians, the teaching curriculum varied enormously between schools. Virtually all the teachers were practicing physicians who taught part-time. Although being taught by actual practitioners is a good thing, at least for clinical subjects, the academic pedigrees and skills of these teachers varied as widely as the schools — some were excellent, some were terrible, and the majority were somewhere in between.

Whatever the merits of the teachers, students of these schools usually saw and treated their first patient after they had graduated because the teaching at these schools consisted nearly exclusively of lectures. Although they might see a demonstration now and then of something practical, in general students sat all day in a room listening to someone tell them about disease rather than showing it to them in actual sick people. There were no laboratories. Indeed, there was no need for them because medicine was taught exclusively as a theoretical construct, and some of its theories dated back to Roman times. It lacked much scientific basis because the necessary science was itself largely unknown at the time.

As the nineteenth century progressed, many of the proprietary schools became affiliated with universities; often several would join to form the medical school of a new state university. The medical school of the University of Minnesota, for example, was established in 1888 when three proprietary schools in Minneapolis merged, with a fourth joining the union some years later. These associations gave medical students some access to aspects of new scientific knowledge, but overall the American medical schools at the beginning of the twentieth century were a hodgepodge of wildly varying quality.

Medical schools were not regulated in any way because medicine itself was largely unregulated. It was not even agreed upon what the practice of medicine actually was; there prevailed at the time among physicians several occasionally overlapping but generally distinct views of what the real causes of disease were. All these views shared a basic fallacy — they regarded a symptom, such as fever, as a disease in itself. Thus they believed relieving the symptom was equivalent to curing the disease.

The fundamental problem was that all these warring medical factions had no idea what really caused most diseases; for example, bacteria were only just being discovered and their role in disease was still largely unknown, although this was rapidly changing. Human physiology — how the body works — was only beginning to be investigated. To America’s sick patients, none of this made much difference, because virtually none of the medical therapies available at the time did much good, and many of the treatments, such as large doses of mercury, were actually highly toxic.

There were then bitter arguments and rivalries among physicians for other reasons besides their warring theories of disease causation. In that era before experimental science, no one viewpoint could definitely prove another wrong. The chief reason for the rancor, however, was that there were more physicians than there was demand for their services. At a time when few people even went to the doctor, the number of physicians practicing primary care (which is what they all did back then) relative to the population was three times more than it is today. Competition was tough, so tough that the majority of physicians did not even support themselves through the practice of medicine alone; they had some other occupation as well — quite a difference from today.

In sum, medicine a century ago consisted of an excess of physicians, many of them badly trained, who jealously squabbled with each other as each tried to gain an advantage. Two things changed that medical world into the one we know today: the explosion of scientific knowledge, which finally gave us some insight into how diseases actually behaved in the body, and a revolution in medical education, a revolution wrought by what is known as the Flexner Report.

In 1910 the Carnegie Foundation commissioned Abraham Flexner to visit all 155 medical schools in America (for comparison, there are only 125 today). What he found appalled him; only a few passed muster, principally the Johns Hopkins Medical School, which had been established on the model then prevailing in Germany. That model stressed rigorous training in the new biological sciences with hands-on laboratory experience for all medical students, followed by supervised bedside experience caring for actual sick people.

Flexner’s report changed the face of medical education profoundly; eighty-nine of the medical schools he visited closed over the next twenty years, and those remaining structured their curricula into what we have today—a combination of preclinical training in the relevant sciences followed by practical, patient-oriented instruction in clinical medicine. This standard has stood the test of time, meaning the way I was taught in 1974 was essentially unchanged from how my father was taught in 1942.

The advance of medical science had largely stopped the feuding between kinds of doctors; allopathic, homeopathic, and osteopathic schools adopted essentially the same curriculum. (Although the original homeopathic schools, such as Hahnemann in Philadelphia, joined the emerging medical mainstream, homopathic practice similar to Joseph Hahnemann’s original theories continues to be taught at a number of places). Osteopathy maintains its own identity. It continues to maintain its own schools, of which there are twenty-three in the United States, and to grant its own degree—the Doctor of Osteopathy (DO), rather than the Doctor of Medicine (MD). In virtually all respects, however, and most importantly in the view of state licensing boards, the skills, rights, and privileges of holders of the two degrees are equivalent.

Government payment for health care: the long view perspective

January 5, 2011  |  General  |  No Comments

With all the arguing about how to pay for healthcare it’s useful to step back and take a long, comparative view. To do that takes both knowledge and experience. Victor Fuchs, distinguished professor of economics and healthcare policy at Stanford, has both of those qualities, and recently shared his perspective in an excellent editorial in the New England Journal of Medicine here. A simple graph serves as his reference point.

What the graph shows is that, since 1960, governmental payment for healthcare has been steadily increasing as private payment has been decreasing; in 1960 the split was 80% private, 20% government. The two are nearly at parity now, a 50/50 split.

Fuch’s points out that, although the government pays for half the care, it makes relatively little attempt to use that clout to restrain costs:

Thus, in one sense, Americans wind up in the worst of all worlds, with government bearing a big part of the burden of paying for health care, with the concomitant large burden of taxes, but exercising very little control over the cost of care. As an indication of how absurd the situation is in the United States, government currently spends more per capita for health care than eight European countries spend from all sources on health care.

One of my principal concerns with how we do things now is that I think insurance companies add a large measure of cost without adding much value. We simply cannot continue to devote the huge chunk of our GDP that goes to healthcare, a number that is steadily rising.

The solution will be a political one, as it should be. But people should look at Fuch’s simple graph and realize that government already is the largest single payer. Judging from the firestorm of rhetoric in the last election about keeping Medicare strong, I don’t see that changing.

US health care stacks up poorly with other countries. Again.

December 24, 2010  |  General  |  1 Comment

A recent study by the Commonwealth Fund highlights what Americans experience in what passes for our healthcare “system” — higher costs, higher risks, and more stress. You can read about it on Chris Fleming’s excellent Health Affairs blog here, or else see the full study published here, in the journal Health Affairs.

The study surveyed eleven countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. Survey samples sizes per country ranged from 1,000 to more than 3,500. From Chris Fleming’s blog, here’s a taste of a few things the survey showed.

• Twenty percent of US adults surveyed said they had had serious problems paying medical bills in the previous year. Responses to the same question from the other ten countries were all in the single digits. US respondents were also significantly more likely than adults in other countries to have gone without care because of cost.

• Thirty-five percent of US adults had out-of-pocket medical spending of $1,000 during the previous year, a far higher percentage than in any other country.

• Nearly one third of US adults (31 percent) reported either denial of payments by insurers or time-consuming interactions with insurers, a higher rate than in all other countries. Twenty-five percent of US respondents reported that their insurance company denied payment or did not pay as much as expected; 17 percent said they spent a lot of time on paperwork or disputes for medical bills or insurance — the highest rates in the survey.

• The United States had the widest and most pervasive differences in access and affordability by income of the eleven countries. The United Kingdom had the least.

We didn’t finish last in everything, at least — patients in Canada, Norway, and Sweden reported longer waits on average to see the doctor. But the key point to me is that America spends far, far more per capita on healthcare than any other country. For what we’re paying, we should get the best. We’re not. And those costs just have to come down — they’re unsustainable.

How are doctors trained, anyway? (Part 1 — the past)

June 1, 2009  |  General  |  1 Comment

A couple of conversations I’ve had with patients’ families over the past month have made me realize that many folks don’t know how our system produces a pediatrician, a radiologist, or a surgeon. And a lot of what people know is wrong. Physicians are so immersed in what we do that we forget that the process is a pretty arcane one. Just what are the mechanics of how doctors are trained? Understanding your physician’s educational journey should help you understand what makes him or her tick. As it turns out, a lot of standard physician behavior makes more sense when you know were we came from. This post concerns some important history about that.

Most physicians in the nineteenth century received their medical educations in what were called proprietary medical schools. These were schools started as a business enterprise, often, but not necessarily, by doctors. Anyone could start one, since there were no standards of any sort. The success of the school was not a matter of how good the school was, since that quality was then impossible to define anyway, but of how good those who ran it were at attracting paying students.

There were dozens of proprietary medical schools across America. Chicago alone, for example, had fourteen of them at the beginning of the twentieth century. Since these schools were the private property of their owners, who were usually physicians, the teaching curriculum varied enormously between schools. Virtually all the teachers were practicing physicians who taught part-time. Although being taught by actual practitioners is a good thing, at least for clinical subjects, the academic pedigrees and skills of these teachers varied as widely as the schools — some were excellent, some were terrible, and the majority were somewhere in between.

Whatever the merits of the teachers, students of these schools usually saw and treated their first patient after they had graduated because the teaching at these schools consisted nearly exclusively of lectures. Although they might see a demonstration now and then of something practical, in general students sat all day in a room listening to someone tell them about disease rather than showing it to them in actual sick people. There were no laboratories. Indeed, there was no need for them because medicine was taught exclusively as a theoretical construct, and some of its theories dated back to Roman times. It lacked much scientific basis because the necessary science was itself largely unknown at the time.

As the nineteenth century progressed, many of the proprietary schools became affiliated with universities; often several would join to form the medical school of a new state university. The medical school of the University of Minnesota, for example, was established in 1888 when three proprietary schools in Minneapolis merged, with a fourth joining the union some years later. These associations gave medical students some access to aspects of new scientific knowledge, but overall the American medical schools at the beginning of the twentieth century were a hodgepodge of wildly varying quality.

Medical schools were not regulated in any way because medicine itself was largely unregulated. It was not even agreed upon what the practice of medicine actually was; there prevailed at the time among physicians several occasionally overlapping but generally distinct views of what the real causes of disease were. All these views shared a basic fallacy — they regarded a symptom, such as fever, as a disease in itself. Thus they believed relieving the symptom was equivalent to curing the disease.

The fundamental problem was that all these warring medical factions had no idea what really caused most diseases; for example, bacteria were only just being discovered and their role in disease was still largely unknown, although this was rapidly changing. Human physiology — how the body works — was only beginning to be investigated. To America’s sick patients, none of this made much difference, because virtually none of the medical therapies available at the time did much good, and many of the treatments, such as large doses of mercury, were actually highly toxic.

There were then bitter arguments and rivalries among physicians for other reasons besides their warring theories of disease causation. In that era before experimental science, no one viewpoint could definitely prove another wrong. The chief reason for the rancor, however, was that there were more physicians than there was demand for their services. At a time when few people even went to the doctor, the number of physicians practicing primary care (which is what they all did back then) relative to the population was three times more than it is today. Competition was tough, so tough that the majority of physicians did not even support themselves through the practice of medicine alone; they had some other occupation as well — quite a difference from today.

In sum, medicine a century ago consisted of an excess of physicians, many of them badly trained, who jealously squabbled with each other as each tried to gain an advantage. Two things changed that medical world into the one we know today: the explosion of scientific knowledge, which finally gave us some insight into how diseases actually behaved in the body, and a revolution in medical education, a revolution wrought by what is known as the Flexner Report.

In 1910 the Carnegie Foundation commissioned Abraham Flexner to visit all 155 medical schools in America (for comparison, there are only 125 today). What he found appalled him; only a few passed muster, principally the Johns Hopkins Medical School, which had been established on the model then prevailing in Germany. That model stressed rigorous training in the new biological sciences with hands-on laboratory experience for all medical students, followed by supervised bedside experience caring for actual sick people.

Flexner’s report changed the face of medical education profoundly; eighty-nine of the medical schools he visited closed over the next twenty years, and those remaining structured their curricula into what we have today—a combination of preclinical training in the relevant sciences followed by practical, patient-oriented instruction in clinical medicine. This standard has stood the test of time, meaning the way I was taught in 1974 was essentially unchanged from how my father was taught in 1942.

The advance of medical science had largely stopped the feuding between kinds of doctors; allopathic, homeopathic, and osteopathic schools adopted essentially the same curriculum. (Although the original homeopathic schools, such as Hahnemann in Philadelphia, joined the emerging medical mainstream, homopathic practice similar to Joseph Hahnemann’s original theories continues to be taught at a number of places). Osteopathy maintains its own identity. It continues to maintain its own schools, of which there are twenty-three in the United States, and to grant its own degree—the Doctor of Osteopathy (DO), rather than the Doctor of Medicine (MD). In virtually all respects, however, and most importantly in the view of state licensing boards, the skills, rights, and privileges of holders of the two degrees are equivalent.

Teenage drinking and the PICU

March 9, 2009  |  General  |  2 Comments

Every PICU cares for teenagers who are injured in car accidents. Many times these adolescents have been drinking alcohol. We also see teens in whom alcohol has led to a variety of other injuries besides car accidents. So underage alcohol use is a PICU issue. What do we know about it?

You can find some statistical answers to the question here, courtesy of the United States Department of Health and Human Services. Overall, alcohol is the most commonly abused drug by teenagers, dwarfing all others, including tobacco. In fact, underage drinkers consume eleven percent of all the alcohol consumed in the United States, an astonishing statistic. Nearly half of high school children report drinking some amount of alcohol during the previous month, and half of those teenagers did so during a session of binge drinking, defined as five or more drinks on a single occasion. By the time they graduate, three-quarters of high school students have tried alcohol. Among even younger children, forty percent of eighth-graders have tried alcohol, and sixteen percent of them report drinking within the previous month.

Those are the cold, abstract statistics. But teen drinking is not just about statistics–it is about individual children and what happens to them. Overall, a child who starts drinking as a young teen is four times more likely to develop alcohol-related problems as an adult than is a person who does not use alcohol until becoming an adult. Such children are also more likely to abuse other drugs, develop school problems, or engage in early and risky sexual activity. All these things correlate with teen drinking; they are not necessarily caused by it. Even so, such ominous associations tell us we should be greatly concerned.

One of the most dangerous problems connected with teen drinking is drunk driving. It is common among teens–ten percent report having done so. An even larger number–one third of all teenagers–report having ridden in a car during the previous month driven by a teen who had been drinking. Motor vehicle accidents are the leading cause of death among teens, and many of those who die show evidence of recent drinking. Although alcohol impairs the reaction time and abilities of all drivers, inexperienced teen drivers are even more affected. All these dry statistics translate into the unique, individual tragedies of thousands of teens killed or injured.

What can a parent do about teen drinking? Does any intervention help? Talking to your children about alcohol before they find out about it on their own is not only commonsense advice, it actually works. For example, one survey showed that parental disapproval was a far more powerful deterrent than were legal restrictions to getting alcohol. Teenagers whose parents talk to them frankly about alcohol, including a firm expectation that underage drinking is not acceptable, are less likely to drink. Equally important, parents who themselves use alcohol need to set an example of responsible behavior, especially with regard to driving.

You can find more excellent discussions, answers, and comprehensive resources for parents here, part of the recent Surgeon General’s initiative to reduce underage drinking.

The problem of finding which medical treatments work

November 23, 2008  |  General  |  No Comments

One thing everyone agrees on is that our economy cannot sustain the amount of money we spend on healthcare. That was clear even before the Wall Street meltdown, and it’s even more true now. The United States spends 16% its gross domestic product (GDP) on healthcare, a figure half again that of the next highest spending country (Switzerland, at 11%). Most other European countries spend 9-10%. We also spend much more per capita than anybody else. (These figures are from 2003, but little has changed since then — if anything, it’s worse.)

Not only do we spend more than anybody else, but by many measures, as a society we get much less for our money. That is, in spite of our high healthcare bills, the United States does not compare well with other countries in many measures of health.

What’s to be done? How can we find ways to spend less on healthcare but get better value for our dollar? One answer is that much of the money we spend is on unproven or even worthless treatments. Many authorities advocate we establish an independent agency of some kind to evaluate which treatments work and which ones don’t. Britain already has such an agency, called the National Institute for Health and Clinical Excellence. The way it works is that patients and physicians are free to use a non-approved treatment, but insurance won’t pay for it. As you can read in the linked article, there are some vocal opponents to the agency, something probably inevitable. But in the words of its director: “We are not trying to be unkind or cruel. We are trying to look after everybody.”

Opponents of such a concept complain this represents rationing of health care, because inevitably it would mean that patients won’t get all they may want. This is true, but in fact we’re already rationing care; we just use a more insidious method. Anyway, what else are we to do? There is simply not enough money, especially now, to pay for everything. It’s time we recognize that. An independent evaluation agency of this sort would make the decision-making process transparent and fair.