
Doctors, Revolt - jseliger
https://www.nytimes.com/2018/02/24/opinion/sunday/doctors-revolt-bernard-lown.html
======
araes
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 disease of America.)

\- They treat the customers like replaceable widgets

\- Costs are spiraling out of control. ($2-3000/day hospital, $3.4 TRILLION in
total health spending [this equals the entire federal budget])

\- Doctors / teachers often don't seem to communicate / care. (Friend's mother
was recently in hospital, multiple doctors thru a single day, each one had to
completely relearn what was going on.)

\- The infrastructure systems are counter motivated (hospitals, drug
companies, ect.. are profit not care motivated corps w/ "high" administrative
overhead, schools are often public, yet view students as revenue and spend
large amounts on noneducational costs to attract "talent". [$500k-$1.5M admin
salaries])

No wonder many just want to self educate these days, and their health would be
about as well served going to a shaman who cared about them.

~~~
kbenson
> 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
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.

~~~
BurningFrog
Each doctor also has an incentive to re-examine the patient so they can bill
for that examination.

~~~
mikecsh
And this certainly isn't the case in the NHS in the UK where doctors have no
financial incentives interfering with their clinical decisions (barring saving
the service money). What you describe is a pitfall of private medicine.

~~~
chimeracoder
> And this certainly isn't the case in the NHS in the UK where doctors have no
> financial incentives interfering with their clinical decisions (barring
> saving the service money)

This meme really needs to die. The NHS has _massive_ financial incentives that
impact clinical decisions. In fact, you literally go on to mention as such in
your next sentence.

It turns out that having an incentive to "save the system money" results in a
different set of clinical decisions. And no, those don't always work out in
favor of the patient. (They're particularly problematic for the patient in
cases of long-term care, which is why the NHS does rather badly on complicated
and chronic conditions like treating cancer compared to the US and other
countries).

~~~
gaius
_This meme really needs to die. The NHS has massive financial incentives that
impact clinical decisions._

Not to mention that many if not most NHS-employed doctors run private
practices on the side. Some only spend a day or two a week on their NHS
duties. Others such as GPs are NHS-branded, but every GP practice is a private
business that bills the NHS for time and materials.

~~~
mikecsh
In a discussion of NHS vs private practice, the fact that some (certainly
_not_ most) NHS-employed doctors also do private work, has no baring on the
incentives placed upon them within their NHS employment.

I am certainly not saying the NHS system is perfect, and all private medicine
is bad, so if that is the impression you got then perhaps I was unclear.

In almost every single clinical situations within an NHS hospital that I have
seen or can think of, the clinicians treating you will not receive any extra
money, bonus, promotion, etc. for the treatment they provide you or do not
provide you.

I have lived in countries with more private systems, where there is a direct
relationship between what treatment/investigations you receive and what money
ends up in the doctors pocket. For example, a private doctor in HK referring
for not-strictly-necessary-but-ultimatelhy-clinically-justifiable MRI scans at
a private MRI clinic which, provides a percentage of the (expensive) scanning
fee back to the referring clinician. Contrast that in the NHS, no one gets
given money for sending a patient for an MRI scan, and in fact, if it isn't
going to change the management of the patient, the request is likely to be
refused to constrain resources. In the HK system, neither the doctor nor the
MRI provider is incentivised to not do the scan, quite the opposite.

The NHS system is not perfect, but pointing out different the pros and cons of
different incentivisation structures that do have an impact on patients is not
something that is a "meme that needs to die"…

------
OliverJones
Let's be careful about nostalgia for the "good old days" of medical practice.
Keep in mind that standardizing medical care process has done more to get
physicians to WASH THEIR HANDS than all kinds of exhortations about
relationships, partnerships, and healing. And washing hands has, since
Semmelweis's discoveries 150 years ago, been known as the easiest way to
promote healing that medical people don't do.

Why do the overnight shift of nurses take vital signs every four hours? So
they catch rapid unexpected changes in patient conditions more quickly. Put
more crudely, so they don't accidentally leave a corpse in a bed for the next
shift. Having to write, or type, the patient's blood pressure into a log is a
way to help the overnight nursing shift remember to pay detailed attention to
each patient, at least for a few moments. If their instructions were "stop at
each door and listen for the patient breathing" those nurses might well miss
important changes.

Hospital care these days is not only about the towering figure of the heroic
superhuman doctor, Harvard Medical School lore to the contrary
notwithstanding. It's about all the folks who look after patients, from the
community primary care doctor to the RN, to the chaplain, to the "hospitalist"
physician, to the person who cleans up, to the person who maintains all the
electronic gear. The challenge is getting all these people to cooperate with
the patient and for the patient's benefit.

The superhuman healer approach to medicine demands superhuman people to be
doctors. They aren't, any more than the rest of us are. They have to sleep,
and to eat, and to see many patients. So, a good hospital needs to be
organized like a good company: where each person's skills and passion
complement the others, and gets an extraordinary result from a collection of
ordinary people. The buzzword for that is "synergy." Good discipline--good and
predictable process--is part of synergy.

And, at the end of all that excellent care on our behalf, each and every one
of us will become a corpse. A nineteen-year-old with a broken leg can be
cured. A 90-year-old with cancer and pneumonia, not so much. It doesn't matter
how towering a figure the doctor is, or how kind the nurse is.

A radical move in medicine would be to come to terms with death as a natural
part of life rather than as a failure of the system.

~~~
paulcole
>Why do the overnight shift of nurses take vital signs every four hours? So
they catch rapid unexpected changes in patient conditions more quickly.

The first sentence of the second paragraph of the article you seemed to have
avoided reading says:

“Checking things like temperature, blood pressure and respiratory rate every
four hours on hospitalized patients has been the standard of care since the
1890s, yet scant data indicates that it helps.”

~~~
mikecsh
> yet scant data indicates that it helps

But this is not the case. In the UK, these observations are entered into a
proforma by the nursing staff which allows them to calculate a "National Early
Warning Score". Based on the patients score, the nurse __has to __escalate to
an appropriate team and the doctor on the appropriate team __has to __take the
referral.

Not only does this help identify deteriorating patients, but it helps to fight
human factors like "I don't want to call such and such a doctor because they
are always rude on the phone so I'll just leave it and hope it gets better"

In terms of actual data, we have a national body (NICE) that provides
guidelines and recommendations based on appraising the available data and
research. For NEWS scores, see:

For an overview:
[https://www.nice.org.uk/guidance/cg50/chapter/1-Guidance#phy...](https://www.nice.org.uk/guidance/cg50/chapter/1-Guidance#physiological-
observations-in-acute-hospital-settings)

For the full report and evidence used to compile the guideline:
[https://www.nice.org.uk/guidance/cg50/evidence/full-
guidelin...](https://www.nice.org.uk/guidance/cg50/evidence/full-guideline-
pdf-195219037)

------
bawana
Hospitals should post prices of their procedures in the lobby. A surgeon gets
$500 to repair a hernia and the hospital pulls in $5k for the ancillary
services. The surgeon has to see the patient,make the diagnosis, provide the
treatment, provide the aftercare and be the 'face'. The hospital-insurance
complex has managed to create this fantasy world with complicated rules and
somehow have sequestered themselves from the free market. They set their own
prices and by virtue of being of local monopolies thwart the ability of the
individual to choose. Hospitals have become like cable companies.

~~~
savanaly
It's not like hospitals are wildly profitable to run though? I think the
inflated costs are due to the little understood phenomenon of "cost disease"
rather than owners of hospitals extracting outrageous rent for themselves as I
think you are implying.

~~~
adventured
You're correct about the spread of cost disease, it has essentially reached
every corner of US healthcare. The part that hospitals are particularly guilty
of, is unnecessary admin expense inflation. The US education system has seen
an almost identical problem. Building buildings that aren't needed, hiring 10x
the admin staff that the system had 30 or 40 years ago, etc. It's the system
rewarding itself, bureaucrats hiring more bureaucrats, playing lords as they
go on building sprees that aren't needed. There are very few readily available
levers in the US healthcare system, that can be used to properly pull back
against such cost spirals and spending behavior.

~~~
gregw134
Last time I was out the hospital they had robots running around to just to
pick up towels. Robots are great and all, but that's a symptom of not managing
costs.

~~~
bawana
thank you all for your input. The hospital you linked in Asia. It seems that
SE Asia has leapfrogged us in the concept of capitalism and the free market.
Indeed, it is a 'free-for-all' in terms of lack of regulation, but certainly
it is not 'free care for all'. Here in the US, The medical-industrial complex
has seen how other industrial complexes deal with our government and are
trying to mimic that gravy train. I still remember articles about the $500
hammer, and $2000 toilet the Navy had purchased in the thousands.

We need to get back to our roots. A free market where people can buy what they
want when they want it. Health care insurance is an oxymoron. Everyone gets
sick. There is no probability of someone NOT using the system. The minute you
try to amortize the costs over time or large populations to provide services,
there is infinite demand.

Insurance would make sense for events that are RARE. House fires, automobile
accidents, gun accidents, etc. (BTW, why isnt gun insurance mandatory? That
way everyone could be happy- you could still buy a gun as long as you paid
your $5000 premium. The insurance companies could make more money, there would
more 'gun control', and the money could go to the emergency rooms that take
care of shooting victims. But OH NO! Hospitals would figure out a way to spend
that money too and it would never be enough!! Maybe the gun insurance premiums
could be given to the victims !)

Anyway, there is no easy fix until we start to force our politicians to GET
OFF THEIR ASSES. It particularly annoys me that they offer 'thoughts and
prayers' after each mass murder and do nothing else. They should be in Florida
digging the graves. Representing their constituents properly.

------
tensor_rank_0
>Despite his reputation, Dr. Lown was treated like just another widget on the
hospital’s conveyor belt. “Each day, one person on the medical team would say
one thing in the morning, and by the afternoon the plan had changed,” he later
told me. “I always was the last to know what exactly was going on, and my
opinion hardly mattered.”

yes, this is what it is like to be a patient at a hospital these days. And
good luck if the patient wants to speak to a physician. and don't ever go to a
teaching hospital if you have the choice. some intern will have the brilliant
idea to adjust every medication you are taking.

~~~
Spooky23
You have to bring an advocate who is able to sniff out bullshit, establish
rapport with senior nursing staff and be a pushy asshole when necessary.

A modern hospital is a zero trust environment.

------
motohagiography
The health sector is the Afghanistan of the tech business. It's entire history
is of empires arriving to solve its problems, and after a decade and massive
losses, they leave, mystified at how something so contained could be so
intractable. The only people who survive there are the ones who don't try to
change it.

When you can send your diagnostic images to get a consult from 2 clinics in
India and an expert system for less than the price of a three block ambulance
trip in the US, prices for domestic care will come down.

~~~
HillaryBriss
not sure where your confidence comes from, though i hope you are correct. i
don't see it yet though.

in the US healthcare market the payment model will have to change before
Indian healthcare market prices have an impact.

in other words, US legislation that takes money away from the current system
of providers would need to be passed. (i mean, why doesn't the US
medicare/medicaid system take advantage of the lower costs you're describing
by flying US patients to hospitals in other countries for major, expensive
procedures and other treatments? they could save a lot of money, but US law
does not currently allow payment to providers all over the world.)

US hospitals, doctors, pharma, etc have created a closed system wherein they
are the only service and product providers. i think they like that aspect of
the current system. they've built themselves a moat and globalization cannot
enter.

~~~
motohagiography
Tell me more of your impregnable fortresses and unsinkable ships.

I agree that the barriers you mention are real, but those are in the domain or
class of solvable problems. Apps like Figure1 are a good example of how
doctors are moving around this.

To borrow from Nial Ferguson's new book, the big CMS/EHR players (nightingale
and another one here) control the integration points and hierarchical
relationships, but I think they are vulnerable to networks.

------
dr_
>The medical team was concerned that because Dr. Lown was having trouble
swallowing, he was at risk for recurrent pneumonias. So we restricted his diet
to purées. Soon the speech therapist recommended that we forbid him to ingest
anything by mouth. Then the conversation spiraled into ideas for alternative
feeding methods — a temporary tube through the nose followed, perhaps, by a
feeding tube in the stomach.

Maybe not the main point of this article, but there are numerous occasions
where I’ve encountered just this. Allied health professionals, all of whom are
very well intentioned, making recommendations that physicians readily follow
without taking into consideration the needs or desires of the patient and
family. If as a physician you are being advised to declare a patient NPO or to
send them off to a skilled nursing facility instead of home - please remember
that this is just a recommendation and that it’s your job to look at the
patient as a whole, including their general medical condition, likelihood of
their family supporting them, etc. before following through.

------
sampo
Going to a doctor in America, for whatever reason, the first thing that
happens is that a nurse comes and takes your blood pressure. I wonder why?
Never happened to me in Europe.

~~~
Thriptic
Two reasons. First, it's a clinical quality measure that needs to be collected
by law. The government mandates that you collect certain data about X% of
patients you are in contact with and transmit that data to relevant parties or
else you will be penalized financially by Medicare.

Also, BP, weight, and temperature are important diagnostic indicators

------
nugget
For better or for worse, everything in America is a business -- healthcare is
no exception. Helpful to keep in mind when you think about potential
improvements or solutions.

~~~
lkrubner
" _everything in America is a business_ "

If by "business" you mean a public/private hybrid in which profits are
privatized while losses are socialized, then you are correct, in so far as
health care goes. And that seems to be the model that is now being adopted in
more and more areas of economic activity.

~~~
wyager
I don’t like that wording because it implies that hospitals somehow benefit
from government involvement; in reality, it just sucks for everyone. In
general, I agree - very few medical institutions in the US actually get to be
private.

I will say that truly private medicine is, in my reasonably broad experience,
excellent. I use a private subscription-only medical service in the US which
is excellent (and procedures are generally cheaper than they would be in a
public hospital, whether I’m paying with insurance or out of pocket), and my
experiences with private medicine in SE Asia and Mexico have been excellent
(and affordable) as well (to a greater degree than can be explained by labor
cost differences).

~~~
jdminhbg
> it implies that hospitals somehow benefit from government involvement

But they very clearly do. A huge proportion of their income comes from
government sources (Medicare/Medicaid/VA), they are subsidized by tax
exemption for health spending, and government grants them the power to deny
competitive entrants into their markets via "certificates of need."

~~~
chimeracoder
> But they very clearly do. A huge proportion of their income comes from
> government sources (Medicare/Medicaid/VA)

Hospitals _lose_ money on Medicare and Medicaid patients on the margin. They
have to overcharge private insurers to make up the difference.

It's so bad that Medicare has not one but _multiple_ programs to compensate
hospitals that don't see enough private patients to make up the difference,
because otherwise they wouldn't be able to sustain themselves on Medicare
reimbursement rates.

I don't know why you're even mentioning the VA; it's not relevant here at all.

~~~
jdminhbg
Hospitals are obviously capable of accounting such that Medicare patients are
money-losers on the margin, but they keep taking them for some reason.

> I don't know why you're even mentioning the VA; it's not relevant here at
> all.

Normal non-VA hospitals accept VA patients and are reimbursed for them.

~~~
chimeracoder
> Hospitals are obviously capable of accounting such that Medicare patients
> are money-losers on the margin, but they keep taking them for some reason.

You seem to be under the impression that there's some deception going on here.
There's not, and it's pretty plainly evident. Medicare's reimbursement rates
are below COGS. Hospitals control neither of those two things (Medicare sets
rates by fiat, and if hospitals could lower COGS by paying vendors less, they
would).

As for why they keep taking them - they oftentimes have no choice, legally.
Though, incidentally, in recent years, we've started to see hospitals find
more creative ways to close their doors to Medicare patients for this exact
reason.

> Normal non-VA hospitals accept VA patients and are reimbursed for them.

The number of VA patients hospitals see is negligible. The amount of revenue
they receive, proportional to the number of patients they see, is even less.

------
zoom6628
Stories like this are not uncommon in so-called developed countries. Makes you
realise why medical tourism industry does so well. From my own experience i
would prefer to return to Guangzhou or Shanghai for procedures rather than
anywhere else. Not really that much cheaper but at least i can determine up
front the size of the bill. Added to that is that in spite of factory-scale
medical care in China(remember there are basically no private medical
practices - all doctors are linked with hospitals), they are actual (in my
personal experience) quite caring and dont charge unnecessarily.

But as with all things YMMV.

------
aaavl2821
Healthcare in the US has left the era of the small business and is entering
the era of the nameless corporation. What wal-mart did to all of the mom-and-
pop shops is happening to healthcare. Except that instead of lowering prices,
it is raising them

Physicians have gone from small business owners to rank and file employees of
large corporations. The burnout that is increasingly common among physicians
is not unlike that of american office workers in the 1990s.

I'd love for the next stage of the evolution of healthcare to see physicians
as customer focused, tech savvy entrepreneurs

------
abecedarius
> To restore balance between the art and the science of medicine, we should
> ... make room for training in communication, interpersonal dynamics and
> leadership.

How would this help solve the problem the article started with, that patients
don't heal because they're deprived of sleep by being woken up every 4 hours?
It's a problem everyone knows about (I saw complaints about it online years
ago) -- so it's not directly a communications problem. Leadership I can see:
it seems needed to dig the system out of an inadequate equilibrium
([https://equilibriabook.com/molochs-
toolbox/](https://equilibriabook.com/molochs-toolbox/)) but that's pretty
different from college courses in leadership.

~~~
ianai
Proper communication includes proper action respecting that communication.

------
ardualabs
As a survivor of stage IV cancer, I can say my experience strongly mirrors
that. I would go further to say that the assembly/widget mentality in a health
care setting made it difficult for some of the staff to see me as a human.
Abuse or care-full neglect (is that a thing? working on the words) is, in my
experience at least, common.

It's not to say I don't appreciate being alive, but we can do better for those
suffering.

------
jhanschoo
It is a nice coincidence that a video by an educational YouTube channel
Kurzgesagt discusses homeopathy and why it still remains popular—hypothesizing
that one reason may be that their practicioners pay good attention and
affection to their patients.
[https://m.youtube.com/watch?v=8HslUzw35mc](https://m.youtube.com/watch?v=8HslUzw35mc)

------
JasonFruit
This article and the comments here combine to illustrate for me the difficulty
of making healthcare work in all the different ways it has to. I read the
article, and I think, "Yeah! That's the kind of healthcare I want!" I read the
comments with contrary opinions, and I think, "Those are great points — these
counter-intuitive practices make sense when you need healthcare to scale." I
talk to my wife, a physician, and I hear about what results in the rare cases
when these protocols and consultations don't happen, and I think it's a wonder
that hospitals function at all.

I think it's not a matter of finding _the_ solution to the problem, but a
maximization problem, where we have:

\- patients who need to be cared for as human beings and allowed to make their
own informed decisions, but who are generally not experts in medicine

\- physicians who have more patients than they can keep in their minds at
once, and who are reliant on nurses and computerized systems to keep patients
breathing and not get sued, but who are also skilled, highly-educated
professionals whose human judgment is frequently superior to any algorithm

\- nurses who are both underpaid and responsible for more than their training
considered

\- hospitals that need to pay the bills, pay salaries, attract new physicians,
etc.

There are so many conflicting aspects of this problem that any simple solution
is probably unrealistic.

------
da02
This article might also help too: "Life in Yorkton before Medicare came along"
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1269399/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1269399/)

------
ageek123
"[W]e should curtail initial coursework in topics like genetics, developmental
biology and biochemistry, making room for training in communication,
interpersonal dynamics and leadership. Such skills would [...] strengthen our
ability to advocate for health care as a human right and begin to rectify the
broken economics and perverse incentives of the system."

In other words, train doctors to be social justice activists rather than
scientists? No thanks.

------
bob_theslob646
Article does not address the problem why the doctors' behave this way:
insurance companies.

Unfortunately, treating makes more money than curing and the United States is
scared to death of what shall they do with all that free time if they actually
do cure, while other countries do not work themselves to death because they do
not have an artificially controlled supply of Doctors...

~~~
robbiep
This is an absurd and oft-repeated claim that taps into variations of the
conspiracy thinking around 'doctors keeping the cure for cancer (or insert
other condition here) secret' because powerful lobby groups insist that there
is more money to be made in 'treating' than 'curing'. It is patently untrue.

Firstly, it assumes that neither doctors, nor the scientists and researchers
working in the companies and universities that drive medical progress forward,
have an ounce of self-respect for either themselves, their family members or
members of the community - because if true, either family members and
themselves would never get cancer or other chronic diseases that we 'treat',
or if they are somehow as vulnerable as the rest of the population to these
conditions, that maybe there is a secret stash of 'cure' somewhere that they
allow out to the people in the know. The conspiracy goes deep...

Secondly, it throws out the window all the evidence around what we can
actually cure and what health policy seeks to do. We have an entire field of
medicine called preventative medicine that aims to stop conditions before they
happen, by lobbying governments to ie. Ban or decrease rates of Smoking and
alcoholism, to provide safe needle exchange so IV Drug Users don't get
bloodborne diseases, to improve exercise rates, to provide vaccination
programs - all of which stop disease from happening. The fact of modern life
in a western country is that most of the burden of disease is related to
lifestyle factors or age related - Osteoarthritis (Age and Obesity), Cancers
(Lifestyle risks and age), Diabetes (Diet, exercise, genetics) Cardiovascular
disease (Exercise, Age, Lifestyle risks, diet).

It also ignores the tremendous advances that are _still_ occuring. When I was
in my final year of Medical school, 5 years ago, Metastatic Melanoma was a
condition with an average survival of 6 months. It is now (thanks to some
incredible, and incredibly expensive drugs - don't get into a debate about
cost here, I live and practice in Australia and the cost for a patient is
capped at $46.60 per year as it is on the PBS) more of a chronic disease with
average survival in the 4-5 year range. Incredible, and this progress occured
in 5 years. Similarly, Hepatitis C, a condition that in it's chronic form
invariably results in liver cirrhosis and failure, can now be cured - this was
unthinkable 5 years ago, and is now a fact, with a 12 week course of medicine.

Please inform yourself and don't just trumpet that which you hear on the
internet. Your ignorance is not as valid as my knowledge and to assume that in
your version of this myth that insurance companies (but in the more common
version of this myth, Doctors, Pharmaceutical Companies etc) are primarially
interested in keeping the population teetering on the edge to milk them dry is
disingenuous.

~~~
bob_theslob646
> Your ignorance is not as valid as my knowledge and to assume that in your
> version of this myth that insurance companies (but in the more common
> version of this myth, Doctors, Pharmaceutical Companies etc) are primarially
> interested in keeping the population teetering on the edge to milk them dry
> is disingenuous. You really know how to talk to people haha. It seems like
> you were triggered by something I said even though it did not apply to
> you.Take a breath. It is okay for other people to have different viewpoints
> on the medical industry in the United States.

>This is an absurd and oft-repeated claim that taps into variations of the
conspiracy thinking around 'doctors keeping the cure for cancer (or insert
other condition here) secret' because powerful lobby groups insist that there
is more money to be made in 'treating' than 'curing'. It is patently untrue.

Where are your sources? I never stated that they are hiding the cure for
cancer? It is a fact that treating vs curing is a business model in the United
States. The U.S outspends everyone yet gets them same results
>[https://www.npr.org/sections/goatsandsoda/2017/04/20/5247741...](https://www.npr.org/sections/goatsandsoda/2017/04/20/524774195/what-
country-spends-the-most-and-least-on-health-care-per-person)

It is also true that privacy data laws and business models are impeding the
impact of disruption in healthcare where technology is disrupting every other
field.
([https://www.bloomberg.com/news/articles/2017-11-28/alphabet-...](https://www.bloomberg.com/news/articles/2017-11-28/alphabet-
s-deepmind-is-trying-to-transform-health-care-but-should-an-ai-company-have-
your-health-records))

I never mentioned anything about Australia, I was talking about the United
States. I cannot speak for Australia.

>Please inform yourself and don't just trumpet that which you hear on the
internet.

The fact that medical records are not electronic being a standard is
laughable. I cannot speak for anyone else but the United States. HIPA laws are
one of the reasons which makes it harder for researchers and doctors to
actually get data they need to develop cures because of the need an individual
signature for everyone.

Regarding Supply of Doctors >In the United States, the supply of doctors is
tightly controlled by the number of medical school slots, and more
importantly, the number of medical residencies. Those are both set by the
Accreditation Council for Graduate Medical Education, a body dominated by
physicians’ organizations. The United States, unlike other countries, requires
physicians to complete a U.S. residency program to practice. (Since 2011,
graduates of Canadian programs have also been allowed to practice in the U.S.,
although there are still substantial obstacles.) This means that U.S. doctors
get to legally limit their competition. As a result, U.S. doctors receive
higher pay, and like anyone in a position to exploit a cartel, they also get
patients to buy services (i.e., from specialists) that they don’t really need.
([https://www.politico.com/agenda/story/2017/10/25/doctors-
sal...](https://www.politico.com/agenda/story/2017/10/25/doctors-salaries-pay-
disparities-000557))

Limits on the supply of doctors a conspiracy? >[https://mises.org/library/how-
government-helped-create-comin...](https://mises.org/library/how-government-
helped-create-coming-doctor-shortage)
>[https://skeptics.stackexchange.com/questions/4561/does-
the-a...](https://skeptics.stackexchange.com/questions/4561/does-the-ama-
limit-the-number-of-doctors-to-increase-current-doctors-salaries)
>[https://www.quora.com/Who-or-what-controls-the-number-of-
med...](https://www.quora.com/Who-or-what-controls-the-number-of-medical-
doctors-in-the-U-S)

It is also a fact that insurance companies are the most powerful lobby in the
United States. >[https://www.cbsnews.com/news/ex-dea-agent-opioid-crisis-
fuel...](https://www.cbsnews.com/news/ex-dea-agent-opioid-crisis-fueled-by-
drug-industry-and-congress/)

Business Model Point >Imagine a portable, low-intensity X-ray machine that can
be wheeled between offices on a small cart. It creates images of such clarity
that pediatricians, internists, and nurses can detect cracks in bones or lumps
in tissue in their offices, not in a hospital. It works through a patented
“nanocrystal” process, which uses night-vision technology borrowed from the
military. At 10% of the cost of a conventional X-ray machine, it could save
patients, their employers, and insurance companies hundreds of thousands of
dollars every year. Great innovation, right? Guess again. When the
entrepreneur who developed the machine tried to license the technology to
established health care companies, he couldn’t even get his foot in the door.
Large-scale X-ray equipment suppliers wanted no part of it. Why? Because it
threatened their business models. ([https://hbr.org/2000/09/will-disruptive-
innovations-cure-hea...](https://hbr.org/2000/09/will-disruptive-innovations-
cure-health-care))

~~~
robbiep
> The fact that medical records are not electronic being a standard is
> laughable. I cannot speak for anyone else but the United States. HIPA laws
> are one of the reasons which makes it harder for researchers and doctors to
> actually get data they need to develop cures because of the need an
> individual signature for everyone.

In the US it is a standard that Medical Records are digitised. Unfortunately
the existing eMRs are so awful that they decrease efficiency, so much so that
many american clinics are removing them - [0, 1, 2]. If you think that the
limiting factor on advances in medical research are access to digital records,
you are severely misguided.

We have the same control on medical school spots in Australia. We train 1 per
6,285 people per year. You train 1 per 16,150 (roughly). However you also have
Nurse Practitioners and a range of other allied health professionals and are a
huge importer of overseas Doctors. It's not an ideal solution for the country.
In Australia the medical colleges can limit training positions and this cartel
behaviour has been the focus of the ACCC a number of times. On the other hand,
How can you ensure that people are appropriately trained in the field they are
representing, and going to be a net positive to patient safety? I have some
ideas that I will be trying if I get to Series B.

I can't speak to your inventor of the X-Ray machine but would suggest that if
in the last 18 years he has still been unable to get a market for it, or to
launch it himself, than probably the technology has other problems than having
a distributor. Disruptive technologies always find a way.

Let's be very clear: there are a lot of problems with healthcare, particularly
in the United States. One of the biggest problems worldwide is that healthcare
is a demand-inelastic good. When someone needs it, they will pay whatever they
can to get it. In my opinion the US model is so completely fucked that the
only way I see it being fixed is by transitioning to a post-scarcity economy.
An illustrative example: When I was undergoing my medical school elective in
Boston in 2013, which under Romney introduced State-wide access to insurance,
I observed people accessing their care inefficiently. For example, Tram
Drivers coming to Beth Israel Deaconess to have their Lipoma operated on by
the Professor of Plastic Surgery at Harvard, because they had insurance.
Normally this patient would have presented to the County Hospital, which in
the US is the most efficient provider of care, but because they were able to
access insurance, they wanted gold-plated healthcare. This is an example of
'universal care' twisting the market forces even more, as the most efficient
providers of care are put under more pressure.

[0] [https://www.fiercehealthcare.com/it/study-docs-spend-more-
ti...](https://www.fiercehealthcare.com/it/study-docs-spend-more-time-
computers-than-patients) [1]
[https://www.fiercehealthcare.com/practices/unhappy-ehr-
one-p...](https://www.fiercehealthcare.com/practices/unhappy-ehr-one-practice-
ditched-it-and-went-back-to-paper-records) [2]
[https://twitter.com/gphymel/status/952559168975769600](https://twitter.com/gphymel/status/952559168975769600)

------
Froyoh
Imagine if something like "Chinese Citizens, Revolt" appeared in the
headlines.

------
rdiddly
So once again, and as usual, the missing ingredient ends up being human
leadership, not technology.

------
muninn_
> implying doctor’s don’t want 6-figure salaries

The manufacturing operations-ization of hospitals is both good and bad. Good
because that means we have standard care (as desired by regulators and single-
payer advocates) but bad because doctors lose the ability to perform
customized care solutions.

I’m in favor of single-payer but we have to guard against turning healthcare
into a manufacturing operation while also bouncing out bad actors and poo-
quality physicians.

~~~
aaavl2821
The issue with hospitals controlling healthcare is that they are the group
with the least incentive to lower the cost of care

Hospitals account for the largest chunk of healthcare spend (30%). Hospitals
make money by increasing inpatient admissions, particularly for profitable
surgeries. The standardization of care in hospitals is intended to maximize
profit under the constraints of various regulations around readmissions
penalties, reimbursement limited length of stay, etc. If you look at the
financials of public hospital companies like HCA and Community Health and
Tenet, their major metrics are growth in admissions and surgeries. Even non
profit hospitals are driven by this

The expansion of hospitals into owning tons of formerly independent specialist
and generalist physicians is scary. Once in a hospital's system, these
physicians act as loss leaders funneling patients into the hospitals profit
center

Having hospitals in charge of the healthcare system is like having a fox in
charge of the proverbial chicken coop

