Why is American health care so expensive?

'Tis the season Every year at about this time piles of mail comes to my box asking for money. I look through the pretty envelopes, some with calendars and return address stickers, some with wrapping paper and greeting cards. Some have cleverly glued nickles or plastic membership cards so I can't recycle them without opening them. Occasionally there is an organization which has devised a new model of charity and I'm glad I looked a little further. Giving to charity is a privilege which I have because I make more money than I spend. Not everyone has that luxury. Doctors, as a profession, are much better paid than most people in the world. We may have educational debts to pay off, but eventually we usually end up in the happy minority of people who have enough stored value to take care of themselves and their families and to feel secure if they live awhile past retirement. John F. Kennedy used to like the quote from Luke (this is the passage from the New Standard Revis...

In about 1990 we got our first computer. I say "we" because my husband and I shared a desktop which I used infrequently. I mostly used it for word processing, and the internet was very young. At the turn of the millenium, my children were using computers and they were limited to 1 hour of computer time a day, which was on a shared desktop. By 2001 I was communicating with my grandmother, then in her late 80's, by email. My grandmother had received, probably just prior to the millenium, an email machine from her son. It was a little thing on which she could type messages to a dear friend who lived in London. She loved the ability to spontaneously send him a message and get an answer in a day or less. She was a retired reference librarian and had worked in the Bay Area school system where an exhaustive knowledge of the Dewey Decimal System allowed her to connect students to the resources they needed. We thought she would be delighted to have an Apple Macintosh. With suc...

A letter written to JAMA (Journal of the American Medical Assn.) by Robert Tessler MD and colleagues at the Harborview Injury Prevention and Research Center in Seattle presented evidence that the United States'  approach to guns has significantly increased deaths from terrorism. Using the Global Terrorism Database from 2002-2015 they found that, compared to Canada, Europe, Australia and New Zealand, The US has a considerably higher percentage of terrorist attacks that used firearms and firearm related terrorist attacks were more deadly than any other method, including bombs. Of the 2817 attacks in that time period, only a bit over 9% used guns, but these attacks were responsible for more than half of the fatalities. It's not just terrorism that is more lethal using guns. Suicide attempts are much more successful if they are made with a gun. In fact, over 80% of suicide attempts made with a gun are effective compared to only 1.5% with drug or poison ingestion. Over half o...

Physician burnout and physician suicide has been getting more attention in the last several years. Suicide among physicians is horribly tragic, and maybe moreso because of several factors. Suicide is the quintessentially most preventable fatal event. In order to prevent suicide, the person killing him or herself needs only not do it. To anyone who knows the victim/perpetrator it seems that if only the right words had been spoken, the right sentiment expressed, comfort offered, their death would not have happened. Among the family and friends of a suicide, this is one of the agonies that is added to the pain of loss. Physicians have a huge number of close contacts, patients and coworkers, who have a pretty intimate connection with them, all of whom mourn their loss and many of whom question whether they might have had something to do with it. Beside the emotional impact of the loss is the very real fact that physicians are responsible for some part of the care of potentially thousands...

I bought a pocket ultrasound in 2011, determined to learn how to perform and interpret ultrasound at the bedside and thus transform my internal medicine practice. I bought it new and it cost over $8000. That was a staggering amount of money to spend on something I knew very little about. In 2015 after having performed many thousand ultrasound exams with my little GE Vscan with the phased array transducer, I replaced it with the new model which had a dual transducer, with one side for deep structures and one for superficial structures, such as bones and blood vessels. It cost around $10,000. This was an even more staggering amount of money, but more of a sure thing. I knew that it made a difference and that the cost of the machine was a very small portion of the benefit that I would get from using it. Since the time I bought the new machine, GE has come out with an even fancier machine that is just a wee bit faster and has internet connectivity and a touch screen. Because everyone n...

Today in the New England Journal of Medicine I read an editorial that discussed how lectures are being phased out in medical school education. I was, at first, a little bit appalled. Why would they eliminate an educational method that worked so well for me and my generation of doctors? Or did it? I actually remember only a few things now from lectures, and all of those things don't support the idea that lectures were an effective way of teaching. I remember vividly how I would fall asleep and write progressively more poetic and less linear notes in my binder. How I would startle myself awake, causing heavy textbooks to fly in the air. I remember the time when the professor showed us the structure of vitamin B12 and I considered learning it, just for grins, and decided not to. I remember formulating questions for the lecturer that would display such minuscule understanding of the material that he or she would actually understand how deeply we students had been left in the dust....

It's been hard to be a concerned American citizen lately. We are facing huge problems which will become larger in our lifetimes, including the need to take care of our increasing global population and the medical complexity of taking care of people who are becoming older and sicker. There is global climate change, which is hard for all but the most stalwart of partisans to ignore. There is an increasing gap between rich and poor in our nation and in many others, which places the rich and powerful at odds with the much more numerous and therefore potentially powerful poor. To help guide us through these challenges we have a government so deeply divided on democrat/republican party lines that it is mostly unable to do anything creative at all. And we all pay them lots of money to be dysfunctional. I have been following the activities surrounding repealing and replacing the Affordable Care Act. The ACA (Obamacare) was passed without a single republican "yes" vote in th...

Today in the JAMA (Journal of the American Medical Association) I read that a group out of the University of North Carolina had actually done a randomized study of whether non-insulin treated type 2 diabetics (usually the adult onset ones) achieved better control of their blood sugars if they did a finger stick test of their blood glucose daily. It turns out that they do not. Blood sugars were not improved in a group of patients who monitored their blood sugars once daily compared to patients who did not monitor them at all. Also combining the blood sugar testing with an automatic message from the machine telling them how to interpret that blood sugar did not improve blood sugar control. Since 75% of patients with type 2 diabetes are estimated to check their blood sugar and there are over 29 million Americans with type 2 diabetes, and blood sugar monitoring is moderately expensive (though better than it used to be), not checking blood sugars could save billions of dollars a year. ...

About 5 months ago I embarked on an adventure in healthcare . My healthcare. I decided to take medicine to reduce my cardiovascular risk. I recognize that my cardiovascular risk is pretty low, and when I am much older I may wish for a nice clean cardiac death before I lose my faculties. Having found a plaque in my carotid artery while ultrasounding myself, I decided that perhaps I should enter the ranks of consumers who take drugs to reduce their blood pressure and cholesterol. Astute readers made various comments, including that perhaps I should first try diet, weight loss, exercise and that I should be aware that someone of my description has a low likelihood of actually benefiting from drug treatment of these things. These were reasonable comments. It turns out that I don't need to lose weight, being at the bottom of the healthy range of body mass index, and that my exercise level is pretty optimal, my diet is as evidence based as I can make it, and although I have a low ris...

"Annie, Annie, are you OK?" Many of us learned to resuscitate a person who has collapsed using Annie, the manikin based on a death mask of a young woman who had drowned in the Seine in Paris in the 19th century. Bystander cardiopulmonary resuscitation (CPR) has become increasingly accepted and expected as the years have passed, and we have even begun to make affordable machines to deliver a life-saving shock (defibrillation) to the heart of a person who has collapsed with an otherwise life threatening heart rhythm disturbance. We lack, though, much good information about how useful the procedure is in saving lives and bringing people back to meaningful existence. A recent study completed in Denmark looked at the outcomes of bystander performed CPR and defibrillation. Denmark has been quite aggressive in training and encouraging citizens to perform CPR when a person collapses and is found to have no pulse. They have also been scrupulous about keeping records of what h...

Gilbert Welch  has written an excellent commentary on the fresh-out-of-the-printer recommendations of the US Preventive Services Task Force (USPSTF) regarding screening for thyroid cancer. Dr. Welch, a professor at Dartmouth University, has spoken out about wasteful and harmful procedures done in the name of prevention. He is a compelling writer, has written several books aimed at people who are not doctors, and has captured the essence of the thyroid cancer screening controversy in this article , published in JAMA today. Briefly, he applauds the recommendations of the USPSTF which state that there is no evidence that looking for thyroid cancer in people who have no concerning symptoms (symptoms such as a neck lump, difficulty swallowing or hoarseness) helps them. He looks at the population data on thyroid cancer, first evidence out of Finland that suggested that nearly everyone probably has a small thyroid cancer if you look hard enough, and evidence that discovering and treat...

There is enthusiasm in politics about reducing regulation to stimulate creativity and economic growth. Maybe. But reduction in oversight of medication and medical devices by the Food and Drug Administration (FDA) will probably lead to a proliferation of expensive potions and gadgets that don't actually help. This week, the New England Journal of Medicine published an article detailing the near miss associated with an injectable monoclonal antibody for Alzheimer's disease. (Spoiler alert: it doesn't work.) Authors Chana Sacks, Jerry Avorn and Aaron Kesselheim detail the saga of Solanezumab, a drug that attacks the protein in the brain that is associated with Alzheimer's dementia. A monoclonal antibody is a molecule that binds to a specific target allowing the immune system to clear it from the body. Solanezumab binds to amyloid beta protein which is increased in the brains of patients with Alzheimer's disease. Although it may help clear amyloid protein from pa...

Medicaid , the program that provides funding for adults, seniors (along with Medicare), children and people who are blind or disabled who can't pay for their own healthcare, is expensive. It is painfully expensive. The program, along with CHIP (the Children's Health Insurance Program), marketplace subsidies and Medicare is responsible for 25% of the federal budget. Total Medicaid costs in 2016 were around $532 billion per the Kaiser Family Foundation. States fund up to half of the cost of Medicaid, and in my state, Idaho, our share of Medicaid and related payments makes up about 21% of the state budget. Medicaid is a safety net that allows people who can't afford private insurance or to pay out of pocket to get healthcare. It pays for doctors' fees, preventive care services, hospital care, mental health care, the majority of women's costs for pregnancy and childbirth and costs for the impoverished elderly who are in nursing homes. It pays for emergency room visi...

Last week was a big week. Many patients. Lots of bedside ultrasound. I've blogged on and on about my undying love for ultrasound at the bedside as a part of my physical exam. It keeps being powerful. It saves peoples' lives. It keeps me from making stupid mistakes. I am eternally grateful. This week it helped with the usual things--hearts and bellies and bladders and lumps and bumps. I was able to tell patients what was going well and not so well, in real time, and show them pictures. But ultrasound of the lung needs a little advertisement. Ultrasonographers and radiologists are terrific at imaging the internal organs, even those of tiny babies. Cardiologists and echocardiogram technicians are amazing in their ability to image the heart and describe its innermost workings. Although I leverage my ultrasound abilities by using my other exam and history taking skills, I do not have the extensive training in imaging that these people do. But in the US, only clinicians suc...