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Second sad thought for the day
Arnold Kling has sad news about his father and also a very important point:
...[in the hospital] what you deal with are people who are doing their job. For example, the cardiologist's job is to make sure his heart does not give out, even if it means he lies on his back for so long that the prospects for restoring diginity recede. Everyone wants to shunt him around, giving him more Hansonian medicine, which detracts from his ability to remain lucid. For the larger goal of trying to do the best with his remaining life, nobody is in charge and nobody is empowered.
Posted by Tyler Cowen on January 30, 2008 at 10:25 AM in Medicine | Permalink
Comments
Always a sad phase of life to deal with losing parents.
Has no one in the family heard of hospice? The concept is to prevent over treating and to promote dignity (admittedly I have limited information but this sounds like an option).
Sometimes families have to get involved and push for what they want, rather than simply letting events take a medical course. Hopefully dad made his own wishes known orally and/or in a living will.
Posted by: save_the_rustbelt at Jan 30, 2008 11:04:22 AM
I just went through this with my mom, a stroke survivor. Before she died her quality of life continued to decline in a way that left her in the position of, as Kling so accurately describes, being shunted from one specific type of coverage to another. There was no overall case management or help with tying together the many different options, treatments, medications, etc. I learned far more about medicine, health care, falls prevention, pressure ulcer management, physical therapy, and cardiovascular care than I ever dreamt I would. I was the local kid, the one who advocated, questioned and prodded-- you have to do that now more than ever.
The experience taught me how to listen to politicians who promise to "fix" healthcare in the US without any reference to how the systems actually work now. Most politicians talking about healthcare actually would not pass a simple quiz asking about the roles of nurses, doctors, technicians, aides, and other personnel. They would fail a test on how insurance actually works, is paid for, and what it pays for.
Healthcare in the US is as complicated as Science (capital S) is, as a system. Science in the U.S. is pursued by university researchers, particle physicists, microbiologists, NIH researchers, high school science teachers, water treatment facilities, agronomy labs, etc. From car manufacturing labs that do metals research to food developers working with corn syrup Science is a system with a set of common purposes. Imagine how idiotic it would sound if a politician blustered through a speech saying they would "fix science in the U.S.".
Posted by: The other Eric at Jan 30, 2008 12:03:47 PM
Be nice to your kids. Teach them to be skeptical of authority. If you have a point person, it is likely they will fill this role.
If you don't have a point person in the hospital, god help you.
Posted by: Andrew at Jan 30, 2008 12:23:16 PM
Full-blown socialized healthcare might destroy the medical industry. It's sounding better and better.
I looked up "Hansonian." I keep finding people who believe the way I do. Maybe it's confirmation bias. But I doubt it.
Another example of how bad it is; The "customer advocates" that I met with (before the procedures) were basically there to make sure we were going to pay and not likely to sue. I never saw them again. Noone ever asked me about my consumer experience. I daily get requests from Amazon to rate my experience buying the last set of earbuds.
Why aren't more people working on this? Every time I have the misfortune of dealing with a hospital I come away thinking that they need a staff of industrial engineers. I'm an engineer. I see engineering solutions to engineering problems. If economists dealt with hospitals from the patient's perspect they may see more realistic economic solutions.
One of the reasons I changed careers to biomedical engineering is the belief that engineering solutions is one of the only real improvement possiblities.
Posted by: andrew at Jan 30, 2008 5:35:33 PM
To answer my own question, I think it's because of the crowding out effect of the single-payer debate. Tragic. A non-solution blinds us to the reall problems and opportunities.
Posted by: andrew at Jan 30, 2008 5:38:09 PM
I'm sure regulation has no part in creating this situation.
Posted by: Erik at Jan 30, 2008 5:44:53 PM
As the first commenter pointed out, it appears that Arnold's father would be far more comfortable in hospice care. I'm sorry that he, or the family, couldn't or wouldn't select that option because hospice care was designed to specifically meet his stated goal: Similarly, what I want for my father is the best possible combination of dignity, lucidity, and absence of pain. Acute care hospitals are just not set up to provide that. I wish them the best.
Posted by: Randy at Jan 30, 2008 6:58:15 PM
Hospice seems to do very good work, if I can generalize.
I think the problem there is that the assumption is made that it is the option when there is no hope.
If there is hope (will the medical establishment tell you objectively? Probably not), or if a family member has to make the decision, they are not likely to go that route, especially if there are any lingering emotional issues.
That's why you need one family member who can be stone cold objective AND passionate, not a common combination. There's no limit to the amount of services they will offer if someone is willing to pay.
Nothing ticks me off more than the idea of people getting abused at a time like this. That is the angst I use to get myself fired up to be THAT GUY in these situations.
Posted by: Andrew at Jan 30, 2008 8:06:25 PM
I read that story too. I wish him and his dad well. I always enjoy his columns.
Posted by: Chris Meisenzahl at Jan 30, 2008 8:32:44 PM
@andrew: I'm a programmer with an ER doc fiancee... I badly want to do something to make the system better, it makes me extremely angry. But the whole structure is so tangled and large that it seems intractable to do so.
We often daydream of taking over a small community hospital and trying to make the place sing.
(Also: hospice is an amazing thing, we should have more of it. And take more lessons from it.)
Posted by: Bill Mill at Jan 31, 2008 12:09:49 AM
Something else:
I forgot to mention this. You also need to get the nurses on your side. They know how to work the system and you don't, even if you have the will to. It fascinated me how much latitude people displayed at the hospital. Bad analogy- the skilled positions come in and do their job (and just their job), but the basic blocking and tackling could vary considerably.
Anecdote: at one point, I was so annoyed by the constant badgering we got every 15 minutes (the hospital operates at the convenience of the system, not the patient) that I made my displeasure known to the next nurse assigned to us. We never saw a nurse again. Maybe she was just hands-off style, but I think it was she didn't want to hang around. She probably spent more time with other patients. Contrast that with the nurse who wasn't even assigned to us who came by to visit because we brought cookies to the hospital and she liked us.
So, it probably works best to have a kind of good-cop / bad-cop routine. You need that one hard-@$$, but the nurses will not like them, so you obviously don't want that to be the patient. Then, you need someone who is sweet as honey but still assertive. That can be the patient if they are up to it.
Bill Mill: I don't have broad ideas on improving the system in its entirety. However, people tend to do the job they are paid for and do what's expected of them. I think if you did have someone assigned to the well-being of each individual as they came in, they might take care of the patient's overall experience better. The problem here is that a hospital stay is a 24 hour thing and even the best nurse you could hope for is probably only there for 12 hours and may be on vacation or reassigned the next day.
Aside from that, buy anyone you know at a hospital a book on Lean Thinking and remind them what their product is.
Posted by: Andrew at Jan 31, 2008 4:43:39 AM
His post, his wonderful post, reminds me of the book 'Overtreated', which I'd sincerely recommend he read - she seems to be arguing the same point in certain passages, about how nobody is empowered with taking care of a patient and - instead - it's an endless stream of faceless specialists.
Anyway, she does a better and less melodramatic job of it than I, so I'd advise!
Posted by: Noel Rock at Jan 31, 2008 5:34:11 AM
Bill Mill:
Programmer with an ER doc fiancee? You are in a unique position to determine if the holy grail of electronifying the system is really the solution people think it is. I don't. In the short term, it is akin computers in elementary schools.
However, it could be with the right programming. Good programming could reduce the "transaction costs" and friction of a better incentive system.
Example: I think the system is set up because the people in it like it that way, more or less. By having multiple nurses, they can all get away. If you had one nurse assigned to you, they would be accountable. How could programming address this?
Maybe the best thing you could do is write a book. I'm serious. Partner with an economist and maybe an industrial engineer and you and your fiancee could really do some damage. Who would be better positioned to do this than such a team?
As to your clinic idea, that sounds really hard. However, I do think that with the right billionaires backing it, the medical industry is ripe for a hospital franchise that addresses the whole customer experience. With all the money people spend on medicine while hating every second of it, imagine what they'd pay if it was an enjoyable experience. Also, the problem is one of being to draw in enough doctors and skilled nurses and technicians to such a venture. However, from what I know, doctors hate the current hospital management system, so it wouldn't be hard to find the right recipe for them that gives them the benefits of a corporate job without making them feel like they work for GE.
What I'm saying is, I know very little. Nobody knows much. I've gone the route of trying to make a minor contribution. To work on the overall problem would be a career. You could do it if you wanted to.
Posted by: Andrew at Jan 31, 2008 6:13:46 AM
It seems to me the roadblock of starting a hospital is that because there is so little inherent structure (by necessity) and almost no quality control (by choice, noone likes self-examination), the system is only going to be as good as the people in it. A business model based on hiring away the best people is not good, especially when what you offer is accountability and structure. Herding cats comes to mind. You have to overcome this.
The miracle of a franchise, the likes of a McDonald's, is that it creates a system whereby people you wouldn't otherwise trust to feed your dog, you will happily eat their hand-made burgers without a second thought. Harsh but true. The same could be true for a hospital franchise, on a different scale.
The benefit of a programming and franchise approach is that it reduces the problem of having to convince the best doctors and nurses to join the staff. You can replicate it at a new location relatively easily. If you can develop a reputation for being the best mix of independence and security, the best of both worlds for medical staff, they will seek you out. I wonder what the turnover is for trained staff at a hospital. This has to be a major drain on resources. I considered a medical profession and didn't go through with it after talking to doctor friends about how terrible it is (they have sunk costs that keep them in) and my personal experience with hospitals. The latter tells me they were being honest.
Really showing what could be done might head off the coming socialized medicine debacle. But probably not. To the people who only know hammers, every problem looks like a nail. When the government hammer wielders nail the medical problem, we're all screwed!
Posted by: Andrew at Jan 31, 2008 6:38:49 AM
I apologize for hijacking an economics thread that was basically a sympathy post with non-economics chatter that isn't sympathetic. But it strikes a chord with me.
http://www.ama-assn.org/amednews/2007/11/05/bisb1105.htm
This is just one example of how costs could be reduced at a hospital. And these cost savings could be used to improve conditions for patient and staff. Then the snowball starts rolling.
People aren't idiots. They are already doing more things than I can think of. But chances are, each of the 10 best hospitals are probably doing 10% of what they could be doing. Visit the best and take notes on the best practices. Maybe someone already wrote this book. Maybe not from a behavioral economics perspective.
This looks like an interesting start:
http://www.bos.frb.org/economic/conf/conf50/papers/frank.pdf
http://en.wikipedia.org/wiki/David_Cutler
David Cutler is Dean of the Social Sciences Professor of Economics at Harvard University. He served in the administration of Bill Clinton and was an advisor to the presidential campaign of John Kerry.
A "pay for performance" advocate to the Clintons and Kerry? Maybe a good sign. But they'd probably overdo it. I kind of view the government as society's complaint department. They are among the first to recognize there is a problem. That's their role. The problem is when they try to solve it.
There is definitely a problem. Here's another anecdote of how bad it is. We were there, and the doctor literally decided to do a specific type of procedure because of the piece of equipment the nurse happened to be able to find in the cart. I kid you not. Why they can't pay some highschool girl (yes, I'm stereotyping) minimum wage to make sure all the carts are stocked is beyond me. Well, I can think of one reason; you can't let just anyone into the stockroom where they keep the drugs, but that seems to have some easy fixes. Besides, I've heard that there are already so many nurses on drugs that if they started rigorous drug testing hospitals would go out of business.
I've got my hands full. This is obviously a keen interest of mine. If anyone has any ideas how a biomedical engineering grad student with an interest in economics and policy and a heart for the medical industry could make his hobby help him achieve his PhD rather than just sucking away his time commenting on blogs (I know, "stop!"), I'd appreciate it. If I don't finish my PhD, I'll probably not do anything medically related (it's a hard industry to break into and make money, and without my PhD I won't have that sunk cost anchoring me to it), so a good idea will be a service to humanity :)
Posted by: Andrew at Jan 31, 2008 7:28:05 AM
http://www.bos.frb.org/economic/conf/conf50/papers/frank.pdf
The experience of patients at the end of life offers a disturbing reflection of medical
decision-making and resource allocation that reflects larger issues in health care
delivery. Specifically, the majority of terminally ill patients state a preference to die
at home but frequently do not. Spending for care at the end of life accounts for a
large share of Medicare spending that has been estimated at about 25% of the past
two decades. There is considerable disagreement regarding how much this level of
spending can be reduced. However, Skinner and colleagues compare regions with the
highest and lowest deciles of physician utilization during the last 6 months of life.
They report utilization of diagnostic tests that differ by factors of between 2 and 3.5.
I think a lot of people would be disgusted talking about this subject in terms of the dismal science. But if you really want to help people, that's where the solution is.
The irrationality of patients is another factor not to be trifled with. In "Blink," Malcolm Gladwell asserts that doctors and are much more likely to be sued based simply the patient's impression of bedside manner. One particular relative of mine really likes the doctors that I can't stand, because our personalities are so different. I'm in the minority. So, doctors learn to be showmen, and salesmen, and are paid to be decisive and convincing. Or, at least these are the qualities that survive. This has to come at a tradeoff, maybe at the expense of being thoughtful, objective, brutally honest and right!
Posted by: Andrew at Jan 31, 2008 7:40:26 AM
More (read the last line)
http://www.bos.frb.org/economic/conf/conf50/papers/frank.pdf
The median physician estimate of survival time was 75 days after admission to
hospice, while the median actual survival time was 26 days. In addition, physicians
then communicate more optimistic prognoses to patients than they actually believe.
For example, in the Lamont and Christakis study of cancer patients physicians
reported optimistic outlooks about patients to their colleagues about 12% of the time,
whereas the same physicians reported optimistic outlooks to the same patients 41% of
the time.22 The true prognosis was only communicated to 37% of the cancer patients.
The unrealistic optimism potentially affects both the physicians’ decisions about the
therapies to pursue and the patient’s demand for care. Optimism has been posited to
lead physicians to over-prescribe intensive interventions aimed at cure while underreferring
to hospice.20
I'm always fascinated when people who know about something assume everyone else knows about it. Of course people don't know about hospice. The experts we pay to tell us about it, don't!
Posted by: Andrew at Jan 31, 2008 7:45:08 AM
The statistic for healthcare and the elderly is that the average American uses 80% of their lifetime healthcare budget in the last 10 years of their lives. These last 10 years usually includes having Medicare pay (a mismoner if there ever was one) the bills at whatever rate the government decides is fair. Is it any surprise that the care these people receive is somewhat below standard, when at the same time their families are demanding any and all measures be taken to ensure dignity and quality of life?
This is allegedly an economics blog. Is the model for your average American hospital one that makes for a successful business? The payer for a large percentage of your customers is paying below market (Andrew, ask your fiancee' how many visitors to her ER are Medicaid/Medicare or the uninsured-for my girlfriend, a nurse case manager at a large teaching hospital in Boston, it was 68%).
The instruction to make nice with the nurses can't hurt, but with their case loads at historic highs, the dilution of staffs with foreign imports with dubious skill sets and, according to my girlfriend, the modern nurse going into the profession as a high-wage job and not a avocation makes it a bit more difficult work the system as has been suggested.
The institutional arrogance of the medical professional (especially management), government interference, the influence of Big Pharma and Big Insurance and the expectation that we all get ALL the medical care we want is killing healthcare in this country at an accelerated rate.
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