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"What's Wrong With You?"
Don't get sick anywhere but at home:
...doctors in Tanzania complete less than a quarter of the essential checklist for patients with classic symptoms of malaria, a disease that kills 63,000-96,000 Tanzanians each year. The public-sector doctor in India asks one (and only one) question in the average interaction: "What's wrong with you?". In Paraguay, the amount of time a doctor spends with a patient has nothing to do with the severity of the patient's illness...these isolated facts represent common patterns...three years of medical school in Tanzania result in only a 1 percentage point increase in the probability of a correct diagnosis...One concern with measuring doctor effort through direct observation is that the doctor may work harder in the presence of the research team.
That is from "The Quality of Medical Advice in Low-Income Countries," by Jishnu Das, Jeffrey Hammer, and Kenneth Leonard, in the Spring 2008 issue of the Journal of Economic Perspectives. The editor is now Andrei Shleifer and this issue is one of the best in a long time.
Posted by Tyler Cowen on June 7, 2008 at 07:12 AM in Medicine | Permalink
Comments
"three years of medical school in Tanzania result in only a 1 percentage point increase in the probability of a correct diagnosis"
Geez, talk about a bad ratio of costs to benefits!
Posted by: James Hanley at Jun 7, 2008 12:59:07 PM
Could the low benefit of medical school be due to the high prevalence of common and easily diagnosable (and curable) diseases in countries like Tanzania? For example, maybe you don't need to have a medical degree to diagnose malaria, which accounts for a lot of cases that doctors see in countries like Tanzania. Hence the statistic that three years of medical school results in only a 1% increase in probability of correct diagnosis comes as no surprise.
This also explains the "What's wrong with you" attitude: if most people suffer from common, easily-diagnosable diseases, the doctor could simply ask the patient what was wrong with him rather than have to get into an involved diagnosis.
Posted by: tom at Jun 7, 2008 1:36:34 PM
In 1996, my expensive doctor in Chicago told me the large swelling that had been in my armpit for months was "probably just a muscle pull. Don't worry about it."
It turned out to be a lymphoma tumor the size of a Polish sausage.
Anyway, the point is that the real world of diagnosis isn't like an episode of "House," where a surly genius and his hard-working acolytes drop everything to figure out what's wrong with you.
Posted by: Steve Sailer at Jun 7, 2008 2:25:07 PM
I have spent a little time observing field medicine in a third world country, and while my observations agree with those of this paper, my take-away is quite different. I think that all the extra patient-doctor interaction that we are used to in the first world doesn't add much value.
Certainly the panoply of dianostic equipment available in the first world (rapid and accurate bloodwork and culturing; X-ray, CT, and MRI imaging; EKGs and EEGs) adds tremendous value. But that's not available in the third world no matter how much time the doctor spends with you.
On one visit when I accompanied a team of three local doctors to an IDP camp in Uganda, they saw about 150 patients in 3 hours, which works out to 3-4 minutes/patient. If I had not even looked at patients, but had merely handed out anti-malaria drugs, my rate of correct "diagnosis" would probably have been over 60%. Given the quick examinations they did do, I'm pretty sure the rate of correct diagnosis for this team was over 80%. Without more diagnostic equipment than they had (which was pretty much just a stethescope and a blood-pressure cuff), I doubt that doubling or trippling the time spent with the patients would have pushed the rate up much beyond that. Probably the most common mis-diagnosis is mistaking one type of infection for another (e.g. typhoid fever for malaria).
You also have to keep in mind that the correct diagnosis of more subtle metabolic, degenerative, or slow-acting diseases isn't of much use anyway, because there is no treatment available.
So I would say: yes, better to get sick in the first world. (Duh!) But that's because of the better diagnostic equipment and treatments available, not so much because of the better doctors.
Posted by: David Wright at Jun 7, 2008 6:55:11 PM
Jesus Crist comes to earth to work as a medical doctor.
The patient, in wheelchair enters . JC without seeing him, says get up and walk.He leaves walking. He is asked what the Doctor said.Nothing he didnt even ask me What's wrong with you?
Posted by: k at Jun 7, 2008 7:22:50 PM
And where is "home" supposed to be for a reader of this website?
Posted by: Andrew John at Jun 7, 2008 10:11:55 PM
I got some kind of infection in India. Went to my friend's uncle, who is a specialist in diseases of the skin. I felt that his treatment was the equal of anything I've received at home. Photos (not appropriate for mealtimes): http://flickr.com/photos/russnelson/sets/72157603794356820/
Posted by: Russell Nelson at Jun 8, 2008 1:57:52 AM
My guess is that a large part of the problem in many of these countries is that education is done largely through bribes. Bribes are paid to get in, to pass exams, and to graduate. This isn't true for everyone, but even for those who don't take part this makes learning harder since you have fewer serious colleagues, professors are less interested and able to actually teach, and so on. This problem has grown massively in Russia, for example, where the over-all quality of education has gone down massively from Soviet days and where the medical field has been especially badly hit. I'd not be surprised to see a Shleifer-led publication not talk about this (maybe they do but I'd be surprised) since Shleifer clearly thought there was nothing wrong with corruption of this sort, especially in Russia, and especially when he was a big winner from it. About him that should never be forgotten.
Posted by: Matt at Jun 8, 2008 10:25:06 AM
I must be misreading the report....
[In particular, the competence of doctors in low-income countries is low, the quality of care provided to
patients is even lower than would be suggested by a doctor’s competence and the poor have access to worse quality care than the rich, whether from the public or the private sector.]
Could this be because of the following?
[Dr. SM and his wife seem highly motivated to provide care to their patients and even with a very crowded consultation room they spend more time with their patients than a public sector doctor would. However, they are not bound by their knowledge of health care and instead deliver the health care, like the crushed pills in a paper packet, which will result in more patients willing to pay more for their services. Indeed, over-medication in India is a widespread (for instance, Greenhalgh, 1987; Phadke, 1998). Note, this is consumer driven and not “supplier induced demand” of practitioners exploiting asymmetric information to talk people into unnecessary treatment.]
That last sentence seems paradoxical, if not disingenuous, to me.
Posted by: ideogenetic at Jun 8, 2008 2:09:10 PM
And libertarians argue that we would all be better off in the US if we sharply reduced or eliminated the standards for doctors in the US.
Posted by: spencer at Jun 8, 2008 2:30:03 PM
Spencer:
If you think that decreasing barriers to entry reduces the quality of health care, then presumably you think the increasing barriers to entry increases the quality of health care. It would follow that third world countries could increase the quality of their health care by introducing the kind of restrictions on doctoring that the U.S. has.
But that's clearly wrong, because introducing those kind of restrictions would result in there being even fewer doctors in already doctor-starved nations. (In the U.S., there are 600 persons/doctor; in Uganda, there are 18,000 persons/doctor.) Actually, it would result in black-market doctoring, because those governments don't have sufficient control of their countries to stop it, but for the sake of argument I'm assuming your policy could be successfully imposed by fiat.
As I argued above, I don't think that quality of doctors is a very important factor in health care, at least compared to factors like the quality of technology ahd treatments. But even if I did think that quality of doctors was an important factor, and increasing barriers to entry increases it, it would still be true that the availability of those doctors was also an important factor, and increaseing barriers to entry reduces it.
Posted by: David Wright at Jun 8, 2008 3:00:25 PM
Anyone see the elephant in the room?
three years of medical school in Tanzania result in only a 1 percentage point increase in the probability of a correct diagnosis
Root cause anyone?
The poverty of the American national political discussion will only end with really cheap DNA sequencing. Meanwhile the waste of brain cycles is appalling.
Posted by: Randall Parker at Jun 8, 2008 4:16:51 PM
being a medical student in Tanzania is the best opportunity in life i've had, and one should never judge the whole country from experience they've had with one person out of the 35ml people country that Tanzania. personal homework on tropical diseases (which am sure are not covered well in medical schools in developed countries)read on Konzo disease to keep up with us;-)
Posted by: medical student at Jul 17, 2008 10:04:59 AM
I think, don't compare the doctors or the country to the developed
countries. We can't compare the resources and environment found in T
Tanzania with the one in developed countries.
However, Many doctors in most countries value what they learned
in medical school. They don't think that they can learn from
patients. Patients don't need pills only, but pills with care,
value, couragement from their caregive.
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