Why is American health care so expensive?

People have smoked tobacco for centuries, possibly thousands of years, and cigarettes were first machine made in France in the 1880's. In the US, smoking peaked in the year 1965 when 50% of men and 33% of women smoked, with a per capita consumption of over 4000 cigarettes per year. When health effects of smoking began to be widely publicized, particularly its association with lung cancer, cigarette smoking began to decline. Nicotine, the psychoactive ingredient in cigarettes, is addictive , producing a withdrawal syndrome that is at least partially relieved by nicotine replacement. Cigarette smoking, though, also has cultural meaning, which has contributed to its popularity. For decades therapeutic nicotine replacement has been available to people who want to quit smoking, first only by prescription, but now over the counter since the 1990's. The first product, a nicotine chewing gum, was released in the late 1970's, followed by a patch, a nasal spray and finally an inh...

For about 2 years now a tiny ultrasound machine has been part of my standard physical exam tools as I take care of patients in the hospital and in the outpatient clinic. In November of 2011 I first picked up an ultrasound transducer in a continuing medical education course on bedside ultrasound for emergency physicians. I am an internist, not an emergency physician, but I was interested in bedside ultrasound and it was the emergency physicians who were giving the most interesting course. It was transforming for me. I was able to see internal anatomy and physiology and eventually, with lots of practice, I was able to make diagnoses more quickly and accurately. I bought a pocket ultrasound machine so I could make bedside ultrasound a seamless part of my practice It was an unexpected and welcome bonus that my patients and their families loved it. I would share the moving ultrasound pictures with them, often having them hold the machine so I could point out how beautiful their internal...

In November of last year the American Heart Association released new recommendations on who should be taking "statins" (drugs like lipitor/atorvastatin), the most common medicines we use to control cholesterol levels. High cholesterol levels are associated with higher risk of heart attacks and strokes, and taking statins, which lower cholesterol, can reduce those risks. The drugs have pretty significant side effects , though, and not everyone with high cholesterol or other cardiac risks will actually have a heart attack or stroke, so it seems clear to most of us that not everyone should take statins. The American Heart Association's 2013 guidelines The new recommendations departed from prior ones in saying that we should prescribe statin drugs to patients with higher risk of heart attacks rather than just patients with high cholesterol. I wrote about the new recommendations here . It actually kind of makes sense, since even patients with relatively normal cholester...

A few weeks ago I wrote a blog which addressed a newly released study of the effectiveness of mammograms. This article , in the the British Medical Journal, looked at women who were followed over a 25 year period as part of a Canadian study, found that there was no evidence that mammograms reduced deaths from breast cancer. Most women who will die of breast cancer do so regardless of whether that cancer was diagnosed by a mammogram, and the few who are saved because their cancers were diagnosed earlier than they would have been if only clinical exam were used may have been canceled out by the far more significant number of women who were harmed by overdiagnosis, that is being diagnosed with a breast cancer that would never have troubled them had they not had mammogram screening. I was concerned that this didn't set off a huge discussion among doctors and all of the rest of us about whether we should really continue to do regular screening mammograms. Our lives, health and bill...