Why is American health care so expensive?

I recently attended the death of a friend at his home. He had a disease that was terminal and untreatable and he and his wife had finally decided on no further medical treatments that would require hospitalization. He was not very old and had been cared for by his children and wife during the previous 4 months that he couldn't care for himself. Time had become short and valuable and he had become weak, so he didn't amend his POST (Physician's Order for Scope of Treatment) to indicate that he wanted no resuscitation, though his wife and family knew his preferences. He had not entered hospice because his needs were adequately fulfilled by his family, friends, his physicians and home health. When his wife noticed his breathing had changed, she called me, a friend of the family. I had offered to be available to come over for any medical situation in which they might need a rapid house call. I arrived about 15 minutes later and he had just died. I confirmed the situation wit...

Today in the New England Journal of Medicine (NEJM) an article has appeared reporting the results of the Heart Outcomes Prevention Evaluation-3 (HOPE-3)trial. Exciting simplifications are sure to follow in the news. If you would like to stop reading now, the answer to the question posed in the title is probably no. The question: For many years researchers have discussed the possibility of a creating a pill that might contain several kinds of medication that would reduce people's risk of dying of cardiovascular disease. It is an attractive thought. Since cardiovascular disease is the major cause of death globally, reducing that risk has the potential to vastly reduce death and disability. Originally we thought that a suitable "polypill" might contain something to lower the blood pressure, something to lower cholesterol and something to reduce the risk of blood clots. Many studies have looked at the mortality benefits of various blood pressure pills, cholesterol lo...

Splashed over news feeds this last week is a reference to an article published last week in the BMJ (formerly known as the British Medical Journal) that states that "medical error [is] the third leading cause of death in the United States." What is this article actually about? The new article refers to research done over the last 2 decades, and most recently an article by NASA toxicologist and patient safety advocate John T. James PhD in the Journal of Patient Safety in 2013. Dr. James evaluated 4 previous studies and estimated that 400,000 people, approximately, die yearly in the US of conditions that were either caused by or, more often,  made worse by medical error. That article, too, was met by outrage and was widely quoted and misinterpreted. I think hardly anybody actually read the article. Headlines read "Deaths by Medical Mistakes Claim the Lives of 400,000 People Each Year." No new data, but a new way to think about it: As far as I can tell fr...

Today in JAMA online (the Journal of the American Medical Association) a delightfully practical article was published regarding how to help little children recover from gastroenteritis (stomach flu.) The authors, Doctors Stephen Freedman, Andrew Willan, Kathy Boutis and Suzanne Schuh, compared the health of over 600 children aged 6 months to 5 years, when given a medical rehydration solution to drink versus diluted apple juice along with the fluids that the child preferred. These children were not chronically ill or severely dehydrated, but were sick enough to have been brought by their parents to the emergency department and were at risk for needing hospitalization or intravenous fluids. In previous studies oral rehydration with electrolyte solutions such as Pedialyte, which contain over twice as much sodium and 6 times as much potassium as sports drinks, along with much less sugar, had performed well in preventing hospitalization or return to the emergency department. Theore...

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...