Specialization, Communication, and Data in Medicine

In the first NYTimes article on modern medicine (early this week, but I'm too lazy and too far behind to check), they said the outcome for patients with no personal physician going into an illness was far worse than for patients with a physician. And talked about the problems of the patient in dealing with multiple specialists who might offer multiple recommendations for treating an illness.

Based on my recent experience, the article is true enough. I'd focus on the data problem: each specialist needs his or her own data. Actually, "specialist" is misleading--it raises the specter (ouch!) of a white coated expert "...ist". What I, as a layman with no recent experience of modern medicine, didn't realize was that each test involves a different organization. For example, the patient is referred by the personal physician to a medical lab for X-rays and blood work preparatory to a hip replacement operation. But in this case, the "lab" is a building, housing multiple testing organizations, X-ray being one and blood work being another. So the patient ends up going from one to the other, filling out forms for each with partially redundant information. Because the lab is separate from the personal physician, there's potential delay and loss of data. In fact, in the case of my sister, the blood work didn't get back to the physician for several days. This failure to communicate delayed diagnosis and treatment of an infection, which means a considerable cost in money, use of scarce hospital beds and staff, and suffering.

Comparing this experience under private health insurance to my own limited experience with HMO's, it's likely the communication among units would be better and the costs reduced. Costs for the patient and the system. But what's a cost for the payer is income for the payee. And the physician and labs have more freedom under the current system. It's all tradeoffs. (More to follow).

Islam Has the Right Idea

Travelers are much more sanitary than health care workers and visitors. That's a fact I gleaned from recent experience:

* the rest stops along I-81 were very busy, usually 2 or 3 men in the restroom at a time. Very seldom did someone urinate and leave; the pattern I observed was that everyone washed.

* in the upstate NY hospital I was visiting, the vistor's lounge had its own bathroom, which seemed to be used both by hospital staff and visitors. Sitting in the lounge you could hear the toilet flush and the sink run. But much of the time, I'd say at least half, you only heard the flush and no running water.

Why the difference? I'd guess it's the visibility. While you don't look at each other in the restroom, you're very conscious of others so you live up to the norms they display. In the bathroom, you're by yourself and easily forget that your activities can be heard. So you don't wash your hands, which is the cause of much death in hospitals.

If I understand correctly, Islam doesn't have this problem because it's taken specialization to the point of dedicating the left hand for sanitation. Failure to comply may be a sin.

As a true American, I'd suggest that we put a sign outside bathrooms. Most new public bathrooms have motion recognition triggering the flow of water, that that to the sign and to the door. The sign goes dark when the door closes, lights up when it opens if the water has run and says: "last user washed hands". I offer the idea free in the interests of improving life expectancy.

NY Times Articles on Hospitals and Patients

This NYTimes article, entitled In the Hospital, a Degrading Shift From Person to Patient - New York Times: includes a reference to one of my favorite thinkers, Erving Goffman:

"In Dr. Goffman's account of life in a mental institution in the 1950's, he describes the admission process as a stripping away of possessions, 'perhaps the most significant of which is not physical at all, one's full name.'

In modern medicine, patients more commonly become exasperated because they do not know the names of the doctors or other medical staff. At many clinics and hospitals, staff members come and go without introductions, patients say. Name tags are in lettering too small to read easily; the names embroidered in script on doctors' coats can get lost in folds."

Based on recent (vicarious) experience, all true, but somewhat overdone. In the hospital I was visiting (I plan more blogs on this, and will limit identification to "upstate hospital") they were trying. Staff were supposed to identify themselves to the patient. There was a white board for each patient that was to show the nurse and aide assigned on each shift.

But as with any bureaucracy, changing procedures and instilling habits is difficult. The white board was someone's bright idea, but it was too small for an older patient without her glasses to read. The markers for use with the board got mislaid. And, I strongly suspect, the "someone" was an administrator who never really got buyin at the working level. A big part of the problem is that change takes time and money. If an organization is strapped for both, the "bright ideas" don't get fully implemented, which increases cynicism and makes future change harder (see Dilbert).

What was good in this hospital was the acceptance that names should be known, so there was little awkwardness about asking. The social norm had been established, even though the practice was somewhat ineffective.

Resuming Blogging

No travel planned for a couple weeks, and should do better even then. As I said in a very early post, we never do things right the first time.

Nini's

My previous post was a little optimistic. I'm stuck back in upstate New York, using a PC at the local library (omit terrorist joke here). Seriously, libraries are one of the great inventions--we should thank Ben Franklin and Andrew Carnegie regularly.

My title takes off from thoughts on the health care system--it's pervaded by the influence of American individualism. (More to follow.) But the "nini's" are also a symptom of individualism--nini as in:

• "Not invented here"--NIH
• "Not in my backyard"--NIMBY.

Are there more ninis?

Curses

I'm back to blogging, at least for a while. If my earlier blog this morning sounded jaundiced, 17 days with a Presbyterian elder, my sister, will do that to you. (Also lost 5 pounds; I'm now almost as thin as I was at 26.) I could be grand and talk about the effect of dealing with pain and issues of life and death, but it's more accurate to say my foul mood is just the result of fatigue.

At any rate, I'll be blogging a bit, perhaps talking about the amazing prevalence of silos, both in the Northeast and in hospitals, at least until I take off again to see my sister.

Update on Divestment

An update to the controversy in the Presbyterian Church over divestment. You can say one thing for them: they don't act speedily--took one year to decide to "press". (They also added a bank that may have helped channel money to Palestinian terrorists. Presbyterians want to be right, they also want to be perceived to be fair.) They still get called anti-Semitic, though with an adjective.

Threat to Divest Is Church Tool in Israeli Fight - New York Times: "The Presbyterian Church U.S.A. announced Friday that it would press four American corporations to stop providing military equipment and technology to Israel for use in the occupation of the Palestinian territories, and that if the companies did not comply, the church would take a vote to divest its stock in them."

Intermittent Blogging

I'll be blogging less over the next few weeks. My older sister is going to have hip replacement surgery and I'll be traveling a couple times to help during this time.

Finland Bureaucracy Is Innovative?

Robert Kaiser has another interesting article on Finland in today's Post. (Caution: he makes 2 math errors in one paragraph; I've written the editor.) He claims the country is united in pushing innovation, trusting the government to guide R&D, and devotes more GDP to R&D than the US:

"'We are helping to plan R&D projects that we will then fund,' he said. About a third of the projects Tekes funds fail completely, Saarnivaara said. He would like that percentage to be higher -- in other words, he would like to take more risks."

I'm amazed by the statement--I can't imagine any US government agency boasting that 1/3 of its money is wasted (at least, that's how the politicians of the out party would phrase and the media would be hot on their tails). If I'm right that you almost never do things right the first time (witness Chertoff's reorg of Homeland Security), the ability to learn from your failures is critical. That assumes you're free to fail, which most US agencies aren't.

It's possible though that Kaiser and I are over-enthusiastic. Both DARPA and NSF probably have a bunch of failures that are mostly hidden. And the history of government steering development isn't always good. I remember in the early 90's Japan was pushing the "5th generation computers". A blind alley, I believe. But with all the cautions, I'm still envious of a society that seems to trust its government that much.

Homes As Hummers

Sometimes I agree with Robert Samuelson of the Wash Post; sometimes I don't. Today's column is one I agree with. Among the nuggets is a poll that showed 35 percent of Americans think a home theater (room) is highly desirable. (There was a bit in the Post over the weekend where builders said they weren't building libraries anymore.)

"Another cause of this relentless upsizing is that the government unwisely promotes it. In 2005, about 80 percent of the estimated $200 billion of federal housing subsidies consists of tax breaks (mainly deductions for mortgage interest payments and preferential treatment for profits on home sales), reports an Urban Institute study. These tax breaks go heavily to upscale Americans, who are thereby encouraged to buy bigger homes. Federal housing benefits average $8,268 for those with incomes between $200,000 and $500,000, estimates the study; by contrast, they're only $365 for those with incomes of $40,000 to $50,000. It's nutty for government to subsidize bigger homes for the well-to-do."

Why don't liberals make proposals here? (Samuelson just points with alarm but doesn't make suggestions like the following.) From H&RBlock:

If you take out a mortgage to buy a second home, the interest is deductible if the mortgage is secured by the home and you itemize deductions. Your deduction may be limited if the mortgage exceeds the fair market value of the home or if the mortgages on your main home and your second home exceed $1 million ($500,000 if you are married, filing a separate return).

Granted, these days $1 million doesn't buy as much of a home as it used to. But my great grandfather had a cabin that was about 600 square feet, with 7 people (mother-in-law, wife, four kids). I'd think 500 square feet per person is a very reasonable cap. Limit deductibility of interest to the lesser of $1million or interest on the average cost of a home in the ZIP code sized to the number of dependents reported x 500 square feet.

There's no way the taxpayers should subsidize beach houses, ski houses, etc. This issue appeals to the populist instincts we still have.