Book Club: An American Sickness

The U.S. healthcare system is a hot mess. Even people who know things are convoluted and expensive might not realize the extent: we pay far more for just about all aspects of healthcare here than anywhere else, and our outcomes are worse pretty much across the board (see this article from the Commonwealth Fund for details).  As tempting as it is to implicitly trust that you’ll get the best care in the world right here, the facts would suggest otherwise. Every other major developed economny in the world as some form of universal access. So why do Americans cling to the idea that our healthcare market is somehow sacred, and that a market-based approach is the answer? I’ve talked about why healthcare is not just another commodity before, but it’s still true.

Elisabeth Rosenthal, a physician turned journalist who has worked for the NYT and Kaiser Health News, wrote a book last year. In it, she exposes a lot of the causes and effects of the major malfunctions in our healthcare system. Much of this is illuminating— examples about hospital conglomerates and pharmaceutical pricing are spot-on. But what seems to lack punch is the explanation for why this upside-down, losing system persists. When healthcare is treated like every other business, greed drives, incentives are bonkers, and lobbyists shape policy. When healthcare is considered as a public service, things are different. But once powerful people are making obscene amounts of money, it’s nigh impossible to unring that bell. Are there market failures? Big time. Can the people affected muster enough influence to combat the big-money lobbying of professions and industry that have become accustomed to fat-cat money? Fat chance.

Aother quibble: Rosenthal is mercelessly physician-centric. She doesn’t consider the unique added value of team-based healthcare or other professional expertise, choosing instead to lump unique professions like NPs and PAs together as “extenders”. Barf. Dr. Rosenthal, I wish you’d take a broader view of health.

That said, give it a read. It’s interesting/depressing. And you might pick up some useful tips for your nex hospital visit, knock on wood.

What we talk about when we talk about research findings in the news

What happens when journalists report the findings of a scientific study to the general public? Often, the findings are stated out of context, broadly interpreted, and stripped of the nuance and uncertainty that characterize much of scientific research.  Should this scare us back from publicizing findings to a wider audience than you might typically find in a scientific journal? Or is publicity critical to uptake?

What is our responsibility as scientists to communicate our findings, not only through dedicated dissemination and implementation planning, but also through the popular press?

Here’s a recent example. JAMA published the findings of a study by Mandager et al.  on the association of cardiorespiratory fitness (CRF) with long-term mortality. CRF was measured by exercise treadmill testing in a sample of over 120,000 patients who were having this test done anyway as part of their care (that means these people were mostly being evaluated for symptoms potentially related to cardiovascular disease). The investigators quantified CRF as peak estimated METs. They separated by sex and age to calculate percentiles and then stratified CRF based on those percentiles. They used public and hospital records to determine mortality. Median follow-up was 8.4 years. The investigators concluded that CRF was significantly inversely associated with all-cause mortality (i.e., the fitter you are, the less likely you are to die). They went on to state that low CRF was as risky as or riskier than diabetes, CAD, or smoking. They also noted, importantly, that “there does not appear to be an upper limit of aerobic fitness above which a survival benefit is no longer observed”, but “there continues to be uncertainty regarding the relative benefit or potential risk of extreme levels of exercise and fitness”. They go on to offer several other sensible caveats, including that the study population may not be representative of the general population, and there are potentially significant unmeasured factors in this retrospective study. All things considered, though, this seems to represent very good news: a modifiable factor is strongly associated with increased longevity in a large sample with a long follow-up.  Bravo!

So how did this get reported in the popular press? Gizmodo’s headline reads “No Such Thing As Too Much Exercise, Study Finds”.

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From hard targets to risk models: Who are we helping?

There’s something appealing about a threshold-based approach to treatment: if your cholesterol is over 200, it’s high. If your blood pressure is over 140, it’s high. If you A1C is over 7, it’s high. It’s clean, easy to understand and easy to communicate. But is it helping to improve meaningful outcomes, and is it doing so equitably? Does 140 for me create the same problem as 140 for you? Is 141 worlds away from 139? These aren’t easy questions to answer. It complicates the already complicated conversations around taking medications for prevention.

We’re starting to see evidence across different conditions that risk-based approaches to treatment, i.e. those that treat based on aggregation of multiple risk factors into a predicted risk of some adverse outcome, might be better. The first major test-case for this was lipid guidelines, but recommendations for other conditions are starting to change too:

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Why patients clash with doctors

I’ve seen several loved ones frustrated by interactions with the medical system lately, and after my initial knee-jerk reaction of “how dare they mess with one of my people” and “we have a shitty system, and we probably always will,” I got to thinking more about it. Why do people who are seeking help from a medical professional so often walk away feeling demoralized and disrespected, in addition to whatever problem brought them in in the first place?

Generally speaking, people choose careers in medicine because they want to connect with and help others. Medical school is grueling, and expensive, and people generally don’t do it if they don’t have some inclination towards service of others. Likewise, people seek out care from physicians because they want to feel better. Something isn’t right, and physicians are there to tell you what it is and how to fix it. They’re not stupid or lazy, just sick. By and large, this all lines up. So where do things go wrong? Let’s check out this handy chart:

Medical Visit


A few thoughts:

  • Doctors expect to be able to fix any “real” problem. This is how they’re trained— “true disease declares itself” is a common mindset.
  • Patients expect doctors to be able to fix any problem. All problems are “real.”
  • Some problems are well defined and understood within the structure of allopathic medicine.
  • Some problems are not well defined and understood within the structure of allopathic medicine. But they are not less real!
  • When patients present to doctors with problems from column b, things can go bad. Patients feel like they are not being listened to, taken seriously, or understood. Doctors feel like patients are being non-compliant, have unreasonable expectations, or are hypochondriacs. Everyone thinks everyone else is a jerk.

So what’s the root of this mess?

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why how we pay for healthcare actually matters

I have a patient in my practice, Francisco, who showed up to the walk-in clinic one day looking awful. His wife had driven him— insisted, he told me.  Fransisco was an always-upbeat guy who I had treated over the years for the major and chronic (uncontrolled diabetes) to the minor and self-limited (smashed thumb). He’s an auto mechanic who supports a big extended family. He’s hard-working. He always says thank you. He’s downright jolly, even when life gives him lemons. But this day, he was struggling to remain cheerful. He had nearly fallen in the shower, he told me, and felt dizzy, weak and sweaty. He had a headache, or sometimes more of an upper back/shoulder pain. It wasn’t going away.

I had a sinking feeling as I asked the medical assistant to check his blood sugar and vital signs. Francisco’s medical history put him at high risk for a number of life-threatening problems— things like a heart attack, or a diabetic coma. His blood sugar was normal. Damn, I thought, that would have been relatively easy to fix. His heart rate was too high. His oxygen level was too low.

He needed an EKG. He needed some blood tests. A full-service primary care clinic would have those things. My free mobile clinic did not. Even if I had more resources at hand, though, he needed to go to the emergency room where there were nurses and cardiologists and resources and machines. They would evaluate him, stabilize him, and treat him. They have to— it’s the law. But then, I knew, they would bill him. He might quality for emergency Medicaid, but given his and his wife’s modest incomes and their family’s complicated immigration status, it wasn’t clear whether he would. But when you need medical care right now, you’ll figure out how to pay for it later. You want to live right now.

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Why healthcare isn’t just another commodity

If you are a person with a lot of choices, with a job that offers health insurance, with a social security number and a safe place to sleep and knowledge of where your next meal is coming from, I can see how you might think a market-based healthcare model is a good idea. You might be annoyed at your doctor, or the confusing bill, or the insurance company, but when something shitty happens to you, you aren’t really worried that you’re not going to be able to get help.

And I know that a lot of people in this position of privilege think (wrongly) that these basic pieces of a stable, comfortable life are accessible to anyone willing to work hard enough to get them. That everyone has basically good options but some people take advantage while others are lazy, entitled, or whatever other excuse might bubble up. This is infuriating because it is so, so wrong. It’s like that old adage of being born on third base and thinking you hit a triple. A lot of folks were born without even a bat to swing. Those folks are just as human as you are.

So imagine you are 58 years old, and your daughter just had a baby. Continue reading