Why is American health care so expensive?

I sometimes do locum tenens assignments as a hospitalist in rural hospitals. It is a good way to find out how other systems work, or don't work, and meet new people and interact with new communities. It's great to be home and also good to go away and come back later.  Besides the usual trappings of doctoring, including stethoscope, otoscope and white coat, I wouldn't be caught dead without my pocket ultrasound. I just got back from a week of 12 hour shifts in a 48 bed hospital and once again was very happy to have the ultrasound. They do have ultrasonography in the radiology department at this hospital, but echocardiography (ultrasound of the heart) is only available on weekdays from about 8 to 5, and it needs to be scheduled in advance. Also the ultrasonographers don't necessarily look at the things I find interesting, and can't combine imaging with physical exam findings and what the patient tells me in real time. Patients also really enjoy seeing what's g...

I just finished reading a very delightful "A Piece of My Mind" essay in JAMA (The Journal of the American Medical Association.) The JAMA is primarily a research journal, filled with new scientific or semi-scientific studies and comments on those, plus reviews of the literature and editorials on science or politics. There are also letters and announcements and educational sections for doctors or patients, even poems, but the part I like to read all the way through is called "A Piece of My Mind." These essays are almost always stories about something that has made a profound impression on the writer. The most recent title was "A Place to Stay," written by Benjamin Clark, an internist at the Yale New Haven Medical Center. He describes a patient who is stuck in the hospital probably for the rest of his life due to a medical condition whose treatment requires management that can't be done anywhere else. It's lovely, and true (even if the details are ...

In 2005 Dr. John Ioannidis, a Greek researcher and professor of health policy at Stanford University, best known for his critiques of the science of medicine, published a paper entitled "Why Most Published Research Findings are False." This was not from the point of view of a science denier--actually closer to the opposite. Ioannidis loves good science, but points out that the vast majority of scientific studies today are biased, often asking the wrong questions and making the wrong inferences. In the case of medicine, this often means that claims of the effectiveness of a treatment or diagnostic test are exaggerated and often just plain wrong. This stems partly from the fact that positive and exciting results lead to further funding for the researcher involved and that the sources of this funding are often entities such as drug companies that stand to benefit from a certain outcome. Recently Dr. Ioannidis published a new article, much more accessible than the first, ent...

I just got back from a couple of weeks in Old Fangak, a community of people living by the Zaraf River in South Sudan. It's normally a small community, with an open market and people who live by raising cows, trading on the river, fishing and gardening. Now there are tens of thousands of people there, still displaced from their homes by the civil war which has gone on intermittently for decades. There are even more people now than there were last year. There is a hospital in Old Fangak, which is run by Jill Seaman, one of the founders of Sudan Medical relief and a fierce advocate for treatment of various horrible and neglected tropical diseases, along with some very skilled and committed local clinical officers and nurses and a contingent of doctors, nurses and support staff from Medecins Sans Frontieres (Doctors Without Borders, also known as MSF) who have been helping out for a little over a year. The hospital attempts to do a lot with a little, and treats all who present ther...

Mnemonics can be incredibly cool. When I was in medical school there was just too much stuff to remember and memory aids were so very helpful. Most specifically I refer to the vile and inappropriate one that helped me remember the cranial nerves which I remember to this day and will not share in print. In ancient times orators used memory palaces to memorize long speeches or poems, associating words with familiar and sometimes bizarre images. All this is to say that I have nothing against a good mnemonic. Lately though, as I have struggled to memorize a new acronym which is supposed to be good for me, I've been thinking about what makes a mnemonic good and what makes one annoyingly terrible. The most irritating mnemonic in recent experience is probably the "H's and T's" from Advanced Cardiac Life Support (ACLS). When a person's heart has ceased to be able to sustain life or blood pressure, we use a memorized sequence of interventions to resuscitate them, the A...

In the United States, biomedical research, including basic science and clinical studies, is paid for mainly by companies that expect to make money off of new discoveries. The government, through the National Institute of Health (NIH) funds a little over a quarter of it, but most of the money comes from drug and device manufacturers. This means that interesting research that might result in breakthroughs that save patients money is unlikely to find funding. This is terrible. If gummy bears cured cancer, we might never find out about it. If anything that is easy to come by, from various sources, were to show promise therapeutically, we as US citizens would not be likely to find out about it through our own research. Some examples: 1. Red yeast rice, a dietary supplement made of rice fermented with the fungus Monascus purpureus in a centuries old process, contains a widely marketed cholesterol medication (lovastatin) that is naturally produced by Monascus . The doses are high eno...

In July of 2015 the US Food and Drug Administration (FDA) approved an injectable monoclonal antibody alirocumab (Praluent) which lowers the LDL or "bad cholesterol". The drug is produced by Regeneron, given by injection once every 2 weeks, and will cost $14,600 wholesale per year. In August, evolocumab (Repatha) was FDA approved. It, too, is a monoclonal antibody and will cost $14,100 wholesale when it is finally released. It was developed and will be marketed by Amgen. These drugs are antibodies, produced in hamster ovary cells in vats, which, when injected, bind to proprotein convertase subtilisin/kexin type 9 (PCSK9), making it less active. PCSK9 normally reduces the liver's ability to remove low density lipoprotein (LDL) from the blood. The main drug class that we have now which reduces LDL is the statins, also known as HMG CoA reductase inhibitors, which reduce the production of cholesterol. A couple of common statins are atorvastatin (Lipitor) and simvastatin (z...