13 ms·

Health care and education are IMO the next two major car wrecks coming for America. Both are like patients with similar symptoms (indicative of the general dis

• kbenson 9y ago
  > Friend's mother was recently in hospital, multiple doctors thru a single day, each one had to completely relearn what was going on. What's the alternative? 24 hour shifts for the doctor and the new doctor each day needs to relearn everything? Having to relearn everything might be a problem, depending on what it actually means, but as long as we want a normal human being as a doctor, they will cycle over time as people start and end shifts, and they will need to learn what happened before their shift started (and they may receive patients from multiple doctors leaving over their shift, making 1-on-1 hand-off infeasible). It's easy to call this out as a problem, the question is what's the alternative that's better?
  • mikecsh 9y ago
    In addition to this, many doctors want to re-take the history from the patients and re-examine them for themselves, rather than rely on a brief handover or potentially sub-optimal notes from another doctor. Clinical signs can be subtle, as can points in a patient's history that may point to a diagnosis. I see patients often frustrated at being asked the same questions by each doctor they see, but most of the time this is in their best interest.
    • arkades 9y ago
      I try to preempt the frustration by saying that we each take our own history for the purpose of making sure no details are missed, but rest assured, I’ve gotten the overview from your other docs. I then make sure to complete a sentence for them once in a while, to evidence that that is the case. A good percentage still get frustrated. Can’t be helped. Patients reshape their narrative, remember new details, just plain open up more to some docs, etc. the repeated history taking really pays off in improving patient care. Where I find patients get most frustrated is when docs come in for a specific job, and patients don’t have the health literacy to understand what that is or is not. “Doc, can I go home today?” “ I’m just the consulting cardio here to check out your heart for your primary doc, Doc McStuffins, I have no say in that at all, you need to ask McStuffins.” “Oh. But when do you think I can go home?” There’s no good response to that. No one wants to cough up cash to pay for health professionals time to repeat themselves all day long. But the patient that’s asking? They want that answer. They don’t -feel- like they’re asking an inappropriate or stupid question.
      • mikecsh 9y ago
        I think this hits the nail on the head. There is a huge information gradient between most patients and the doctor and perfectly bridging that gap takes more [time|money] than any system is willing to support. I think about this when it comes to providing a patient with "informed consent" for a particular treatment/operation. What does "informed" really mean in this case? A brief overview of the main risks and a couple of statistics? Or a thorough understanding of the pathophysiology of the disease and the trial data supporting the therapy? How long is a piece of string?
    • BurningFrog 9y ago
      Each doctor also has an incentive to re-examine the patient so they can bill for that examination.
      • arkades 9y ago
        No, they don’t. Most patients get admitted under a DRG, which is a lump sum payment. It’s true that doesn’t apply to every patient, but enough of them that doctors habits aren’t going to be shaped by the minority. For that matter, you can come in and see a patient without asking the same history as the guy before you, if you’re just checking a box for a billing.
  • WhatIsDukkha 9y ago
    The doctors individually spending 5 quiet minutes reviewing the case files of the patients they were about to treat BEFORE they arrived. That's not modern reality and its shameful.
    • araes 9y ago
      This was the desired behavior. Its not that they reviewed existing info to check for changes, its that they knew nothing. Like the last 30 minutes of questions and chart didn't exist. On the side of the patient, this does not inspire confidence. It projects a sense of confusion and disorganization.
      • kbenson 9y ago
        Twenty years ago when I did tech support for a living, I had a series of questions worded in very specific ways I would ask at the start of a call. Sometimes the content of the answer was the useful part of the response, sometimes how the answer was said. More often than not, if I got someone on the other line that seemed to know a bit, skipping the questions ended up being counterproductive, as I would assume some knowledge about a specific item from the other end that didn't exist (but other knowledge did). I learned to trust the process, and glean the extra bits of information that weren't what the other side was trying to convey, but did nonetheless. I think it's a mistake to assume that just because the doctor asks you questions and doesn't always seem to take into account a prior answer the doctor is not listing. I think it's more likely that they have learned that the small percentage of time that asking similar questions in different ways has led to new, important information has led them to be careful and methodical, even at the expense of patients thinking they aren't listening. When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other.
        • civilitty 9y ago
          > When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other. This is an important point but I feel you're approaching it from a very short term view. Look at Pakistan, for example: after the CIA used a vaccination program as cover for a genetic testing scheme meant to find Bin Laden [1], there was (and still is) a significant impact on the Pakistani and other population's trust in their domestic healthcare industry [2]. Even if it was a real Polio vaccination program that saved thousands of lives in a purely utilitarian short term calculation, the damage that distrust causes long term can far outweigh the benefits. Worst of all, due to the nature of that distrust, measuring that damage becomes so much harder. The point is, doctors don't just need their patients to trust them, but to trust the institution of modern medicine and healthcare as a whole. They need the patients to trust their nurses, pharmacists, specialists, and technicians just as much as the primary doctor. Given how critical patient cooperation/honesty and preventative care are to clinical outcomes, I don't see any convincing evidence that patient perception isn't just as important as the rest of the process. [1] https://www.theguardian.com/world/2011/jul/11/cia-fake-vaccinations-osama-bin-ladens-dna https://www.theguardian.com/world/2011/jul/11/cia-fake-vacci... [2] https://www.scientificamerican.com/article/how-cia-fake-vaccination-campaign-endangers-us-all/ https://www.scientificamerican.com/article/how-cia-fake-vacc...
  • shawndimantha 9y ago
    Part of this can be solved by having better care managers associated with each patient (primary care doctors), who can share relevant information with different parties. Works mainly for chronic care. In the case of acute cases, information needs to be readily accessible in a format that is interpretable by doctors when they go through the process of assessing differential diagnoses. That information is not captured well right now, hence the ask for patient's history with each new physician. Personal health records with smart annotation of key pieces of information can play a part in solving this problem, but are only part of the answer. One of the most dangerous periods in the emergency room is the transition of one care team shift to another. It takes forever, and often leads to key information loss.
    • asimpletune 9y ago
      I don't really understand is this concern about having to "relearn" everything when doctors change shifts, because that's not how it works. Maybe that's how patients perceive it, but generally before each shift ends, in order to be relieved of your shift, you have to sign your patients out. This is basically an hour long phone call with the next doctor, where you tell them everything that happened for all their patients.
  • thesagan 9y ago
    We can start by treating this as an important problem and tasking ourselves with looking for and finding alternatives and putting political/financial pressure on these institutions to consider them. Just asking "but what are the alternatives" isn't productive in itself, and doesn't really carry the conversation forward. It more likely shuts it down as a hopeless problem. We can do better. It's not hopeless and we're not powerless as a collective. I'm sure there are alternatives but we're not looking for them very well. We could start there. I'm doing my part by bringing this up in conversation whenever it's relevant and getting to know my state representative and state senator. I also make noise towards the hospital's admins in the meanwhile. --------------- Also, the article discusses possible alternatives. Here are a couple of paragraphs from it: "This begins with our own training. Certainly doctors must understand disease, but medical education is overly skewed toward the biomedical sciences and minutiae about esoteric and rare disease processes. Doctors also need time to engage with the humanities, because they are the gateway to the human experience." "To restore balance between the art and the science of medicine, we should curtail initial coursework in topics like genetics, developmental biology and biochemistry, making room for training in communication, interpersonal dynamics and leadership."
  • deleted 9y ago
    [deleted]
  • mindslight 9y ago
    The problem isn't really the 20 minutes it takes to get up to speed, but that each patient visit is only allocated to get 15.
  • andmarios 9y ago
    Is there really a need for 24 hour doctor visits most of the time? No. Doctors can have mostly normal 8-hour workdays, 5 times per week. Nurses administer drugs and monitor the patients. If a problem arise, they can call the doctor in charge of the patient or bring the doctor doing the night —or weekend— shift.
    • alsetmusic 9y ago
      This is what you responded to: >> Friend's mother was recently in hospital, multiple doctors thru a single day, each one had to completely relearn what was going on. > What's the alternative? 24 hour shifts for the doctor and the new doctor each day needs to relearn everything? This is from your response: > Is there really a need for 24 hour doctor visits most of the time? The exact situation described is hospitalization. Pointing out that most treatment may not be on a 24h basis is not relevant here.
      • andmarios 9y ago
        In the last few years I've spent almost a triple number of days in hospitals (not as a patient). I can tell you from first-hand experience that most patients that are hospitalized —except in the ICU— do not need multiple doctor visits per single day. Maybe they need a couple different specialties, but certainly they do not need multiple doctors of the same specialty in the same day or more than a few specialties. As has been pointed out in many submissions on HN about USA's medical practices, the main reason you get many visits is to inflate your bill. I think someone even wrote that he was charged $600 per 1-minute visit during his stay in the hospital.
  • pishpash 9y ago
    The alternative? How about not artificially restricting the number of doctors in the system so the ones in it don't play musical chairs and ones aspiring to don't do 28-hour shifts?
    • djrogers 9y ago
      Artificially restricting? Could you elaborate? I was under the impression that the only restriction on the number of doctors is the ability for people to get through med school.
      • maxerickson 9y ago
        There's a fixed number of seats in medical schools and a fixed number of residency slots. When you add foreign doctors that would like to practice in the US to medical school graduates, there's less residency slots than doctors that would like to take them. Most residencies are paid for by Medicare. Big hospital systems just can't seem to find the funds to train doctors on their own.
  • hiram112 9y ago
    Gracefully dying?
  • gaius 9y ago
    What's the alternative? Methodologies such as Kepner-Tregoe explicitly make handovers very easy, used very effectively in manufacturing, energy, and other industries. But God forbid that almighty doctors should ever take any advice from outside their profession.
  • philwelch 9y ago
    So I took my dad to the hospital a couple times in his last year or so, and I think the main thing every patient needs but doesn’t necessarily have is someone to do the top-level coordination. There might be a surgeon and a hospitalist and a cardiologist and a neurologist and whoever, but no one is actually in charge. Most hospitalized patients mentally check out—humans don’t do well in captivity—so unless you have a family member advocating for you, you’re kind of fucked. Doctors come and go, but none of them take responsibility for the patient’s overall well-being. It doesn’t require 24-hour shifts or even a medical degree to do this kind of coordination. I did it and I have no medical training whatsoever. But it was pretty important work, and my dad would have been lost without it.
• maxerickson 9y ago
  An awful lot of hospitals are organized as non profits. Same with insurance. Spending goes up because a majority of politically engaged people have good access to care that they don't directly see the cost of.
  • GiorgioG 9y ago
    > An awful lot of hospitals are organized as non profits. Same with insurance. Yep, and they all have administrators that make a ton of money. I worked for a Blue Cross Blue Shield franchise a decade ago. It is/was a "non-profit", the CEO made 2.1 million dollars per year. Non-profit != Money well spent
    • maxerickson 9y ago
      Gee I wonder why I used the exact phrase organized as non profits. But hundreds of millions in executive salaries at companies that pay billions in insurance claims isn't the thing driving health care costs. It barely registers.
      • GiorgioG 9y ago
        Administrative overhead in 2014 accounted for 25% of US hospital spending. http://www.commonwealthfund.org/publications/in-the-literature/2014/sep/hospital-administrative-costs http://www.commonwealthfund.org/publications/in-the-literatu... Overall the administrative overhead is 8% for healthcare in the US, more than double global average (3%) http://money.cnn.com/2017/01/11/news/economy/healthcare-administrative-costs-us-obamacare/index.html http://money.cnn.com/2017/01/11/news/economy/healthcare-admi...
        • adventured 9y ago
          And further to that point, the admin side of US healthcare costs have massively expanded - similar to what has occured in education - over the last 30 years. That 25% share, is about double what it is in Canada (although a few are equally high, the Netherlands is at 20%). The famous chart showing the US growth in admin vs physicians since 1970: https://i.imgur.com/lnIcjo2.jpg https://i.imgur.com/lnIcjo2.jpg
• bsder 9y ago
  > Doctors / teachers often don't seem to communicate / care. You really don't have much contact with teachers if you believe this. The education system runs in spite of its systemic horribleness precisely because there are enough teachers who do care and fight/ignore the system when necessary. If you want to actually fix the educational system, we have models for doing so in several different countries. However, they all tend to share the same characteristics. You have to raise standards for both admission and completion; you test to those standards; you raise salaries to match those standards; and you give respect, autonomy and authority to the people now adhering to those standards. HOWEVER, that is going to cost money. Quite a lot of money. And, really, nobody is actually interested in doing that in the US. They're really only interested looking like they are concerned rather than actually fixing the problem.
  • whatthesmack 9y ago
    > HOWEVER, that is going to cost money. Quite a lot of money. And, really, nobody is actually interested in doing that in the US. This seems to imply that the US doesn’t spend enough money on education, even though it is (one of?) the highest spender(s) on education in the world (just from a quick Google search). I believe the real change needed is better management of how the existing money is spent.
    • bsder 9y ago
      You are regurgitating a "misused funds" talking point that Republicans always fall back on when facts don't support their position. The US isn't that out of line with spending: US is $15,171 per student while Switzerland is $14,922 per student. US is 7.3% of GDP while Denmark is 8% of GDP. Source: https://www.cbsnews.com/news/us-education-spending-tops-global-list-study-shows/ https://www.cbsnews.com/news/us-education-spending-tops-glob... There is not some magic bank of "misused" money waiting to be tapped. The US also has a lot of students who fall into the education assistance category (free breakfasts, lunches) who would fall into a "social safety net" in countries like Sweden and Norway. A lot of the poorest students eat up the largest chunks of funding. Finally, the Gates Foundation, whom I don't necessarily like, has shown time and again two fundamental things about education attainment: 1) any SUSTAINED focused resource improves educational outcomes 2) resource allocation is strongly sub-linear--it takes FAR more than 10% more resource to cause 10% improvement in outcome from our current system
• dkarl 9y ago
  They treat the customers like replaceable widgets This sounds like first world problems. You have a doctor you trust to go off script? You trust that when your kids' teachers treat them differently they aren't just stereotyping and limiting them? Lucky you. While you work to unshackle your providers from the mediocrity of "best practices" (and I say that as someone for whom "best practices" is a bane in my own work) keep in mind there are a lot of people for whom competent cookie-cutter care is a wish, not a disappointment. In technology we can let a thousand flowers bloom and we all get to choose and enjoy the most beautiful ones, but in education and health care there's no natural elimination of the worst and amplification of the best. Everyone just lives (or dies) with whoever they randomly end up with, so worst-case performance matters just as much as best-case, and average-case matters a whole lot more.
  • candiodari 9y ago
    The problem is MBA administrators looking at their little accounting tables and deciding that not letting patients actually see a doctor is their purpose in life, just so they can pay everyone at a hospital as little as possible. This of course leads to global cost blowups and worse care. Of course, by now there is no turning back, and the government has decided that actually training doctors must be prevented at all costs. VERY short term vision, constantly sacrificing the future for a quick buck, leads over the span of decades, to spiraling costs and worse outcomes. Who knew ? Well, everybody knew.
    • dkarl 9y ago
      I'm talking about teachers with master's degrees and MD doctors, which means many years of education. We've made it standard to have access to these people (unless you have a scratch???) but it's not a panacea. Just got word that my father is seeing the same doctor that has fucked up his care multiple times, not out of creativity or being too smart but because of not guessing the simplest and most common explanation of common symptoms. I'm very angry, but can't convince my father to move out of the home & town I grew up in so he doesn't have to deal with this incompetence. If you live in a town where smart and educated people like to live, you get the cream of the crop of doctors. It's very different from living in a backwater where ambitious young people aspire not to live. And most of the world lives in backwaters, with unexceptional doctors who make simple but deadly mistakes when they go off script.
• kingkawn 9y ago
  Much better for each doctor to directly interview patient than to rely on previous histories that may have omitted crucial info or asked questions in a way that led patient to not realize what was being asked.
• RA_Fisher 9y ago
  Yep and the common thread in both is the government.
  • craftyguy 9y ago
    Specifically, the government's mostly laissez-faire approach to handling both and, for education at least, its inability to prioritize it above other priorities like declaring war on vague concepts (drugs, crime, terrorism, etc)
    • tensor_rank_0 9y ago
      > Health care and education > government's mostly laissez-faire approach to handling both actually those are among the most heavily regulated and subsidized industries in the us.
  • fbdjskajxb 9y ago
    The government is also involved in lots of other things without exploding costs. I’d say the common thread is the combination of these factors: 1) the service is considered essential by consumers and 2) payments are deferred (by insurance or student loans). So consumers never say no due to rising prices.
  • curun1r 9y ago
    To be more specific, the US government. Other governments seem to figure this stuff out, from time to time, but there's something about the FPTP, federal/state split or other such details that's sabotaged efforts here. We should realize that it isn't a fundamental property of government, just the one we have and we have mechanisms for making changes that we haven't yet tried.
    • adventured 9y ago
      The problem in the present US system, is that it's a bad mixture of private and government involvement. We have the negatives from both acting simultaneously. 5% of patients are half of all costs in the US healthcare system; 1% of patients are 22% of the cost. People over the age of 65 are a greater share of cost in the US system than in universal healthcare systems, because the US doesn't have a big lever for rationing care. The healthiest half, is 3% of the cost in the system. A market healthcare system, which is widely considered immoral, will drop many of the most expensive and poorest patients from the system. That's how you can dramatically lower costs in the US system, if you want to go the market route. A market system would particularly focus on the 50% that are only 3% of cost, with costs being far higher for everyone else (resulting in lack of access to expensive treatment for many, and many millions of people would get denied healthcare coverage due to pre-existing conditions). A universal healthcare system smashes costs by rationing care, and tightly controlling everything from drug prices to healthcare worker salaries. The US today has neither of those approaches widely implemented. We have a lot of government and private healthcare without enough of the tight cost checks. The obvious outcome, is a perpetual cost spiral until it can't spiral anymore (which is about where we're at now).
• neffy 9y ago
  Consider who and how benefits. The incentive in for-profit medicine in the US is to spend as much time and treatment as possible per patient. If each Doctor has to order the same tests as the patient is passed around - that is efficient from the perspective of maximising profit.
• jackcosgrove 9y ago
  The underlying problems in these industries are because they are labor intensive. Partly this is due to the difficulty of automating those jobs, and partly it is due to political arrangements that protect incumbents. Technological innovations that reduce costs will be the most lasting ways to reform these sectors.
  • toomuchtodo 9y ago
    Other first world countries don’t require technological innovations to deliver affordable, quality healthcare. They just break the profit motive.
    • nnq 9y ago
      Yeah, but when tech innovation becomes the only way out of a shitty situation, you incentivize tech innovation! I guess some smart folk figured out that in order to maintain superpower status at all costs you need to maintain the lead at hard-to-replicate tech-innovation, and paying the cost of this with your people's quality of life, and sometimes with their lives, is worth it. For some people at the top it's a big difference between being at the top of "just some random first world country", and being at the top of "practically the world". Regular people can change the countries they are living in if they don't like the tradeoffs their government is doing, you know... Or vote to change them, but don't be surprised when improving lives comes at the cost of losing "top dog" status. (Note: I'm not an American, but I see the tradefoffs the U.S. made, and I understand they make sense to some.)
• robbiep 9y ago
  It’s not relearning but making sure you get the facts from a primary source. The ICU motto is ‘trust no bastard’ - if you rely on what is written down without asking the patient directly, can you be sure that it is correct? I have personally come across many instances where what has been recorded is inaccurate or misses important details that careful questioning elicits. I will always take my own history from a patient, but I use the previous records as corroborating records - I know what the general gist has been, but what might they have missed/what might the patient have told them? It is a critical part of good patient care, despite its inefficiencies
  • k__ 9y ago
    lol, I was once in the hospital because I hit my head. I had a panic attack at university, hyperventilated and passed out. They asked me what happend and wrote down "was drunk" so everyone I met at the hospital was like "uhuu was drunk at the uni... one of those guys..."
  • andreygrehov 9y ago
    Well, that's because the underlying approach needs an improvement. As an example, imagine that every doctor-patient communication is recorded with a camera. Now all you need to do to get facts from a primary source is to watch a video with another doctor talking to a patient. I'm not saying that this is the solution, but options do exist and they are worth exploration.
    • YeGoblynQueenne 9y ago
      Say you're a gastroenterologist and in the video, your patient was interviewed by a pathologist. The pathologist would ask pathologist questions, but you need to know gastroenterologist answers. How do you get them from the video of a pathologist asking pathologist questions?
      • andreygrehov 9y ago
        In this case gastroenterologist goes to a patient and asks questions he is interested in. The point is that a patient doesn't have to tell the same story over and over again. The problem is that gastroenterologist would now have to have its own video, which would probably be time-consuming for the third doc.
• propman 9y ago
  Was charged $70k for a procedure that should have cost 5k max even with nurses and doctors and materials. I also was under the impression it was covered by my insurance because the front desk said she would call me if it wasn't. I was also given wrong information about what type of treatment I was going to get and when I requested to check with the doctor, I was given the option of "do you want the procedure or am ai going to just cancel it" and if it was cancelled, the next available appointment with the doctor was in 5 months. I payed just $3k, but that was ridiculous to be surprised by and I'm still confused what the treatment plan is because front desk didn't schedule me until July. The doctor is great but support staff has become so beuracratic...
  • gaadd33 9y ago
    Why should it have cost $5k max? Did you price out the labor/facilities/equipment to do it yourself?
    • propman 9y ago
      No, I looked at how much the exact same procedure using the exact same equipment would cost by a doctor in another state who made the pricing relatively transparent.
• AnIdiotOnTheNet 9y ago
  All I want out of a physician is an expert consultant. I have goals for where I want my health to be, and I could use advice on how to get there that doesn't require me to spend so much time separating the wheat from the chaff of google results. This could be handled over email most of the time. But most doctors I've met don't seem to see themselves in this role. They seem to think their job is to take measurements and tell me how far out of spec I am. Worse yet, most of them believe they are infallible. Its fine if you're making educated guesses doc, just don't act so damn confident about them and dismiss the negative results. Maybe I've had bad luck in doctors. It's not like I get a choice in them, the way the US system works. Three times in my life I have had severe chronic problems that were ultimately solved by my own inexpert research and experimentation or by the inexpert observations of a casual observer. These days I only bother to go to a doctor after I have a good suspicion of what's wrong already, like if I broke a bone or something.