Robert

Pregnancy complaints and their treatments…

This puts the burden on the safety net health care providers, such as public or nonprofit hospitals or clinics. Second, if uninsured pregnant women could get preventative care, this could reduce pregnancy complications and be more ……

Robert

http://www.nytimes.com/2008/08/20/health/policy/20vaccine.html?_r=1&pagewanted=5&ref=policy&oref=slogin

“The exponential growth curve is shaped like a hockey stick or the letter “J.” It describes epidemics, where a critical mass of a given influence on the larger system is achieved – prompting the growth rate to increase dramatically. This is the power of a changing slope (in comparison to linear relationships), and it is at the core of Malcomb Gladwell’s “Tipping Point.” In that NY Times best seller, Gladwell investigates positive epidemics and the influences that, when achieving a critical mass, can generate exceptionally favorable outcomes – most prominently focusing on reductions to New York City’s crime rate under Police Chief Bratton during the Gulliani mayoral administration. With this as the model, I have come to an unexpected conclusion concerning how to reduce the cost of healthcare – namely, increase investment in rural education.”

You could use Steven Levitt’s “Freakonomics” as an alternative hook — noting that outcomes may be strongly influenced by seemingly unrelated events –, or reference Ross Perot’s use of the exponential growth curve during his presidential campaign infomercials (probably before your time). Alternatively, you could reference your course work in statistics to get at the same point (i.e., linear regressions versus curved regressions). You might note the plot line of Dicken’s “Tale of Two Cities,” where the story of unrelated and disconnected Parisians find a joint nexus in that city’s climactic revolution or the sought commonality explaining the demise of those who died on Thornton Wilder’s “Bridge of San Louis Rey.” You could reference the unexpected and disproportionate consequences of Senator John McCain’s seemingly simple selection of Governor Sarah Palin as his running mate (i.e., the positive of uniting the party’s conservative base or the free press provided by Tina Fey and the negative of emphasizing the senator’s age/health or the Governor’s perceived lack of national/international experience).

In each case, the lesson of these examples is the influence of seemingly disconnected actions and influences, which is at the heart of your belief that targeting rural education for reform and improvement will produce a favorable improvement on health outcomes and lower labor costs by providers — which strikes me as a wonderfully nuanced recognition.

In other words, identify a broader theme contributing to the conclusions expressed in your piece and then identify an example of that theme or lesson from a different domain or arena.

Again, nicely done.

Robert

According to the Indian Supreme Court, 3000 Bhopal, Madhya Pradesh citizens were killed during and following the release of 43 tons of methyl isocyanate gas in December of 1984 – exposing another 520,000. The maker of this industrial gas, Union Carbide, was deemed responsible for what is now considered the worst industrial disaster in human history. Formerly a component of the Dow Jones Industrial Average, Union Carbide is no longer an independent company, having been purchased by Dow Chemical in 2001 – such was the loss of reputation, to say nothing of its liability exposure.

In the case of reporting medical malpractice jury awards, the harm to reputation is not simply to an impersonal corporation, but, instead, targets the reputation of an identifiable physician. Should this distinction matter?

Recognizing that the practice of medicine is complex and that human error increases in complex settings, it may be supposed that excellent practitioners will inadvertently or unintentionally perpetrate harm in a small number of cases. Moreover, most cases presented before a jury are contested, and, given the technical complexity of healthcare, it may be argued that the average jury lacks the acumen necessary to render a legitimate finding. Given this, if the purpose of reporting medical malpractice jury awards is to warn the public of a suspect physician, should the state report only those exceeding a threshold number of awards against them, where that threshold is some number greater than one?

Why should it be necessary for the state to report jury awards at all? Isn’t the state and the medical profession responsible for certifying the competency of the practitioner? If so, the perceived necessity of reporting jury awards would seem to evidence problems with the larger oversight and credentialing system. Should individual practitioners be punished for this failure, with the creation of this reporting system?

So, the choice is yours. Should I forgo another meal, given that you would be sharing the road with a light-headed driver?

My wife on the other hand is indefensibly fat (compared to me, who simply needs a little diet and a walk around the block, according to the experts). She, however, is in the gym four days a week, climbs the stairs at work (as lunch hour exercise), and “Walks the Grandma” for hours at one of several local parks each weekend. Our meals are passable in taste (she was an excellent cook), now that sugar and fat have been banished, but I have found it necessary to threaten divorce over the issue of whether dietary health supersedes my carnivore urges (in other words, I put my foot down when it came to compelled vegetarianism). Her cholesterol levels are fine, she runs 2 miles on the tread mill two days a week, takes an advanced “spinning” class on Saturday mornings, and she can bench press my weight. But, according to every leading authority on the subject, she is fat.

Now, I understand the good intentions of those determined to dictate my life, but the standards which declared me scrawny in 1978 and overweight today have changed while I have added no pound or inch in height. My wife, however, is not the woman I married. Her weight problem, oddly enough, began soon after she gave birth to our son. In fact, come to think of it, nearly every over-weight woman I know got that way after children arrived. Given this, it seems reasonable to conclude that the real demon to this overweight thing is children. Stop having them and something on the order of a quarter of our obesity problem seems likely to go away (women are 50 percent of the population, and half of them are outside of child-bearing age; hence, the rough 25-percent estimate). Now, I know of no child that has ever urged a parent to increase food consumption or promoted a sedentary lifestyle. Spend a weekend chasing after a 3-year-old and neither gluttony nor laziness will seem appropriate descriptors of the event. So, perhaps I am wrong to blame this on children.

If so, the only other reasonable conclusion is that adult obesity is attributable to sex, and that, for the sake of our health and economy, it must the stopped immediately. Perhaps the President or the Surgeon General would like to make the announcement.

In the back of my mind, however, I keep hearing the words of Mark Twain, who wrote “Nothing so needs reform as other people’s vices.”

Given this, do you believe that market forces will resolve the issue of comparatively low wages for primary care physicians? If not, why?

By the way, I ran the numbers from your article (providing figures for medical school expense and subsequent incomes and made the appropriate adjustments for taxes and interest) and it appears that the return on investment for primary care physician education is currently around 11%, if the payback period is 7 ½ years. While not luxurious, income during the payback timeframe would be in excess of $70,000, with the full income level realized in year 8 and thereafter. This represents a glass half full/half empty scenario, when compared to the typical required rate of return for standard business investment decisions – where a require return of between 20% and 25% is common. With new product investment by established firms, the risk of failure is more significant than for primary care practitioners – which may explain the disparity or, at least, a portion of it.

Given this, do you believe that market forces will resolve the issue of comparatively low wages for primary care physicians? If not, why?

By the way, I ran the numbers from your article (providing figures for medical school expense and subsequent incomes and made the appropriate adjustments for taxes and interest) and it appears that the return on investment for primary care physician education is currently around 11%, if the payback period is 7 ½ years. While not luxurious, income during the payback timeframe would be in excess of $70,000, with the full income level realized in year 8 and thereafter. This represents a glass half full/half empty scenario, when compared to the typical required rate of return for standard business investment decisions – where a require return of between 20% and 25% is common. With new product investment by established firms, the risk of failure is more significant than for primary care practitioners – which may explain the disparity or, at least, a portion of it.

Even students taking my classes will invariably forget some percentage of what we cover, and the same appears to be the case for med school and residency, regardless of whether a PhD is undertaken. To what degree does this loss of learning for MD/PHD students reflect the decline that follows med school for non-MD/PHD physicians?

[It is worth noting that this quote exists in the first edition of the text, but is absent from the second edition. The original source (case law) is not provided, but the research leading to it is supported with references to American Medical Association publications and analysis conducted by Philip Kotler – perhaps, the most significant name in healthcare marketing.]

While your article represents a hair nicely split (taking no strong position in either direction), it raises several important questions. First, do you believe that marketing represents a form of information delivery that, if absent, would deprive patients and practitioners of needed information? Alternatively, does healthcare marketing represent an exercise of free speech and would a limitation placed on it serve to violate the First Amendment? Second, to what degree do you believe that caveat emptor (“let the buyer beware”)—where the onus of information gathering rests solely with the patient — represents an operational model for health care delivery? Does such a model presume medical knowledge by the patient sufficient to make an informed decision, and can that knowledge be relied upon? Going a step further, are all patients competent consumers of health care? In this case, I am thinking about those without a high school diploma, geriatric patients who have been intellectually sedentary since retirement many years before, those suffering from dementia or neurological trauma (to include stroke).

To what degree do you believe that the costs associated with medical care for illegal immigrants serves that purpose – prompting greater attention to a problem for which no solution has yet been successfully implemented? The reason I ask is that the cost represents a failure of government to address the problem (this is clearly not be obligation of any other group, since maintenance of the borders is a policing function, rather than a vigilante function). Without government bearing the cost, the electorate would not be aware of it, and the status quo would be sustained – which, I gather, has promoted your concern.

The problem confronting physicians is one of information overload (http://www.cnn.com/HEALTH/9601/information_overload/). One study, in fact, indicated that if a practitioner read one double-blinded set of study results, published in a tier one academic journal, every day, he or she would be behind by five years at the end of the first year – a finding supported by the practitioners at Robert Wood Johnson Hospital, in the most recent reference, above.

So, we have a conflict between the patient’s desire for information (and, indeed, their right as consumers to it) and a system that makes consistent delivery of optimal care nearly impossible for the practitioner – judging them by a standard the system seems incapable of supporting. It appears (at minimum) that continuing medical education is insufficient, given the studies indicating that knowledge of optimal care practices decline over time – especially, for those not working in group practice settings or at academic medical centers (http://www.chestjournal.org/cgi/content/full/118/1/129?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=crawford&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT applies to non-small cell lung cancer, but similar studies support the same conclusion for an abundance of other diagnoses).

Add to this the problems that you have identified, and the natural question is not “why hasn’t the outcomes-reporting practice been, either, fixed or discontinued,” but, rather, how do we ensure that optimal care is more reliably delivered? Eliminate the suspicions surrounding healthcare quality, and the need to report goes away. So, how would you resolve the health care quality dilemma? [Take your time. We’re unlikely to break the code on this anytime soon. I am not, however, getting any younger, so sooner is better than later.]

The problem confronting physicians is one of information overload (http://www.cnn.com/HEALTH/9601/information_overload/). One study, in fact, indicated that if a practitioner read one double-blinded set of study results, published in a tier one academic journal, every day, he or she would be behind by five years at the end of the first year – a finding supported by the practitioners a Robert Wood Johnson Hospital, in the most recent reference, above.

So, we have a conflict between the patient’s desire for information (and, indeed, their right as consumers to it) and a system that makes consistent delivery of optimal care nearly impossible for the practitioner – judging them by a standard the system seems incapable of supporting. It appears (at minimum) that continuing medical education is insufficient, given the studies indicating that knowledge of optimal care practices decline over time – especially, for those not working in group practice settings or at academic medical centers (http://www.chestjournal.org/cgi/content/full/118/1/129?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=crawford&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT applies to non-small cell lung cancer, but similar studies support the same conclusion for an abundance of other diagnoses).

Add to this the problems that you have identified, and the natural question is not “why hasn’t the outcomes-reporting practice been, either, fixed or discontinued,” but, rather, how do we ensure that optimal care is more reliably delivered? Eliminate the suspicions surrounding healthcare quality, and the need to report goes away. So, how would you resolve the health care quality dilemma? [Take your time. We’re unlikely to break the code on this anytime soon.]

You might, also, use it with the question of whether one state would be compelled to accept or follow another state’s legislative example when residents move/migrate between states and seek to transfer coverage. While this has changed over the years, the laws concerning the age at which teen couples may legally marry vary significantly from one state to the next (http://www.usmarriagelaws.com/search/united_states/teen_marriage_laws/index.shtml ), presenting a challenge to the gaining state if the marriage was licensed in a different state. This is, as well, the challenge confronting same-sex marriages if sanctioned in one state but not recognized as legal in another.

Of course, none of this addresses the question of whether patients are likely to migrate from one state to the next, shopping for the most generous health-care coverage, if one homogeneous system is not present. This was not a major issue in the past, because the state role was largely limited to Medicaid, but, as this expands (a la Massachusetts) such a challenge seems likely to arise. Your thoughts?

[Note: When I was in the military, we were required to declare a home of record, on which our state taxes were calculated. It was remarkable the number of soldiers who declared Florida, with its low state taxes, as their home record, even though a significant percentage had never set foot in the state, much less lived there. ]

This is the stuff of which “lateral thinking” is made. In policy circles, we tend to think in a linear fashion. It would, for example, makes sense to conclude that, with rising health care costs, patient ability to afford care would eventually decline as discretionary income narrows. This would hold regardless of whether the patient is paying for health care “out-of-pocket” or through insurance premiums – assuming health care costs rise at a pace faster than wages.

There are, typically, unexpected consequences to fundamental change of an established system. The quote, above, references just one such example. It recognizes that a decline in affordability is likely to render a reduction in patient volumes, which would reduce the frequency with which procedures are performed. This becomes a healthcare quality concern when recognizing that favorable treatment outcomes (especially, for complex diagnoses and treatment) are highly correlated to the frequency with which a procedure is performed by the practitioner. Consequently, the negative impact of health care inflation outpacing wage inflation extends beyond the issue of access to care (even with all of the implications related to public health, preventative medicine, and patients presenting for treatment with more-expensive, higher-acuity conditions than if receiving treatment sooner).

Even this connection is relatively linear, however, in its logic. The argument presented in the referenced article becomes less linear when recognizing that the same loss of professional acumen applies to researchers in medical science, as cash flows throughout the healthcare system become more constrained, but it doesn’t represent lateral thinking, just yet.

Instead, it becomes lateral thinking when realizing that this describes the experience in South Africa, but the same logic applies to the health care system in the United States and beyond. Indeed, it may be applied outside health care – representing a challenge for other industries as the world economy seems poised to enter a recession.

Lateral thinking or not, there is nothing brilliant in the recognition that skills atrophy through disuse (which is the focus of my response, taken from the original article). To the extent that a truth is overlooked or absent in an existing debate, however, raising it advances the discussion and, consequently, has merit. Beyond that, it provides an interesting “hook” on which to hang your article and cultivate reader interest.

Throughout, this article references and responds to:

Health Care Reform and the Crisis of HIV and AIDS in South Africa

The New England Journal of Medicine

Solomon R. Bernatar, M.B., Ch. B.

Volume 351:81-92 Number 1, July 1, 2004

Years ago, I received a phone call from a relative about his mother-in-law, who was a long-term throat cancer patient. This wonderful lady (in her 70s) was in the ICU because painful swallowing at meals prompted her to stop eating. Unable to tolerate a tracheal feeding tube, she asked that the doctors allow her to die. An IV to sustain her with nutrients was inserted, but it was unsuccessful, and she entered a coma. At that point, the doctors recommended removal of the IV, and to let nature take its course. The family waffled on the decision for a day or two before calling me.

I recommended transferring her to a nearby academic medical center for a second opinion and treatment – the poor management of her pain was the give-away that prompted my recommendation. The teaching hospital inserted a tracheal feeding tube until she strengthened (sedating her to make it tolerable when she regained consciousness), followed by insertion of an abdominal feeding tube when she became able to survive the surgery. For the next five years, She lived with her son and daughter and, more importantly, two of her four grandchildren — spending significant time with my nieces (who live nearby), as well .

In May of 2006, I gave a talk in Lisbon on whether marketing is the silver bullet of healthcare. In it, I argued that end of life care represents an uncomfortable but necessary conservation for modern societies, given the issues you’ve identified ( http://rcrawford.wordpress.com/2008/01/28/22/) and concluded that, to the extent that marketing enables that and other difficult conversations, it is the silver bullet. Well, one of those hard issues is the uncertainty surrounding quality, where decisions to forego care at the end of life only work if providers reliably provide quality care and accurately determine when heroic efforts are unwarranted.

Well, talk with the most respected medical experts (I have), and they will tell you that healthcare is less a certainty than an exercise in probabilities. Even medical research, where the inputs (independent variables) are controlled and reliable, accepts a p-value of up to 0.05 — accepting a 5 percent level of uncertainty. But that is medical research, not clinical treatment of patients. When asked, my physician students from many courses tell me that we do not know with certainty how to treat roughly 45 percent of diagnoses. Add to that the Rand findings that 45 percent of what we do know to be optimal care is never delivered, and the obligation to die and its reliance on predictable quality becomes questionable.

Of course, we will never achieve perfect quality. Uncertainty will always be challenge — raising the question of how much uncertainty is acceptable before the proposition advanced in your article represents a viable option. You can argue that we are there today or that some defined level represents the threshold, but that is a judgment call, where differing views will make it persistently contentious. Some will be happy with nothing less than 100 percent reliability, while others will accept as little as 30 percent (perhaps lower, as many patients did prior to the 1950s, when the cure was deemed worse than the disease and its treatment for many cancers).

Finally, I appreciate the courage necessary to tackle this difficult question.

I may be wrong, but it would seem the same may hold for medicine, where the patient is unaware of the surgeon’s skill until able to judge the effectiveness of the procedure post-recovery. The difference, which would seem to make healthcare more subjective than art, is that most of healthcare operates outside of the patient’s direct observation — at the atomic level or, more grossly, in operative settngs, when the patient is under anesthesia. Having observed a large number of surgeries and surgeons, it is my impression that not all are created equal — some are artists, while others are more akin to auto mechanics or professional wrestlers. How the surgeon navigates through muscle and around bone (dissection) to reach an organ for resection or repair influences the pain and length of recovery, even though the patient’s discomfort is non-subjective but, for the patient, identifying the cause is.

All of this suggests to me that the customer is less often wrong (in art appreciation or medicine) than imagined, even if their opinions may be discarded as subjective.

What is not subjective is my appreciation for your use of lateral thinking with this and the previous submission. If I could (ethical and legal implications aside), I’d clone you.