The Myth of Prevention
online.wsj.com
online.wsj.com
Seems like if we'd remove the medical doctor gatekeepers and allow people to care for themselves, then health care costs would go down.
It seems so strange that in a free nation, it is illegal for citizens to care for their own health.
If the occasionally recurring calls for licensing of "software engineers" is any guide, some of the people reading this are imagining the legislation of supply and salivating at the higher salary this would mean for them. :/
Maybe the best way to fix our health-care system is to fix our educational system first.
It's more philosophical than whether or not people are smart enough though. I think people should be able to choose. If I make a mistake in my own health care and I die, then that is okay. I could fall off my roof while I'm trying to fix that too or repair my car's brakes wrong.
Doctors make mistakes in patient care too and they are still allowed to practice medicine.
I also think we should fix our educational system and one way would be to allow students to break free from the lowest common denominator factors that are also ruining our health.
Of course. I know more than one person who was forced to diagnose themselves and then insist on the tests that would prove it to the doctor. People know more about themselves than their doctors do, and have a much higher incentive to get it right.
What makes this even more ironic -- as a patient, she has a very difficult time communicating with doctors. When she was in graduate school, she did studies on disparities in health care based on race. Somehow she gets caught up in those mechanisms without seeing the patterns she once studied in grad school. (She's African American, and she constantly has problems convincing doctors that she's not exaggerating the degree of her pain, and at the same time constantly disregarding her doctor's instructions. A couple of days ago, I did a double-take and said, "OMG, a little voice in my head is yelling 'African American Health Disparities!' Do you realize you're living a stereotype?")
Then you haven't had them enough to get to know them well. Get something often enough and you don't need a doctor to tell you which it is, you learn from experience to know exactly which it is.
It seems very simple to me to understand how to eat/exersice properly and how to not poison myself. All the information is readily available to anyone who needs it. Now if so many people can not even get this bit right, what chance is there that they would be able to diagnose more complex cases?
I say this, by the way, as an obese guy with a roommate who smokes, if that matters. :)
I know I'm guilty myself - I need to make 2-3 visits to the dentist to fill some cavities, but I tend to delay this because of time issues, financial cost and pure laziness ... and I think I care about my health reasonably well compared to the majority.
The first case was a woman suffering from prolonged, heavy menstrual bleeding. I don't mean an extra few days a month. I mean 45 days in a row with maybe a week between periods. The bleeding was enough to cause anemia, itself requiring medical treatment. The response of doctors was always the same: birth-control pills. At first they worked, but eventually they didn't. Certain pills, I don't remember which, made it significantly worse.
She finally insisted on alternate treatment. The doctor insisted on another month on yet another pill, certain that her problem was polycystic ovarian diseas despite having found no cysts or other matching symptoms in an examination. It didn't work, so he decided the problem must be uterine polyps and scheduled a dilation and curettage - essentially scraping out the inside of the uterus. He could see no polyps during the procedure, but insisted that they're sometimes too small to see.
It worked for a month. After that, the bleeding was back just as bad as ever. I came along to the doctor's office to help insist on a hormone test. He resisted, but eventually gave in. He resisted more when we wanted a copy of the results sent to us directly - in Florida, it's illegal for a test lab to deliver test results to anybody, including the patient without the doctor's permission. A couple weeks later, the results came in. All the levels were within the normal range, though luteinizing hormone was near the top of what seemed to be a rather wide range. A quick trip to Wikipedia made it clear this was part of the problem[1].
I went looking for a way to reduce the LH level, and quickly found that supressing the activity of another hormone called GNRH would do the trick, and that there are prescription drugs to do so. We brought the test results to an endocrinologist and first waited to see if she saw what I did. She didn't, so I told her. She agreed and wrote the prescription. With a retail price of around $60,000 an ounce, nafarelin acetate is the single most expensive substance I've interacted with, but it beats bleeding to death.
In the second case, I found a treatment simply by talking to the patient on IRC. He had a seizure disorder. The actual cause wasn't and still isn't known, but he had been seeing a neurologist. At one point, the neurologist prescribed gabapentin, a drug that acts an an analog of the inhibitory neurotransmitter gamma-aminobutyric acid. This was effective for about a week, but the patient quickly built up a tolerance. After reading what gabapentin was, and how GABA itself is made in the body, I asked the patient if he noticed a decrease in seizures when he ate foods high in MSG. It turns out that he did. He has been taking glutamine in pill form for about two months now, almost completely suppressing the seizures.
So, is everyone smart enough to care for themselves? Of course not. Are doctors necessarily smarter? At least some of the time, the answer appears to be no. I think most people should see a doctor for treatment of most medical conditions, but the idea of laws that prevent people from treating themselves seems like a fundamental violation of the rights of the individual.
[0] The actual cause of repeatedly coming up with wrong answers may be any number of biases, incorrect uses of heuristics or otherwise bad decision-making rather than a lack of intelligence.
I have nothing against the DIY option. The problem is, there are laws in place to prevent it. In Florida, it's illegal for a lab to collect a blood sample and run tests on the patient's say-so, or even give the results to the patient without the doctor's permission. It's illegal to obtain the drug the patient needed without a doctor's prescription.
There were workarounds available in this case: labsafe.com will have a doctor order any test a patient wants, though they recently quadrupled their prices (other options still exist). GNRH agonists are available without a prescription for research purposes, but they're still absurdly expensive, and not provided in a form that's easy to use as a drug.
[0] Assuming such a test is available and affordable, as it is for female reproductive hormones.
There are greedy physicians. There are bad physicians. These physicians can drive up health costs. I do not find, however, much evidence to support the idea that physician reimbursement has anything to do with our high national health costs.
Most I know are neither bad nor greedy. Generally, my colleagues are the best, most compassionate, smartest humans I know. The physicians I know have worked 60-80 hours a week for their entire professional lives, went into enormous debt to finance their professional educations and make between $140-200K annually before paying for their own expenses, health care insurance, sick time, vacations, etc.
I understand what you are saying about taking your health destiny into your own hands. Most physicians, including myself, want you to do just that, and will work with you to encourage you to efficiently and cheaply monitor and care for your own conditions. Most of us feel that has to be the future. Most of us believe strongly in preventive medicine, and feel caring for chronic disease is like trying to put the toothpaste back in the tube.
I'm with you, notwithstanding your hyperbole about the illegality of caring for your own health in a free nation.
But I think you might agree that when your 9 month old starts wheezing one February day in the midst of a common respiratory syncytial virus outbreak, despite all the self-learning you did on the Internet, you're probably best advised to seek counsel, evaluation, and treatment from someone who has seen a few cases of RSV, seen a few more cases of how fast children can go down with something so seemingly simple, and can treat it effectively.
I have no doubt that you and many of your colleagues are compassionate and well intentioned. But you also pay dues to an organization that has a political lobbying arm. This is of course, entirely understandable. Washington has a ton of power, power which can be used to steam roll you. Thus you support an organization that has a goal of looking out for your interests in Washington. It does so quite well. Too well, in fact. As a result of AMA lobbying, America has far fewer doctors than most other developed countries. The result is higher prices for consumers, and no evidence of better care. See: http://blogs.law.harvard.edu/philg/2009/04/05/the-futility-o... Again, I don't blame the doctors, I blame the design of the political system that creates constant factional fighting over the resources of the country, with some factions getting screwed and others doing the screwing. ( Oh Madison, how wrong you were ... )
Part of the way the restrictions of new doctors work is by restricting medical schools. This of course drives up the price of medical schools, sending doctors into massive debt. Frankly, there is no reason that doctors need four years of college on top of four years of college on top of four years of high school. I'm sure the whole thing could be compressed into eight years, as other countries have done.
For new doctors, loosening the barriers to entry would be a Pareto optimum improvement. Salaries would fall, but so would the costs of schooling. Overall the public would benefit without harming new doctors.
But existing doctors would get screwed, as you point out. To be fair, any reducing of the barriers to entry should include compensation for current doctors.
Every time a politician sneezes someone get screwed. You can't compensate everyone.
It's not at all uncommon to go to the doc knowing exactly what he's going to do, exactly what he's going to say, and exactly what prescription he'll give you, why waste all that fucking time and money just so the guy in the white coat can tell me what I already know?
I want to go to a doctor when I don't know what's wrong with me, not when I do.
1. Access to prescription drugs which are not safe.
2. Access to specialized equipment.
3. Access to highly skilled people to do something you can't do safely.
PS: If it's really safe for you and society then you can buy it over the counter. Do you really think it's a good idea to change this?
Yes. If a drug is not safe for the user, it should come with a warning about the risks involved. Choosing whether or not to accept those risks to get the potential benefits of a drug is up to the individual.
I'm more open to the idea of gatekeepers for drugs that can harm others. Antibiotics are the obvious example. Sure, require a prescription for antibiotics, but first let's get them out of animal feed.
Why? Seriously, all drugs should be OTC because it simply shouldn't be the governments job to protect me from myself. The government should have no say about what I choose or choose not to put in my own body. I can go to the store and pick up enough alcohol to drink myself to death in a matter of hours and that's OK, but pills require special treatment and protection? Bullshit.
Drugs should be clearly labeled with warnings, side effects, all pertinent information a person needs to make a decision. The only exceptions would be things like antibiotics because there's a valid reason to restrict their use and it benefits everyone to do so.
Doctors can still tell me what drug I should take, and in what dose, but they shouldn't be at all involved in my obtaining those drugs. If I go buy a bunch of morphine and overdose and kill myself, well... that's called natural selection, and it's a good thing. If you're really concerned about making sure people are informed, mandate that the pharmacist brief people of the issues.
The very notion of prescription drugs is just absurd really, we've just gotten so accustomed to the nanny state that we don't notice just how absurd it is. Many family doctors are little more than state approved drug dealers these days. Patients know what they want, they know what to say to get them, and doctors are more than happy to write them, so long as their pockets are lined with regular and mostly unnecessary checkups to do nothing more than refill a prescription.
Yes, many drugs are very dangerous and an overdose could easily kill you, guess what, so will an overdose of gasoline. So will an overdose of water, or diet pills, or hundreds of other OTC stuff. Things shouldn't be illegal because they're dangerous if you misuse them, that's not freedom.
> 2. Access to specialized equipment. > 3. Access to highly skilled people to do something you can't do safely.
Which are valid reasons to actually go see a doctor. I can't cat scan myself or operate on myself.
It takes a fucking lot of training to have any clue what's safe to take in what dosage once you start mixing a few drugs. Put all that stuff out on the shelf and tens of thousands of people will die every year. But hey, if you still think that's a good idea feel free to convince other people.
You're ignoring my central point, I didn't say it wouldn't be dangerous, I said it's not the governments job to protect a person from himself. People would learn fairly quickly that it's stupid to just buy a bunch of stuff and mix it, and as I said, doctors and pharmacists can still inform people of what they should take and what not to mix stuff with.
Our current system artificially makes doctors into an extremely overly paid government sanctioned artificially limited monopoly. This keeps the price of health care artificially high, it's a protection racket using people's own health against them to forcefully take their money. Being a doctor should be a way to help people, not a way to become a millionaire. People should be enabled to treat themselves, doctors should be a choice we have, not a requirement forced upon us by the law.
The fact is people already self medicate, that's how it's always been and that's how it'll always be, but they shouldn't have to go to Mexico, Canada, or their local drug dealer to get what they want, they should be able to just go to their local pharmacy.
It is the government’s job to protect people.
Mixing the drugs people take for fun, with drugs people take for their heath is a straw man argument.
Total heath care costs in this country have little to do with how doctors prescribe drugs. Changing how that works on a fundimental level is a high risk change for little payoff.
No it isn't, I don't have to go renew my license every third time I fill my tank. If long term prescription came with unlimited refills that didn't require more trips to the doc, I wouldn't be complaining.
> It is the government’s job to protect people.
From other people, and from outside invaders. Situations where there is a victim. It is not the governments job to protect me from myself, I cannot be my own victim. Well, this is how it should be in a free country, something we clearly aren't anymore.
> Mixing the drugs people take for fun, with drugs people take for their heath is a straw man argument.
Drugs are drugs, and what you call recreational drugs many of its users would absolutely say they take for their health, both mental and physical. It's not a strawman, you just don't like it. The fact is how the drug is classified is irrelevant to the issue of who owns my body and gets to say what does or doesn't go into it?
> Total heath care costs in this country have little to do with how doctors prescribe drugs.
It's one of many factors, I didn't say it was the biggest.
> Changing how that works on a fundamental level is a high risk change for little payoff.
Gaining the freedom to control your own body and not have a government decide for you is not a little payoff, freedom is worth any price.
For example, Iran does not have an epidemic of dying women due to OTC birth control.
You can probably find a fairly large number of drugs that could become over the counter and every year many make that jump. However, antibiotics sould not fall into this category.
Really? I have read that the increases in the mean wage of doctors have outpaced or at least tracked medical inflation at least since Bush took office. Given that doctor salaries are a major component of health care costs, there aren't too many ways that that can not have anything to do with our national health costs.
In general, doctors in the US make close to twice as much as doctors in other rich countries, while enduring similar costs of living. Doctor salaries definitely aren't the whole picture--we also spend almost twice as much per patient on prescription drugs along with twice as much on bureaucratic overhead.
Drug costs:
The NSF funds a near majority of the drug research that is done in the US (and this doesn't include much of their basic biology research even when it later proves crucial for drugs), and meanwhile drug companies spend close to 50% of their budgets on sales and marketing. Of the research that they do carry out, a large portion of it is on developing clone drugs to get around other drug companies' patents. Some portion of their research budgets also go into things which in a sane world I could have categorized under marketing and sales without drawing comment: stuff like cures for baldness.
Overhead: I don't know a lot of details about why the bureaucratic overhead is so much higher; I've heard some handwaving on lawyer costs involved in eeking out payments from estates during medical bankruptcy, the costs of dealing with multiple insurers, etc., but I haven't seen any hard numbers itemizing these things. I do know that malpractice isn't a significant part of it: around the time Bush came into office touting his catch-all solution to the problem of rising health care costs--malpractice reform--the ratio of malpractice judgments in dollars to national health care spending was around 0.60%. I don't know if that included settlements, but there is a pretty decent upper bound on what settlements/judgments could have been in total: the ratio of the amount spent by doctors on malpractice insurance premiums vs. national healthcare spending was 1%.
But, I can't go discuss a problem with my pharmacist then buy a generic. And, I would be surprised to hear I can go directly to a specialist, even if I pay cash instead going through insurance. Just saying, it's difficult.
They can, actually. All of the more common antibiotics are marketed for use in fish tanks and can be bought with no prescription from aquarium stores or ordered from Amazon. Looking up the markings on the pills shows them to be exactly the same pills you'd get from a pharmacy with a prescription.
Of course, you should have a pretty good idea of what sort of bacterium you're infected with before you take antibiotics. If you live with two people who are diagnosed with strep throat, and your tonsils swell up a day later, you probably don't need a culture to tell what you have. Don't abuse antibiotics.
16% of GDP? Other developed nations pay much less: on average 9% of GDP (http://opencrs.com/document/RL34175). Health care in the US isn't 67% better than in other developed countries.
For most situations most doctors are over-educated: why should a podiatrist require 8 years of schooling to remove bunions or do surgery on an ingrown toenail? Does a general practioner need 12 years of training to prescribe an antibiotic for a severe infection? Are economics, politics, physics, calculus and other courses really necessary for a brain surgeon to do his job or for a nurse practioner to give tetanus shots?
1. Break the entire medical profession down into smaller specialties and provide only the necessary training within those specialties. Sure, some should take the entire 12 years college + med school + internship + specialist training, but most won't. This would open the profession to competition and provide thousands more medical workers.Doctors won't like this: they'll fight it every inch of the way, down to refusing to train people. But it must happen. Perhaps only a massive natural or man-made disaster can overcome the resistance of the AMA and doctors and cause this to happen.
2. Mandate that statistics be maintained and published, complete with names, so you can judge who's good and who isn't; who takes risks and who doesn't; who's pricey and who is cheap. That way you can choose better and practitioners can be more easily regulated.
3. Eliminate HMOs and private insurance companies: they just don't work. The only insurance solution that will work is one wherein the government maintains the insurance pool. As long as insurance companies exist they will continue to cherry-pick patients and use legal tricks to eliminate patients who develop costly medical conditions.
4. Eliminating the HMOs and insurance companies immediately gives a gain equal to the profit of those firms. Increasing efficiency (automation of paperwork, scheduling, etc.) gives further gains. Improved technology can also reduce costs (something rarely pointed out about medicine). And we haven't brought up the drug companies yet.
There's lots of room for improvement in the current system, but the doctors, insurance companies, drug companies and the HMOs don't want to change the status quo. And they're the only ones with representatives (their lobbyists) in Washington.
In Sweden they worked quickly to put me on a safer and cheaper drug, one that most of the US is dragging its heels to get into place, why cause it costs less than half to treat a patient this way. Office visits go down because it is entirely self-administrable, instead of an IV that has to be done in a clinic.
No matter what medical system you choose there are going to be mistakes and deaths, I just prefer the Swedish system that seems to triage and try and use resources wisely.
I've had things in the US turn into unnecessary tests and hospital stays, in Sweden they recognize this and treat me appropriately. Of course I can't blame doctors in the US, they have the fear of a big malpractice suit if anything unordinary were to happen.
About (b), I think it might be better in the rest of Scandinavia. My personal experience -- I had a simple knee problems for decades (the sport doctors finally fixing that said it was common to drag them around for that long...) My experience here isn't that atypical.
“The Doctor” happens to be my favorite painting, mostly because of the story behind it: Sir Luke Fildes lost his oldest son
I have a print of the Fildes painting close at hand, a reminder that all the marvels of science, all the advances of medicine don’t replace what patients want of their doctors and what most of us wanted to offer when we felt the calling to medicine: the opportunity to be fully present at the bedside, to bring the human comfort that only the presence of an attentive physician can bring, to convey to patient and family the unspoken promise, “I will stay with you through thick and thin.”
I don't care if it's a person, robot, or pill, just fix me.
Either way the status quo is unsustainable. If something isn't done about it now we'll have a medical crisis in a few years/decades that is every bit as bad as the credit crisis was. And we'll sit around and say gee, someone should have done something about it sooner. It's too bad everyone was so terrified of change and willing to let the rich & powerful con them into thinking everything was just fine when it really wasn't.
> Which brings me to my problem with the president’s plan: despite being an admirer, I just don’t see how the president can pull off the reform he has in mind without cost cutting.
This suffers from two fallacies - the first is that this is not a zero sum game. We may spend just as much on health care but get more value for the dollar and thus live healthier lives and thereby be more productive.
The second problem is the "broken window" fallacy. Doing unnecessary healthcare is a not a reasonable thing to keep people employed. If you take that money out of healthcare it won't just vanish, it will go elsewhere and be productively employed to generate real value for the economy. Far from being a problem with the plan it is the most powerful argument in it's favor.
I'm impressed to see this sort of viewpoint in the WSJ.