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Doctors, Not Gods
June 21, 2010 6:00 AM   Subscribe

What US Health Care Needs Medical doctor and writer Atul Gawande gave the commencement address recently at Stanford's School of Medicine. In it he lays out very precisely and in a nonpartisan way what is wrong with the institution of medical care in the US — why it is both so expensive and so ineffective at delivering quality care uniformly across the board. (via)
posted by kliuless (43 comments total) 16 users marked this as a favorite

 
While Dr. Gawande makes an elegant point, the third comment to the article nails exactly where the elegance goes awry.
posted by kipmanley at 6:13 AM on June 21, 2010 [2 favorites]


The comments seem to be missing.
posted by GenjiandProust at 6:17 AM on June 21, 2010


I never read any of his stuff because I'm afraid he's the next Sanjay Gupta. Sanjay, you disappointed our people!
posted by anniecat at 6:20 AM on June 21, 2010 [1 favorite]


We have a problem where poor people can't get access to a resource but rich people can and we have a political system where one party is devoted wholly to the interests of the rich and one party is devoted 90% to the interests of the rich and there's a "non-partisan" explanation for all this?

On the contrary, I'd argue that what US healthcare needs is less willful blindness as to the source of the problem.
posted by DU at 6:21 AM on June 21, 2010 [12 favorites]


To further what kipmanley points out, the US healthcare system is starting from a great disadvantage. if
"Great medecine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society",
then I should think that a strongly decentralized collection of private healthcare providers lacks the right motivations to optimize the system, rather than its specific (and most profitable) parts.
posted by Popular Ethics at 6:22 AM on June 21, 2010 [2 favorites]


It would be great if the problem could be solved just by making the system more efficient. And making it more efficient certainly won't hurt. But when the main players in the system (hint: they are not the doctors and nurses) have maximum profit - not maximum health - as their goal, then it begins to make a little more sense how it is that premiums go up 10-20% per year.
posted by rtha at 6:25 AM on June 21, 2010 [6 favorites]


Yes, while Dr. Gawande makes a good case for the human elements of the problem, he does little to address the political and commercial aspects. Because, while human failings will always be with us, that doesn't mean that political and commercial mistakes can't be fixed or improved (at least in the short term, until the next round of undermining).
posted by GenjiandProust at 6:26 AM on June 21, 2010


the causes are economic -- that is, the conflict between what's in the interest for the system as a whole and what's in the specific interest of the individuals and organizations that own or control the money

We will be made out computers before we have electronic medical records
To say one more word on electronic medical records, the fact that it's 2010 and we're having a conversation about how to move records from paper to computers is evidence of how screwed up the American health-care system is. In part, you're dealing with the fractured incentives in the system: It's good for patients and good for insurers if doctor's offices spend money setting up computer systems, but it's not necessarily going to make doctors any money, and the doctors themselves are frequently older and don't want to learn a new system. That's one reason why systems where the insurer and the provider are the same -- think Veteran's Affairs or Kaiser Permanente -- tend to be ahead of the curve on electronic medical records.
Controlling health-care costs: Another American way
The success of Kaiser Permanente, an integrated American health-care firm, offers lessons for insurers and hospitals at home and abroad

Bringing Comparison Shopping to the Doctor's Office
A new search engine can help patients search for doctors and find out how much they will charge, depending on their insurance coverage.
posted by kliuless at 6:29 AM on June 21, 2010


Okay, I read this one, and he is not the disappointment Sanjaybhai has been. Perhaps I might read his book now.
posted by anniecat at 6:29 AM on June 21, 2010


anniecat, he's a fantastic writer -- like the Michael Lewis of medicine, but with domain expertise.
posted by callmejay at 6:32 AM on June 21, 2010


Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.

He touches on something really fundamental. A PhD and an MD are not equivalent degrees. Engineers who get to be called "doctor" have actually done research and have contributed something to the body of science. Medical "doctors" have basically completed a program of study and apprenticeship. Calling them "craftsmen" is actually somewhat precise because this is how MDs are trained.

So how is an MD supposed to work like an engineer when the medical profession prefers old-school, hands-on, guild-style apprenticeships and engineers receive a different sort of scientific training?
posted by three blind mice at 6:41 AM on June 21, 2010 [2 favorites]


One of the main problems as I see it is that for-profit healthcare organizations cannot have the patient as their number one priority. By their charters and the law, they must maximize profits for the benefit of their shareholders. Occasionally, the two are not mutually exclusive, but--regardless of how well run the organization and how tightly meshed and well-oiled are the gears of the machine--when the provider must choose, the patient will lose.
posted by spacely_sprocket at 6:44 AM on June 21, 2010 [4 favorites]


what the US healthcare system needs is a version of the Google algorithm - that goes double for the financial markets and campaign finance. We need boards who actively watch for ways doctors/quants/corporations try to game the system in their favor and give the boards the authority to change the algorithm on the fly so the time spent gaming the system becomes unprofitable. It's the reason Google has stayed the leader in search for so long because people have give up trying to figure out their formula since it constantly changes.
posted by any major dude at 6:59 AM on June 21, 2010


Gosh, this is the most confusing graduation speech I have ever heard. (Granted my standards are a little warped.*)
When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.
Science is complex only in the US?
We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well.
Not the best. The most profitable.
And the country is also struggling mightily with the costs. By the end of the decade, at the present rate of cost growth, the price of a family insurance plan will rise to $27,000. Health care will go from ten per cent to seventeen per cent of labor costs for business, and workers’ wages will have to fall. State budgets will have to double to maintain current health programs. And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it’s the economic bailout plan. But take both away and you’ve made almost no difference. Our deficit problem—far and away—is the soaring and seemingly unstoppable cost of health care.
What was that thing about scientific complexity again?


So he starts out by saying, don't feel bad that you can't know/do everything, because science has become too complex and we have had to compartmentalize things. The American individual is too small for all the knowledge America has accumulated.

In the middle he talks about how this compartmentalization has failed us because a car just made randomly of the best parts in the world is not the best car. Also, pencillin fooled us because it made us believe that medicine was going to be easy. What?

He ends by saying, hey - the great thing is, medicine is so fucked that you as individual doctors have to do everything! ("This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility.") And then:
"But the fantastic thing is: This is what you get to do."
(Somewhere in the middle he also congratulates these kids for having the "wisdom" to reject the words of all the experienced old doctors who say they would never choose this profession again. And there's a story in there somewhere that has nothing to do with anything he's talking about - all it does is shill for his book The Checklist Manifesto.)

I think Dr. Gawande has been marketing himself for too long and needs to go back to medicine. And maybe economics. Or at least logic.


Is there anything Time magazine hasn't made into a list?
posted by mondaygreens at 7:05 AM on June 21, 2010 [8 favorites]


Okay, I read this one, and he is not the disappointment Sanjaybhai has been. Perhaps I might read his book now.

While at it, you might want to consider reading the other desi-American doctor-author, Abraham Verghese. Apart from being a compelling tale on how rural communities faced the AIDS onslaught, his excellent My Own Country was one of the books that made me convince why legalizing same-sex marriage is such a big deal.
posted by the cydonian at 7:39 AM on June 21, 2010 [4 favorites]


"Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society."

I think it's that "lowest possible cost for society" part that he really fails to address beyond the implied belief that some "system" will better integrate care and magically reduce costs in a way that will make a difference. I'm not seeing any suggestion that doctors themselves need to do anything personally on their part to reign-in cost. Otherwise, his speech is an exhortation for doctors to do more, to boldly march into the future and be great. Honestly, unless doctors do something serious on their end too (other than complaining about all the reasons they can't do anything) they really aren't going to be happy with the "system" that will probably come about to do the job for them.
posted by Thorzdad at 7:45 AM on June 21, 2010


Science is complex only in the US?

Huh? Since when is the ballooning cost of health care limited to the US? Last I heard, most of Europe is having problems with deficit spending, to the point of causing major financial instability.

Not the best. The most profitable.

Again, huh? True, routine medical care seems to be more accessible elsewhere, but for advanced medicine, i.e. the most expensive medicine, the US really can't be beat.
Five-year cancer survival rates in particular are markedly better (paywall, unfortunately) in the US than in either Canada or Europe.

The thrust of the address is that physicians need to focus not only on their specialty but on integrating the care they provide with that provided by other physicians and practitioners. I fail to see how this is either confusing or inappropriate.
posted by valkyryn at 7:47 AM on June 21, 2010 [1 favorite]


valkyryn wrote:

Five-year cancer survival rates in particular are markedly better (paywall, unfortunately) in the US than in either Canada or Europe.

the rate of medical bankruptcies is also markedly better here as well
posted by any major dude at 8:01 AM on June 21, 2010 [1 favorite]


valkyryn, you're confusing me too. Gawande is saying that the problem of the uncontrollable explosion in US health care costs is not rooted in economics but in scientific complexity. Which I'm taking issue with on the grounds that costs of health care are not uncontrollably explosive in Canada, France, Germany etc. So is medical science unmanageably complex only in the US?

More importantly, if more complex medical science isn't leading to better health care but in fact making the situation worse, what is/has been the impetus for making it complex? Isn't the point of medical science... um, improving health? (Gawande says as much.) But American medical science is not about making health care good (which means, crudely, as affordable and as effective as possible) but about profits - this is an economic problem, not a scientific one. In a free market economy, science is going where the money is. It has to.

So yeah, of course the most expensive medicine is the best in the US. That was my point.

As for your last point, I was pointing out his circular logic, and I don't think I can resummarize it better than I already have. His argument may not be disingenuous but it definitely is flawed.
posted by mondaygreens at 8:06 AM on June 21, 2010


It's a good piece, written by a mostly academic surgeon, and it reflects his perspective on the situation. Furthermore, he's speaking to the graduating medical school class of Stanfurd University, 98% of whom typically go on to become highly paid specialists. Certainly, the problems of health care delivery are complex and are largely about the disparity of wealth. But one facet of this which Gawande wisely chose to address in this venue is the expectation that the pipeline of new doctors might be expecting something vastly different than what the nation really needs from them.

A lot of things need to happen to get to the health care system we deserve (and some of them *are* happening) but we'll never get reform until physicians learn that working together to create a just system has to supercede their own self interest. It is the opinion of this doctor (albeit just a do-gooder family doc to the poor) a just system *is* in our own self interest.
posted by Slarty Bartfast at 8:08 AM on June 21, 2010


Slarty, how exactly are you going to get doctors who are willing to supercede their own self interest when the machine - that begins with premed students in college - is geared toward promoting the most competitive/greedy/cut-throat individuals? Aren't you asking too much for people like this to change when self-interest is what made them successful in the first place? If you want selfless doctors you need to gear the med school machine toward promoting selfless people.
posted by any major dude at 8:17 AM on June 21, 2010 [1 favorite]


Slarty Bartfast - you are right, but don't you think that it's a bit too much to ask from individuals? I mean look at the title of this post. And the beginning of the speech. And most people you know.

Where else in the US are people working together to create 'a just system that supercedes their own self-interest'? Where is this even possible without sacrifice? Isn't capitalism all about self-interest?

It bugs me that individuals are being asked / expected to be do-gooders without insurance companies, medical malpractice or anything else that could help them act in the interest of their patience being properly reformed. It misplaces the burden IMHO. How much does this particular degree cost? What's the average debt of the students? What will they need to work for first and foremost in order to justify / pay back the money and time they've spent in becoming doctors?

Basically, what is being prioritized and incentivized in US medicine? You're a doctor, so you're the best person to answer this for me - is it health care?
posted by mondaygreens at 8:32 AM on June 21, 2010


mondaygreens: "In the middle he talks about how this compartmentalization has failed us because a car just made randomly of the best parts in the world is not the best car. Also, pencillin fooled us because it made us believe that medicine was going to be easy. What?"

These points are the heart of his argument, and they're well-considered if not the most well-presented. I had an old public health prof who once told me that if anyone asks you what's holding up a given healthcare intervention, the answer will almost always be "Systems." Gawande's absolutely correct that a great deal of inefficiency and waste comes as a direct result of having a healthcare system that's as fractured as ours is. Better integration reduces administrative overhead, but more importantly it reduces the number of self-interested agents in the system. Primary care providers and specialists want different things because they don't play for the same team, and don't even think about asking them all to play nice with insurers.

Further, he's absolutely correct on with the penicillin bit. Look at this table of death rates in the US from 1900-2005. Tuberculosis deaths are almost eliminated in the second half of the century while cancer grows to fill the gap. Polio and smallpox rates would have similar trajectories to TB if they were also on the table. Why is that? It's because America's post-war healthcare system was built on advances made in treating communicable disease. TB, Measles, Smallpox, Malaria-- all these illnesses could be treated in relatively short order with short courses of medication and without major lifestyle changes. So what did we do? We set up a public health system based on top-down interventions: mass vaccination, mass spraying, and distribution of the same drugs to millions of people. Doctors could explain the directions for the treatment in about as long as it took for them to write out the prescription, and everyone was happy. Life expectancy rose by almost 20 years since 1940.

Here's the rub, though: diabetes, heart disease, obesity, and cancer are largely multifactorial in their etiologies, complex and long-term in their treatments, and highly demanding on the patient's willingness to make lifestyle changes. The treatment algorithms for these patients (often comorbid with more than one of the above illnesses) make a two-week course of penicillin and a warning not to drink any alcohol look like a goddamn beach vacation. Getting patients to adapt to their new lifestyle requires hours of counseling that our system wasn't built to provide, and something that college bio and chem majors aren't really equipped to handle by the time they finish medical school.
posted by The White Hat at 8:35 AM on June 21, 2010 [2 favorites]


True, routine medical care seems to be more accessible elsewhere, but for advanced medicine

That's a huge, enormous "but" right there. Making routine medical care more accessible and more affordable for more people will obviate the need for some or a lot of advanced, more expensive care. If you can afford the drugs you need to keep your diabetes/HIV/asthma/etc. under control, if you can afford the regular visits to your PCP - because you don't have a $2500 deductible that must be met before your insurance kicks in - then you won't end up in the hospital paying $500 for a tylenol for a condition that was preventable or controllable.
posted by rtha at 8:41 AM on June 21, 2010


The White Hat - (I'll stop monopolozing this thread after this) I totally agree that the answer is systems. And the biggest system, which drives everything, is economy (money system). You can't do a damn thing without it, and whatever you try to do, you have to earn something from it, because - well - you can't live without it. (Never mind that most doctors don't want to earn just enough to live.)

So yes, the answer is systems. But it doesn't stop at scientific complexity: science has become so complex for a reason: because it's not integrated by, nor does it have to answer to, health care. Science needs money. So do scientists, doctors and their patients (to pay for the doctors and the drugs). Capitalism divorces medicine from care - not doctors.

And the solution / hope he's giving to these doctors - after saying that the problem is the complexity of science (and not the thrust of capitalism)? You have to do what the system isn't doing, you have to do what every system around you is going to fight tooth and nail against. You have to use your brains and your time and your energy not for self-profit but for your patient's care. You have to come out of a system of cut-throat competition (med school), go into an even more brutal one (real life) - and suddenly start working in harmony with fellow doctors.

Okay, I'm relatively young so maybe that's why I can brashly bet that that will not work. Most people will not even have that option. Very, very few people will choose it. And the system will punish them for it.
posted by mondaygreens at 8:53 AM on June 21, 2010


Well, it does take a certain amount of altruism to decide to go to med school. I mean, on purely financial terms, going into medicine is a terrible decision. In the application process, you have to not only demonstrate academic excellence, but you also have to pay at least lip service to the idea that you're going into it for the "right" reasons. And actually, I think most pre-med students probably *are* going into for the right reasons. These are generally people who *could* do well in business, or academics, or law school, or whatever but they've chosen a life of much harder work because they see that there is something significant in helping sick people.

20 years later, after the meat grinder of a $250,000 med school education, 100 hour work weeks in residency, and a career as an ineffectual clinician in an unjust system, it's not surprising priorities change. If you want to be a rich doctor that does just enough work to have a comfortable life to take care of you and yours, the current system provides that. It's just that that whole "helping sick people" thing now takes a back seat to you getting your new Lexus. Ultimately, I believe this provides for a very unsatisfying career, but if this is where 90% of doctors are, how is anything going to change? And I think that's what Gawande was maybe getting at.

Absolutely, insurance companies, malpractice etc need to be reformed. But I'm not so sure that the motives of doctors as they are right now are so pure that they could spearhead the reform effort. My whole thing is that doctor's motives would be a lot different if med school was subsidized, if they saw more of their hard work translated into helping patients instead of insurance company profits, and if they felt rewarded doing the thing they got into medicine to do in the first place.

don't you think that it's a bit too much to ask from individuals?


To warn them on their graduation day to brace themselves for the changes that will allow them to follow their ideals, no.
posted by Slarty Bartfast at 8:56 AM on June 21, 2010 [3 favorites]


To warn them on their graduation day to brace themselves for the changes that will allow them to follow their ideals, no.

Okay, I guess that's a kinder way to interpret what he's saying. To me it seems like he's saying the same things adults tell children: be good, because. Don't expect anything else to change, but you have to be perfect.

Basically, it's on you.

(I guess the difference is I don't think individual altruism is the answer to anything, even if it exists. The world is full of well-meaning people and it's mostly going to hell.)
posted by mondaygreens at 9:24 AM on June 21, 2010


Altruism is the only thing we got. We should expect it of ourselves and we should expect it of the people around us. Nothing gets better until we do.

/naive hippy
posted by Slarty Bartfast at 9:33 AM on June 21, 2010


I'm not seeing any suggestion that doctors themselves need to do anything personally on their part to reign-in cost.

"Talking to doctors about money is difficult. It's uncomfortable both for patients and for doctors to think that this most important and intimate service could be contaminated. But the truth is the decisions made by your physician when you enter his office are profoundly influenced by the way that doctors get paid in this country."
posted by weston at 10:07 AM on June 21, 2010 [1 favorite]


More from the same author on this topic. I was so disappointed last summer in the political circus surrounding the healthcare reform debate. It was like no one took the time to even read the Wiki about it, so instead of reasonable discussion about things like comparative effectiveness, we got death panels, socialism, and if federal money might be used to pay for abortions. I guess this is to be expected in the current era of hyper-partisan American politics, but with such a serious issue, both morally and economically, somehow I expected better of us.
posted by Man Bites Dog at 10:27 AM on June 21, 2010


One of the main problems as I see it is that for-profit healthcare organizations cannot have the patient as their number one priority. By their charters and the law, they must maximize profits for the benefit of their shareholders. Occasionally, the two are not mutually exclusive, but--regardless of how well run the organization and how tightly meshed and well-oiled are the gears of the machine--when the provider must choose, the patient will lose.

I don't know why you think that non-profit healthcare organizations (which are commonplace, and which include organizations that have been roundly and publicly criticized recently) or a government-run healthcare organization would fare any better.
posted by Slap Factory at 10:54 AM on June 21, 2010


I don't know why you think that non-profit healthcare organizations (which are commonplace, and which include organizations that have been roundly and publicly criticized recently) or a government-run healthcare organization would fare any better.

The rising cost of health care is affecting all countries (you can thank our greater life expectancies mostly), but the evidence suggests most other systems get more bang for their buck than the US.
posted by Popular Ethics at 11:09 AM on June 21, 2010


mondaygreens: "It bugs me that individuals are being asked / expected to be do-gooders without insurance companies, medical malpractice or anything else that could help them act in the interest of their patience being properly reformed. It misplaces the burden IMHO. How much does this particular degree cost? What's the average debt of the students? What will they need to work for first and foremost in order to justify / pay back the money and time they've spent in becoming doctors?"

IAAMedical Student, or rather, I will be one in about a month and a half. I just signed my first set of Master Promissory Notes on the first installment of a debt that will eventually come to about $250,000 over four years, plus another ~$30,000 if I have to finish my MPH without funding. Yes, this amount of debt does suck. It sucks hard, and it will seriously constrain my options if I want to be able to do the work I love and support a family at the same time. For instance, if I join up with the public health service and stay in Philly to do clinic work as a commissioned officer, I'll start at the OS-5 pay grade, or about eight thousand bucks a month. Right out of the box, about $2,000 will go to paying off my loans every month, knocking my real salary down to about $56,000 after taxes, which is nothing to sneeze at but also not really on-par with folks who used their seven years to work their way up the corporate ladder.

Now, granted, it's not as bad as that. There are a bunch of loan-repayment programs that the government offers in exchange for public service, and USPHS has the same pension system as the rest of the military, but the compensation will never be on par with my fellow students who will become cardiologists, plastic surgeons, or dermatologists and start out at $350,000. It's just never going to happen, but that's where the altruism comes in-- I'm OK with going to school for exactly the same amount of time in exchange for 1/3 of the salary because I'm going to get to provide care to folks who need it more and are less able to procure it, and in the end I'll still be able to have a house and a family and maybe even put my kids through college.

And here's the funny thing: those house/family/college account goals are just about the same for the cardiologist or the plastic surgeon, if maybe a little smaller. Where it counts, I'll get to win just about as much as the next doctor, and I'd wager that I might even get to sleep a little easier than they do. So if we all win, I don't really understand all the competition (pdf, p.11). Maybe it's a prestige thing-- I sense a general antipathy among med students towards general practice-- it's just not where the talent goes. Maybe that's driven entirely by salary, or maybe it has something to do with the amount of respect general practitioners receive today compared to thirty years ago.

I don't know. I just want to use the few neurons I have in the service of something bigger than myself, and give the remainder to a family that won't want for shelter or education. I think that's what everyone wants, so perhaps our shortage of family practice docs is just an advertising problem. Maybe all we need is for med students to understand that there's not a whole lot of difference between $100,000/yr and $350,000/yr. I mean, correct me if I'm wrong on this because right now I make about seven percent of that larger figure, but how much farther does that extra money get you?
posted by The White Hat at 11:10 AM on June 21, 2010 [2 favorites]


The White Hat - Thanks for that, it was illuminating.

Of course doctors doing what you and Slarty Bartfast are doing is the ideal. But is that where things are broken? Between patient and doctor? Even if many (or even most) doctors are choosing a specialty based on what pays the most, I'd say no.

My issue with the speech is that doctors are NOT what is wrong with health care, and individual altruism is not what will or can fix it. To refer back to the title of the link: "What health care needs" is not harmonious, self-effacing doctors anymore than what education needs is committed, self-less teachers.

You can try to do good. Hell, we all can and should, and I'd say most of us are trying. But the system is broken; it does not facilitate good care (or teaching) but rather gets in the way. People who need you can't even get to you without insurance/money - you can be as innovative, humble and ambitious as humanly possible but you simply cannot reach those who need the most help. Or rather, they can't get to you.

If he really wanted to prepare doctors for the tough changes ahead and to affirm their ideals, he could've tried to at least address where those challenges really lie. He could've talked about how money is not what gives a doctor's work meaning, that it's not where the personal rewards lie. He could talk about the real challenges doctors are facing right now with some respect / understanding, instead of dismissing them (which he does). Instead he says, this is not an economics/systems thing - it's a complexity/individual thing and if you want to be good doctors (and of course you do), it's your job to fix what the previous generations have fucked up, put up with this bankrupt system, gather together what's compartmentalized/specialized, and tackle all that the coming decades will bring. It's hard but that's why you got into medicine, right? To help patients? Then you better be an awesome person with a endless inner spring of strength, altruism and creativity. Also, hey, get along with each other! (Also, checklists.)

Thats not a doctor's job. Or a teacher's job. That's a government's job. A doctor's job is to know medical stuff, and to help people get better. It's a hard enough job as it is, I'd think, and I'd want my doctors to have as easy a time of it as possible - so they can focus on what's important to both of us in that relationship: my health.

That said, kudos to you, and good luck.
posted by mondaygreens at 12:14 PM on June 21, 2010 [1 favorite]


Medicine will only improve* markedly when doctors are not the critical decision nodes in the system: http://www.wired.com/science/discoveries/magazine/16-07/pb_theory and http://www.amazon.com/End-Medicine-Silicon-Valley-Reboot/dp/0061130311/ref=sr_1_1?ie=UTF8&s=books&qid=1277150584&sr=8-1.

Expert Systems FTW.

* By improve I mean become cheaper, faster, better.
posted by imneuromancer at 1:05 PM on June 21, 2010


I heard 'solar plexus' all the time as a kid learning how to fight. 'Solar plexus' does this. Hit the 'solar plexus' and knock them out. Etc.
As I studies more and got better training (although my uncles had already schooled me on this, but as a kid you don't think the elders in your family know anything useful) I learned that it was causing spasms in the thoracic diaphragm that causes those 'I can't breathe' type knockouts.
This is not to say there aren't methods of nerve compression that don't have results.
I can make your heart do all sorts of fun things through your laryngeal nerve and other places.
But a lot of anatomy, as I've learned from doctors, has very specific nomenclature and is purposefully differentiated from layman terminology exactly to avoid confusion.
It is, at least in the case of anatomy, complex to a purpose.
'Solar plexus' is a term derived from yoga and new age sources, it's not an actual medical term (celiac plexus is, and should be because there is no nearby solar ganglion or solar ganglia unless you want to get back into the mysticism. Me I like not having 3 or 4 different terms for the same complex system being bandied about while someone has my innards open on a table).
You don't know where the Yin mitral valve is? What kind of doctor are you?

And typically it's a good sign of a non-professional fight trainer or martial artist. Most of the terms people use are subject to how they use them. Doctors are technicians. They need to describe discrete parts. Yoga practitioners need something more systemically descriptive for the internal movement and fighters need something relationally descriptive to do something to an opponent.

As it happens I only know the terms because my studies have overlapped. I speak pretty loosely generally and sometimes jokingly. Write that way too (I've had complaints here and elsewhere). But professionally I'm absolutely razor sharp. Unfortunately I'm not a healer. But I don't expect a healer to know the proper terminology for knocking someone out or directing the energy of his chakras.

I would have thought a doctor with an indian sounding name might have been aware of the term. On the other hand they're a specialized breed (doctors). If his patients refer to their balls hurting or their biscuit or bollocks, given the area the doctor is in, they should know what the patient means.
On the other hand too, some of the slang goes the other way.

In any case there needs to be meticulous attention paid to the verbiage in any technical oriented speak so people know exactly what they're referring to. The language can't be loose.

Beyond that, I've had many of the same complaints about the military. There's something other than our foreign policy interest and fielding the best troops with the best equipment in an integrated spectrum of force at work that seems to be dominant.
Similarly - there is something other than a genuine system of care in the medical field that is exerting influence.

Usually it's people who want to line their pockets - whatever form it takes. I have no idea why we tolerate that as a society.
posted by Smedleyman at 3:14 PM on June 21, 2010


Dr. Gawande also is quoting the statistic of the 9th version of the Int'l Classification of Diseases (ICD-9). Most of the rest of the world is already the 10th version, ICD-10, in which there are 68,000 diagnosis. The U.S. has a timeline to switch providers and payors over to ICD-10 by 2013.
posted by Lukenlogs at 5:37 PM on June 21, 2010


About three weeks ago I broke my foot in four places in the form of a Lisfranc injury. My understanding is that this is a fairly complex injury and the road to recovery is long and very complex. While I have been treated by some very good surgeons the process has been particularly scary, and an eye opener to how truly screwed up the treatment process has become in America. It seems to me that the current system requires that the patient be the one who is truly responsible for treatment, and as such the patient must force each of their individual care givers to communicate with each other. I would be very fearful if I were injured to such an extent that I couldn't supervise my own care. I believe that electronic medical records would help to dramatically improve care, but only because they would serve as a proxy for better communication between caregivers.

In my case I have about five specialists that I see regularly, or I have seen in the past: an endocrinologist (various conditions), a dermatologist (general sensitive skin), a pediatric orthopedist (I had bilateral hip displaysia as a kid), an oral surgeon (I had my wisdom teeth out two weeks before I got injured), an orthopedic surgeon (for this current injury), and a primary care physician. What I find remarkable is that none of them have ever really talked, or were briefed on my current injury. My questions to my orthopedic surgeon about how my current injuries may have been caused by my hip dysplasia, or the medications prescribed by my endocrinologists were met by shrugs, not by, an answer like, "I don't know but I will call around and find out." Similarly I told the surgeon that I have a mild latex allergy and sensitive skin, but no effort was made to contact my dermatologist. Given the specialization of doctors today it would seem the pragmatic thing to do would be for all of my caregivers to meet and discuss my injury, how it may have been mediated by my existing conditions, how this injury could change my future care, and what complications my primary care doctor should look for in the future.

As an engineer who has worked as a project manager and a principal investigator on a number of projects, I find the analogy to engineering in the post to be an interesting concept. It seems to me that there is a great need for a "patient manager" who serves to coordinate each of the patient's caregivers, and serve as a point of contact for the patient. The patient manager would essentially make sure that all of the care givers meet after a major medical issue to discuss what may have caused the issue, how it should be treated and what complications could arise, and how future treatment or future complications would manifest themselves. The patient manager would also brief a new specialist on the patient's current and past care. In the course of treating this current injury I have been told so many different things by so many doctors that I have a hard time keeping everything correct. The patient manager would also and serve as the conduit for treatment information to the patient, and relay concerns back to the various specialists. Perhaps this patient manager job should be done by the primary care physician, but I have never seen it done this way. I would just be happy if I didn't need to furnish every specialist with a list of medications, a list of surgery's and doctors's contact information, and a verbal account of my medical history. I would like to hope they know more about my medical history than I do.
posted by kscottz at 7:02 PM on June 21, 2010 [2 favorites]


kscottz: We have "patient managers" already, they are called doctors and nurses. [sigh]
posted by imneuromancer at 5:37 AM on June 22, 2010


Given the specialization of doctors today it would seem the pragmatic thing to do would be for all of my caregivers to meet and discuss my injury, how it may have been mediated by my existing conditions, how this injury could change my future care, and what complications my primary care doctor should look for in the future.

if you were still in the hospital, that would be the role of the hospitalist, an emerging practice in the U.S.
posted by toodleydoodley at 10:32 AM on June 22, 2010


although the role is still not as holistic or globalized (longitudinal?) as it ought to be.
posted by toodleydoodley at 10:33 AM on June 22, 2010


* By improve I mean become cheaper, faster, better.
My experience with most things is that you can only choose two of those.
posted by Thorzdad at 2:11 PM on June 22, 2010 [2 favorites]


* By improve I mean become cheaper, faster, better.
My experience with most things is that you can only choose two of those.


Over time, you can choose all three. It is only within a time/space/resource constraint that you can only get two.

For example, over the course of 30 years computers have gotten better, faster, and cheaper. Buy a computer RIGHT NOW and you have to pick two attributes between the three.
posted by imneuromancer at 6:05 AM on June 23, 2010


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