Why is American health care so expensive?

I just got an email from a hospital where I sometimes practice with a picture of two aging but clearly active and vital men standing on a beach with the words "Free Prostate Cancer Screening" printed below in an attractive font. The hospital is sponsoring the screening, along with the urology clinic affiliated with the hospital. The advertisement gives guidelines for who should avail themselves of this service, including men as young as 35 years old if there is a family history of prostate cancer and otherwise 55 and older, with no maximum age. The prostate is a walnut shaped gland that surrounds the urethra, in front of the rectum and just prior to the penis. It produces prostatic fluid which helps carry sperm to wherever they eventually end up. Prostate cancer screening, that is checking a man's prostate cancer via a rectal exam and also performing a blood test for PSA (Prostate Specific Antigen) has been of questionable utility for decades, and finally last year th...

I got an invitation in my e-mail a couple of days ago for a dinner presentation to the Central Oregon Medical Society given by H. Gilbert Welch M.D. on the subject of overdiagnosis. I was intrigued. A little less than a year ago Dr. Welch, an internist and professor at Dartmouth Medical School and Archie Bleyer M.D., a former pediatric oncologist and now a research professor at Oregon Health and Sciences University wrote a controversial article presenting compelling evidence that regular mammograms lead to death and disability related to aggressive treatment in many of the patients who were diagnosed with breast cancer but that it did not significantly improve survival. Dr. Welch has been studying overdiagnosis for a couple of decades and has written two books, Should I Be Tested For Cancer-maybe not and here's why  and Overdiagnosed: making people sick in the pursuit of health . I have peeked at the second one and found it to be well written, with a non-physician audience int...

This summer has been full of adventures in and around water, alongside people with and without disease caused by infectious intestinal organisms. It's been lots of fun, and I dearly yearned not to be slowed down by explosive vomiting and diarrhea. Because of this intense yearning not to feel like crap, I have been doing lots of studying and thinking about both hand hygiene and water purification and have been experimenting with various techniques and technologies. Most infectious ills of the gut are transmitted by the fecal-oral route. The bacterium, parasite, virus or other unspecified microorganism must make its way from the feces (or sometimes vomit) of the infected person to the mouth of the new host to be ingested, thence to infect and cause disease. For many conditions it does not take many organisms to cause infection, and some of the causative entities can survive outside of a host in pretty unfriendly environments for various amounts of time (up to around 2 weeks for n...

I have been doing locum tenens work as a hospitalist for nearly two years. One of my reasons for doing this is that the practice of medicine in the US is very interesting, and by working in very different places I get to see how things work and don't work, and make up cool theories. I have time to read and listen to people and have become curious about several true things which don’t seem to fit together.  Hospitals are paid an absurd amount of money to take care of patients. Small hospitals can barely survive financially. Small hospitals, rural ones with 25 beds or fewer (critical access hospitals) are paid more generously by Medicare than large hospitals. Hospitals that employ physicians subsidize them above the money they bring in as professional fees, to the tune of about $100,000 per year per physician. Hospitalists and hospitalist programs are expensive, in the range of 1-2 million dollars per year for a 25 bed hospital. Hospitals are willing, even happy, to start...

American healthcare is expensive. We pay lots of money for it and we have outcomes that we aren't proud of. We gnash our teeth at how terrible we are and look to other countries with lower costs for ideas on how to improve. I have been combining personal and second hand experience of countries that spend very little on healthcare with what I know about medicine in the US, and we really aren't entirely bad. In some ways we are outstanding. Singapore is a city-state comprised of 20 islands, near Malaysia, which began its modern prosperity when it was reinvented as a port by the British empire. It spends a tiny proportion of its GDP for healthcare, on the other hand, and ranks in the top 20 countries in the world in both life expectancy (15th) and infant mortality (1). So how do they do it? There are many factors that might enter into the overall health of the population of Singapore. One very striking thing about Singapore is how strict their laws are and how rigidly enforc...

There are many ways to visit exotic destinations, including cruises, tours, adventure travel, business related meetings and just plain going there. I always thought it would be most interesting to visit a place and practice medicine, since it would give me the opportunity to meet interesting people, do interesting things and maybe actually help. I first went overseas as a doctor about 23 years ago after finishing my medical residency. I traveled north from Bangkok to Chiang Mai where I found my way to the McKean leprosy hospital. There I spent a week rounding with the American physician who was the medical director, surgeon and primary doctor for all of the leprosy patients. There were also visiting dentists from Germany and other people who helped in various ways, including carrying on a religious mission for the Episcopal Church. It was one of the most memorable weeks of my life and flavored my ideas about medicine for the decades I have practiced since then. I have looked for wa...

I have just pretty much recovered from jet lag and my anti-malarial drug induced dysphoria (I will attest to the fact that Mefloquine does have side effects) and am excited to tell the story of a project that I got to be part of. In mid-July I got on a plane and flew to Kilimanjaro airport in Tanzania with 7 medical students from UC Irvine. UC Irvine's medical school is small and encourages its students, after their first year of training, to do interesting projects in the summer, before returning to immerse themselves in massive absorption of data and passing of standardized tests. I met some of these students while doing my mini-bedside ultrasound fellowship, when I acted as preceptor to a group who staffs a regular rural health clinic in Mexico. A project to teach ultrasound in Tanzania was in the planning and not-quite-sure-if-it-would-happen stage, and I signed on, in a not-quite-sure-I-was-coming kind of way. 5 months later I got off of a plane with medical students, took...