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Showing posts from March, 2013

What does American healthcare want?

I know what I want, in healthcare, that is. I want it to be efficient, effective, thoughtful and inexpensive. I want it to create healthy people who don't need very much health care. I want it to involve elegant solutions to problems that take less time, money and effort. I want it to be so much easier and less expensive that taking care of all of our people uses even less resources than taking care of only some of them, as we do now.

But the healthcare industry in America is bigger than me, and bigger than all of the doctors who work in it, even if we could all agree on what we want. So what does it want?

Is it even reasonable to think about healthcare as an entity? I propose that it is, that this way of looking at it makes the direction it has taken much more understandable.

We observe that bureaucracies grow, even though we complain about how they should shrink and become more efficient. Agencies beget more agencies, and attempts to reduce bureaucracies often don't work. I…

23andMe: why might a person want to have their genes explored?

My son, who is 19, wanted a nice jacket and his genome for Christmas this year. He had found out that a company called 23andMe would tell him about his genetic susceptibility for diseases and his ancestry for only $99. 23andMe is a private company that started doing direct to consumer genetic testing in 2007 and has progressively lowered their prices and increased the amount and sophistication of information they give clients since then.

My sister bought my son the genetic kit and the padded envelope was under the tree for him on December 25th. He opened up the little plastic tube inside, spit in it and sent it back. In a couple of months he had all sorts of interesting information. He was most interested to see what parts of the world his ancestors sprang from, but also got information about scads of other things including his sensitivity to caffeine, ability to recognize bitter tastes, whether his muscles were predominantly "fast twitch" suggesting he would be a good spri…

Is a high calcium diet and calcium supplementation bad for you?

An article from Sweden was recently published showing that in a very large group of women, over 60,000 of them, followed for 19 years as part of an also very interesting study of the effectiveness of mammograms, women who get more calcium, in their diet or as supplements, had a higher risk of dying of anything, but especially of heart attacks. It is unclear why this would be true, but there are various theories.

Further, the study showed that this risk was more pronounced if the calcium was taken as supplements, but still present in women who got their calcium from the food they ate. The highest level of risk was in women who got more than 1400 mg of calcium a day, and an intake of 700-1000 mg a day did not particularly increase risk. The women with the lowest average calcium intake were not at any increased risk of death, which was a surprise to the researchers. Information about calcium intake was taken from the subjects' reports of diet and supplement use, which was further va…

Female feticide --ethical issues of ultrasound in India and China

The use of ultrasound has had a large impact on health care in resource poor countries. This article details some of the research that has been done overseas to look at the impact on bedside ultrasound by caregivers to deliver more appropriate care for injured and ill patients in Africa, Asia and Mexico. Using an ultrasound to determine how dehydrated a child is, whether an injured person requires surgery, whether a person who has collapsed has a blood clot or a punctured lung or fluid around their heart and treat those things appropriately is incredibly powerful and, after paying for the machine, costs nothing but the time to train practitioners.

It is possible to find some of the most interesting and cutting edge uses for ultrasound in the literature from developing countries because they have the equipment and, lacking CT scanners and x-ray machines, they have ample motivation to use it to its greatest advantage.

In India and China, however, which both need low cost alternatives f…

Recycling the community physician: how should we really be training the next generation of doctors?

I have been spending time at an academic medical center lately and I’m noticing some obvious flaws in our method of shaping the doctors of the future. When I went to medical school I was trained by physicians who were eminent in their areas of specialty and also did some research. They taught in classrooms and as attending physicians when we were working on the wards as doctors in training. I realize now that the clinical attendings who helped us manage our general medical patients actually specialized in some more narrow aspect of medicine, but were smart enough to be able to manage a diverse array of medical problems.  I thought they were all amazing and never even entertained the possibility that their knowledge was less than exhaustive. I was also taught by the interns and residents who were themselves in training, though with an MD after their names. I thought that they were both wise and skillful. Perhaps they were. I will never find out now.
Watching the training of medical st…