Why is American health care so expensive?

Today started early because I was being the hospitalist as well as the stress test doctor as well as my usual identity as primary care physician. A hospitalist is a doctor who takes care of all of the patients in a hospital who have no other doctor or whose doctor doesn't take care of patients in a hospital. It is a fine job, as it is practiced in many larger communities, though it limits the doctor's ability to make long term connections with patients, who usually see someone else when they are not confined to a hospital. People who take hospitalist jobs work shifts, make a fixed salary and get lots of time off.  In our small town, the hospitalist is my long suffering partner, nearly all of the time, but I and my other internal medicine colleagues spell her evenings and weekends and occasional vacations. We all squeeze our hospital work into a day that also includes outpatient primary care medicine. As the hospitalist I had 6 patients to see before clinic started at 10, only...

The Annals of Internal Medicine occasionally reviews the articles and studies of note in a particular field of internal medicine for those of us who don't read all of the specialty journals. This month there was an update in pulmonary and critical care medicine, the internal medicine specialty that is most intimately involved with caring for the very ill and those people who are at the ends of their lives. Nestled among articles on diagnosis of tuberculosis and novel treatments for non-small cell lung cancer is one about palliative care, that is medical interventions intended to make people more comfortable as they die. This article, published in the New England Journal of Medicine by Dr. J.S. Temel and colleagues from the Massachusetts General Hospital in Boston, looks at quality and length of life in patients with recently diagnosed incurable lung cancer, cancers that have spread metastatically beyond the lung tissue.  These patients cannot expect to be cured of their cancers, ...

The Technology, Education and Design group was founded in 1984 in Monterey, California, to promote ideas that primarily related to information systems. Since that time, the focus has expanded and now includes subjects of global relevance as expressed in their mission statement: ..."We believe passionately in the power of ideas to change attitudes, lives and ultimately, the world. So we're building here a clearinghouse that offers free knowledge and inspiration from the world's most inspired thinkers, and also a community of curious souls to engage with ideas and each other." TED talks have been criticized as being elitist and as reducing scientists and scholars to circus performers, but having watched several of them, I think that the discipline of having to express ones most important ideas in 18 minutes in a format that can be understood by just about everyone is a great idea. As far as elitist, I suppose that probably applies, since it is unlikely that anyone...

Most of what we think of as preventive medicine is actually not that at all. Mammograms, pap smears, colonoscopies, all of these are actually early detection of disease. Abnormal results on any of these tests prompts more testing and sometimes treatment, which may or may not result in better health or a delay in becoming ill or dying.  True prevention of disease would include healthy diet, exercise, accident prevention, safe sex and adequate birth control. These are the kinds of things that truly keep people from getting sick, but most of these are not truly in the scope of care provided by physicians. Today I got a letter in the mail from a company called Life Line Screening, inviting me to "participate in a simple potentially lifesaving screening to assess...risk for stroke, abdominal aortic aneurysms and other vascular diseases."  There will be a bunch of ultrasound technicians in a nearby community center who will be eager to check my blood vessels for narrowings, and m...

Long ago in the late 1900s, that is to say not long after I got out of my residency, wise people had the idea that medical care would be more affordable if patients had a primary doctor who would be paid to take care of that patient and who would act as a gatekeeper to specialty physicians.  Because specialty care was so expensive and often use of specialists fragmented medical care, a patient would see his or her primary doctor before being referred to the cardiologist or the surgeon or the dermatologist.  Emergencies were exempt from this process. The physician would be paid a flat fee, per year, to take care of each patient. Patients became dissatisfied with this model, feeling that it impinged on their autonomy, and doctors didn't like either the gatekeeper role, or the fact that, in situations where patients were unexpectedly sick, the system of capitation could lead to financial hardship for the physician. Managed care and capitation are not gone, but the words have deve...