This is both shaming and inspiring.

[strangeglove]

http://www.newyorker.com/online/blo...cago-medical-school-commencement-address.html

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[Tradewind]

A challenging topic to handle for a commencement speech - but even so, this isn't his best work.

 

[kugel]

The text of the speech made me start thinking about what might change the cost of medical care in America. A couple questions come to mind, which might be testable (maybe already tested), about the things that drive us to order tests and procedures:

1) Is there any evidence that medical care is sloppier in states with a cap on malpractice claims, or that care is better in states with the highest malpractice awards?

2) Is there any evidence that State, Fed, or Joint Commission standards improve the quality of care - or just that they force organizations to spend tons on meeting standards that have never shown a benefit?

3) Is there any evidence that any state's Board of Medical Examiners "catches" a significant number of dangerous or impaired physicians, or do they just respond to what malpractice lawyers and law enforcement officials do?

4) Are there any payor organizations (gov't or insur companies) that provide higher reimbursements for physicians or hospitals that have better outcomes, less admissions, less bounce-back admissions, higher productivity in patients over 70yo, etc.? In other words, does anyone pay based on positive outcomes rather than just saving payor's money?

In Texas, when i worked for the dept of mental health / mental ******ation (MHMR), they had a system that paid the county a daily rate for every pt signed up for outpt services, but removed the daily capitated payment for any patient in the hospital. It produced a strong incentive to provide services that actually prevented hospitalization. Programs had to show a benefit (in the rather crude form of reducing admissions) to be considered useful. It wasn't perfect, but it sure put the emphasis on providing good, useful outpt services, and it provided an automatic benchmark for which new programs were kept and which were scrapped.

 

[BabyPsychDoc]

There are some good ideas with interesting examples in this speech, but ultimately it boils down to two things : doctors must change their mentality to "serving the patient" rather than "making the profit" and then those doctors must somehow find each other to create the appropriate working environment and achieve the benefits of economy of scale. Mayo clinic can afford to be a "positive deviant" because it is an authoritative giant, able both to cut back costs and attract industry partners (like Microsoft with their E-health package). A practice of 10 idealists may not be able to achieve the same benefits.

 

[daru1]

There are some good ideas with interesting examples in this speech, but ultimately it boils down to two things : doctors must change their mentality to "serving the patient" rather than "making the profit" and then those doctors must somehow find each other to create the appropriate working environment and achieve the benefits of economy of scale. Mayo clinic can afford to be a "positive deviant" because it is an authoritative giant, able both to cut back costs and attract industry partners (like Microsoft with their E-health package). A practice of 10 idealists may not be able to achieve the same benefits.

You pay off my 250k in debt from med school, and I'll change whatever part of "making the profit" I have. Tell them to fix it, please

 

[sunscribble]

Thanks for posting. I wonder what the grads thought.

I found the original article ("The Cost Conundrum" in The New Yorker) to be much more detailed and thorough than the speech. I would recommend reading the article first, if you haven't already. It addresses one or two of the issues brought up by kugel.

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

 

[thefighter]

You pay off my 250k in debt from med school, and I'll change whatever part of "making the profit" I have. Tell them to fix it, please

I second that...with the rising costs of medical school tuition, the length of time to pay off all this debt, where are we really making a profit??

 

[Good Solutions]

That speech was garbage. He cites the villagers who were more effective in treating their children's malnutrition then the experts. For the same analogy to work here in the US that would require the PATIENTS to seek life changing treatments themselves, not the physicians. As long as we buffer patients (us, you and me) from the costs of healthcare the longer they will gravitate towards their whiskey, cigarettes, McDonalds, sofas, etc. Until our system crashes and there is no longer a safety net of uncle sam care people will continue to abuse themselves knowing full well that some how they will get treated. Everything we do between now and our healthcare system implosion will be mere symptomatic treatment.

And regarding student debt, quit being so short sighted. It is not about the number it is about the the ability to pay back your loans and life time income. It is very possible to trade the status quo for no debt, but now you will have a decreased life time income. I would be willing to be more indebted if I also had a greater salary increase, it is all relative.

 

[whopper]

3) Is there any evidence that any state's Board of Medical Examiners "catches" a significant number of dangerous or impaired physicians, or do they just respond to what malpractice lawyers and law enforcement officials do?

IMHO--in the state of NJ no. I cannot base this based on an objective study because I have seen none. However I have seen cases where doctors have done some very over the line things, and the Board did nothing. One particular case I know of, the psychiatrist was having sex with several of his patients. The guy was brought to court, lost, but still allowed to practice because his lawyer appealed each time, and used every stall tactic in the book to delay the process. The Board did nothing. (This doctor was not connected with my residency program. I knew of him because his case was in the papers, he used to work at a hospital where my residency was affiliated--and they fired him, and several doctors I knew including family members knew this guy).

IMHO, if the state boards were more active in controlling poor doctors, then I'd very much back the anti-lawsuit philosophy most doctors have (who IMHO have it because they are trying to protect themselves). However, and I say this only because I see very little action taken by the state boards, I do not mind a doctor at all being taken to court who did a bad job that fits the standard of malpractice.