The Heroism of Incremental Care | Hacker News Reader

The Heroism of Incremental Care

newyorker.com

148 pointsmhb65 comments

There's a great book by Paul Dutton of Northern Arizona University called "Differential Diagnoses" comparing US and French healthcare in depth that talks about the ratio of GP's to specialists and its direct correlation with positive health outcomes, among other things. If you're interested in the field, worth a read, here's a good introductory portion:

http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?ar...

That looks like a very interesting read, skimming through it, it says that France spends around 10% of GDP on healthcare while the US spends 15%, but yet France gets a better health coverage, and a better life expectancy.

One of the first tables compares number and there's the most striking one : Obesity in France 9.4%, in the US it's 30.6%.

Could it be one reason that, with less obesity, French people are more healthy to start with, so they require less care? Does the book address this?

In other words, what if:

             Life expectancy with 0 healthcare , Life expectancy with healthcare
    France                 50 (made up)        ,     79.4
    USA                    35 (made up)        ,     77.5

That's weird data. By every measure I've seen France and the USA have almost identical obesity. https://www.google.com/search?ie=UTF-8&client=ms-android-spr...

France and the USA use a different threshold for obesity, so I'm not sure the comparison is straightforward. Someone who is borderline obese in France would be considered far from obese in the US. I can't whip up a source for this at the moment, but I'm speaking from personal experience (born in France, moved to the US when I was 9).

The 9.4% was data from 2002.

The french wikipedia page says a 2012 study shows that while 32,3 % are (25 ≤ BMI < 30 kg/m2), only 15 % are(BMI≥ 30 kg/m2).

If from 2012 to 2014 it jumped from 15 to 23.9 there would be a problem. I'm unable to track down where that 23.9% came from on the English wikpedia, but it looks like those WHO report anything above 25 BMI, whereas the other data is above 30 BMI

EDIT: Wikipedia is simply wrong, if you look at

http://apps.who.int/bmi/index.jsp and search for BMI adults % obese (>=30.0), then France most recent data is 16.9%, (USA is 33.9)

the Wikipedia article claims : Based on World Health Organisation (WHO) data published in 2014, 23.9% of French adults (age 18+) were clinically obese with a body mass index (BMI) of 30 or greater

EDIT2: Found an interactive map http://gamapserver.who.int/gho/interactive_charts/ncd/risk_f...

where it claims 22.0 for 2014 (still not 23.9), but it also claims 18.2% for 2005, but it says 12.4% for 2006 on the table, there's a different in reporting between the two. The interactive maps does an "age standardize estimate" whatever this means :)

Walking around France and walking around the US, that's not remotely what I see.

Walk around in France and you will notice the difference. You rarely see obese people.

Or might it also be that some of France's healthcare, being socialized, has an impact on obesity rates?

It's a combination of factors, of which Obesity is one of them. Part of routine healthcare is to tackle all these smaller issues at the same time before they balloon into larger problems. So it is conceivable that the lower rates of Obesity are a product of the healthcare practice in that country.

That's the theory. And it's certainly something that fits well with the idea that we're all better off with annual physicals and other types of preventative healthcare. From what I read, the evidence is pretty mixed. Sure, have your physical and do other preventative care, but the results are statistically at the margins from what I can tell. (which is, of course, relevant if you're at that margin.)

Other than some corner cases, the idea that there's a lot of spending on issues that could have been caught sooner is a non-starter. We're already doing most of it and it is reasonably cheap and not all that contentious: Vaccinations, pre-natal vitamins for pregnant mothers, etc. Most of the rest turns into the problem with false positives (and the treatment that entails) outweighing actual early detection.

> We're already doing most of it

Population health data suggests otherwise. There are a lot of things that we (readers of HN) do take for granted, but we represent a very biased (dare I say privileged?) cross-section of the population. I live in Altanta but if I look at data in my state but outside of the city, a very different story is taking place. There is a strong correlation with lack of preventative health and certain comorbilities.

Disclaimer: I used to work in population health.

A more plausible model is that doctors help sick people a lot, and are totally useless to healthy people.

From that point of view, consider the American system of providing great health care to people with stable lives and good jobs, and sparing no expense on attempts to save people who are beyond help, while denying treatment to the unemployed and to people with "pre-existing", i.e. long term, medical conditions. It's almost like they're trying to exert the most possible effort for the least possible effect; like someone has memorised the triage chapter of a first-aid manual, then set out to do the exact opposite.

Oh wait, they make lots of money that way, so it's all good.

> Could it be one reason that, with less obesity, French people are more healthy to start with, so they require less care?

French people eat fine cheese, and other fine foods. Americans are fed imitation cheese, and told that it's better for them because it doesn't have 'bad fat'.

The experts call this a "paradox" [1]. I think we're being swindled.

[1] https://en.wikipedia.org/wiki/French_paradox

I seriously doubt it has to do with the type of cheese people eat.

One of the biggest difference is walking. Most cities I've visited in Europe are easily walkable. You can more or less get what you need. People in small and big cities seem to walk much much more.

In Atlanta, this simply isn't possible for most people. We've built out more than up and inhibited public transportation but that's another sorry. Savannah is a much more walkable city similar to places in Europe. I wonder if it's the difference beetween old and new cities.

It might be interesting to do an analysis but it's not obvious that public transportation is an overriding factor.

If I look at obesity by US city [1] it's true that a lot of the top southern cities don't have great public transportation AFAIK, but the greater NYC metro area is relatively high up on the list. And Las Vegas is about tied with Boston and San Francisco.

I suspect eating habits (the US South is notoriously bad in a lot of ways) and poverty have more to do with it than the state of the local public transit system.

[1] https://wallethub.com/edu/fattest-cities-in-america/10532/

I don't like the table but the inforgraph is great. What I really like is % of people overweight.

Here's an example using some CDC data and based on metro areas [1]. Atlantic City is the worst and Boston is 1% more than Atlanta. It doesn't really support my walkability claim.

http://www.governing.com/gov-data/obesity-rates-by-state-met...

I think it's the quality of food. Stay in France for a few weeks and eat French bread every morning and you will be fine. Eat American bread and you will gain weight. Same for milk. I can drink German milk without problems but American milk gives me stomach problems.

you do know whether you gain or lose weight has to do with calories consumed? 100 calories of american bread is no different weight gain wise versus 100 calories of french bread.

Does human body ingest the energy from food the same way calorimeters do when measuring calorie counts?

Calorie counts are typically adjusted; manufacturers don't typically just toss a bag of, say, Ho-Hos in a bomb calorimeter and use the raw numbers from Igor or whatever recording program happens to be around.

The usual macronutrient values (9kcal/g fat, 5 kcal/g EtOH, 4kcal/g carbs and protein) are surprisingly decently calibrated for metabolic inefficiencies.

They do not, however, take into account hormonal responses, which are probably quite a bit more important than once assumed. So there's that.

Actually, that's a myth.[1] It isn't that simple. For example, a calorie of protein is harder to digest, and gets converted to energy less efficiently, than a calorie of carbohydrate.

[1] https://en.wikipedia.org/wiki/A_calorie_is_a_calorie

American milk is just fine.

I suspect your gut bacteria are simply unused to the new environment (possibly including the milk). The same kind of thing happens to most people when they travel overseas. As a child I spent most summers in Mexico. Within the first few weeks I would have a bout of serious diarrhea and vomiting, literally every year. But native Mexicans who ate the same things didn’t have the same problem, being well adapted.

Anyway, what specific type of milk are we talking about? Full fat homogenized milk? Skim milk? Unhomogenized milk?

In the German case you might also be talking about UHT milk, which is common in many countries (not sure about Germany) but vanishingly rare in the USA? I think that stuff is awful, YMMV.

I really doubt that. Surely it can't be uncorrelated with America's pervasive habits of all-day-TV-watching, all-day-computer-use, multi-thousand calorie meals, junk foods, fast foods, car-commuting, and sedentarism?

Well, in France, except for car-commuting, we're going fast gain all those habits.

I didn't say that food quality is the only factor but in my view it plays a role. And I believe a lot of American regular food is very low quality. The things you have listed play a role too.

> Same for milk. I can drink German milk without problems but American milk gives me stomach problems.

There are many different kinds of 'American milk'. A primary difference is what the different farmers feed their cows.

A few years ago I suffered through the History Channel's Modern Marvels episode about cotton. There's a bit towards the about how cottonseed meal (a waste product of the cotton industry) is commonly used as feed for the dairy industry.

Someone commented about how they taste a difference for the week after farmers switch their cows from summer rations to silage -- it takes a week for the cows' bacteria to adjust. I should find that comment & favorite it... Ah, here:

  You can always tell when the cows switch 
  between grass and silage in the spring 
  and fall. Milk tastes like garbage for a 
  week or two until they get sorted out.

- https://news.ycombinator.com/item?id=12893287

The French paradox (and similar observations for the Japanese) is most easily explained by the fact that they eat smaller portions than the Americans. Anyone traveling from Asia or Europe to the US is easily astounded by the large portions of food the typical US denizen eats.

For what it's worth, the story in the post describes a person being helped by specialists who treated solely the condition that the subject had, and nothing else. Not exactly a ringing endorsement of GP's, none of whom were able to help the subject.

In general, I think the linking of good with heroism is a net negative for society. Articles like these are a reminder of how much space there is to redefine heroism, or abandon it altogether, and how important it is to remember the good that is done that is not dramatic, individual, and quick.

This is a bigger issue in the whole society. People who do a good, steady, useful job without much fuzz don't get appreciated. It's like the focus on "job creators" but they also need people who buy their stuff and work for them. A society where everybody needs to be a "hero" will go under quickly.

In Australia, the ratio of officers to sailors on ships has changed from:

1960s - DDG ‐ a ratio of 1 officer to 15.65 crew

1980s - FFG ‐ a ratio of 1 officer to 7.5 crew

modern - Armidale - a ratio of 1 officer to 2.5 crew

I've heard that other nation's services are seeing commensurate changes.

[0]: http://www.defence.gov.au/Whitepaper/docs/036-O'Keefe.pdf

Perhaps due to automation?

Reading through the article I can't help but notice some shortcomings in the analysis. The "similar size" ship dropped from 333 crew to 221 crew. Is this perhaps due to an increase in automation? The article does mention that GPS navigation has eliminated some work for officers, but what about all the tasks that used to be manual but are now mechanized?

Without an analysis of which roles have expanded or been eliminated over time, it's hard to take gross numbers seriously.

(The Armidale is not a comparable ship, it has only 21.)

The US Navy has gone back to having navigators manually calculate positions using sextants as a backup to GPS so I doubt there is any manning savings there. They expect that in any major conflict the GPS satellites could be jammed or destroyed.

http://www.npr.org/2016/02/22/467210492/u-s-navy-brings-back...

That makes a lot of sense. These kind of discussions come up whenever people complain about how crazy military procurement is, when you can get a Raspberry Pi for $10. The military wants to get its job done in worst-case scenarios that most of us have the luxury of not thinking about.

>The "similar size" ship dropped from 333 crew to 221 crew.

The ratio of enlisted to officers on a specific ship class can be misleading because there will always be a certain number of positions on any warship which will require officers: 1 commanding officer, 1 executive officer, 1 chief engineer, 2 or more other department heads, etc. In effect, there is a "floor" on the wardroom size.

For an example going the other direction, U.S. aircraft carriers have a total ship's company of around 3,200, with about 80 of those being officers, for a 40:1 ratio.

JSYK, Nimitz-class carriers have at least 200 officers, which gives a 16:1 ratio, but as far as I know this doesn't include officers from the air wings (which makes sense, since they have less of a "managerial / college graduate" type job. The math surrounding the 40:1 ratio obviously doesn't work out though, because an aircraft carrier is definitely at least 4x bigger and more complex than a DDG, which has around that number of officers.

Source: was on DDG. Looked up Nimitz-class numbers 'cause it seemed low (I know you weren't referring specifically to that type of ship)

Others have mentioned the automation factor, but let me add another one. Those of us outside the military probably equate "officer" to "management", but a more apt comparison might be to "college graduate." Now, how many different ways can we think of that a state-of-the-art surface vessel might need a higher proportion of educated crew vs. maintenance staff who are mostly high-school grads who have received maybe a year or two of ship-specific vocational training?

In most navies the majority of complex maintenance work is performed by senior NCOs (chiefs) and warrant officers, not by commissioned officers. Those chiefs have a lot more than 2 years of vocational training.

Nobody wants to get sorted into Hufflepuff.

You'd be surprised to find out how many people proudly see themselves as Hufflepuff.

Heroism is easy to observe compared to the more mundane yet more impactful day to day work.

My perspective is we need to track better metrics for seeing the latter.

I suffer from severe migraines. My mom does too. I get them at least 3 times a week, and it really knocks me down. This really struck a chord with me. After a couple of paragraphs I couldn't stop reading. Very encouraging.

I'm originally from Italy. Growing up my mom and I tried all sorts of medications available in Italy, but none of them made a real difference. I moved to the US a few years back and I tried a few off the counter headache medications (Acetaminophen + Caffeine + Aspirine) and much to my surprised it really helped. I'm not sure why, but these are not available in europe. I started bringing them back home to my mom. It helps with the really tough migraines, instead of being in my room, lights off, puking, I can walk around and even do some work.

Paracetamol, aspirine and caffeine are definitely available over the counter in Europe!

Are they marketed as a single pill?

(eg https://www.excedrin.com/products/extra-strength/ )

Paracetamol and caffeine is a common combination in Europe too. I wouldn't be inclined to move countries or even to bring home medication from abroad just so I could take my medication as a single pill instead of two.

Of course moving for such generic drugs would be a strange thing, but lack of the combo pills in Europe might explain why moving to the US prompted the other poster to try the combination.

Yes: http://www.anadin.co.uk/our-products/anadin-extra-anadin-ext...

According to Wikipedia, Aspirin is a trade name for acetylsalicylic acid which is apparently marketed as Ascriptin, Aspegic, Aspidol, and Flectadol in Italy. (Switching language in Wikipedia works great as a translation tool!) Acetaminophen is just paracetamol, apparently common Italian brands are Panadol, Efferalgan and Tachipirina.

It is well known that they can be taken together for better effect, which is hopefully what your doctor would recommend trying before trying any stronger stuff. Caffeine helps contract the blood vessels which is especially helpful during migraines. You should be able to buy combination pills with acetylsalicylic acid which is a tried dosage.

Hope that helps your mother. Migraines aren't fun in the slighest.

I think something went wrong here: Acetaminophen is a trade name for acetylsalicylic acid.

Acetaminophen is the name of a drug not a trade name (trade name in the US is Tylenol), and acetylsalicylic acid is aspirin.

Oh, sorry! Wikipedia turned out a lot of interesting stuff about pain medication and their respective trade names in different countries (who knew there was an article on "Paracetamol trade names"?), but I failed the copy/paste bit.

If you have a minute I would encourage you to fix it. No need to stand by a copy paste error.

As a fellow European migraine sufferer, my go-to drug of choice is Solpadeine (marketing name, OTC available, contains paracetamol (500mg), codeine (8mg) and caffeine (30mg) in a single pill, you normally take two pills at once. Aspirine is ubiquitous as a separate pill, which I rather like, since I personally rarely benefit from it and some people (notably children, but also people with certain hematological, gastrointestinal and kidney problems) need to be more careful with its use. I also sometimes get migraines that don't seem to respond to Solpadeine, but respond well to simple ibuprofen, so between those two I'm mostly covered. YMMV, of course, I just wanted to note that there's definitely a variety of cheap OTC options available in Europe, you may just need to look around for them.

So the guy is told that migraines generally improve as you age. He goes to this specialist, and there's minimal progress for three years, and then later things get better. How do we know any of this is causative?

More generally, do journalists without scientific training need to consult with anyone before declaring who we should be praising for health improvements?

Except that's kinda the point, right? Not that there is a cure, but that seeing someone and having support is... helpful. He didn't argue that she cured his headaches...

How do we distinguish between this and snake oil? Most people remain very grateful to their snake oil salesman.

  More generally, do journalists without scientific 
  training need to consult with anyone before declaring 
  who we should be praising for health improvements?

>Atul Gawande (born November 5, 1965) is an American surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women's Hospital in Boston, Massachusetts. He is a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School. In public health, he is executive director of Ariadne Labs, a joint center for health systems innovation, and chairman of Lifebox, a nonprofit that works on reducing deaths in surgery globally.[2]

>He has written extensively on medicine and public health for The New Yorker and Slate, and is the author of the books Complications, Better, The Checklist Manifesto, and Being Mortal.

https://en.wikipedia.org/wiki/Atul_Gawande

Thanks. Certainly good to know, but I am happy to stand by my criticism, both specific and general.

Another child post has addressed your concerns about the lack of scientific training in journalism, so I won't address it other than to say I was incredibly amused to see this charge levied at Gawande of all people.

But on your point, this is exactly the thing that Gawande was mystified by in this article. He noticed a trend of people with better primary care relationships having better outcomes despite there not being an immediately identifiable causal link.

Knowing his style, Gawande will probably start testing this pretty soon with his Ariadne Labs group and publish into a high impact journal when they identify causal explanations.

Obviously, the modified criticism is that the author knows better than to appeal to this kind of anecdote. It doesn't even play a role in hypothesis generation. He's persuading the reader without teaching them, a mistake that can and is made by the even most accomplished people.

The article is about how primary care physicians help people, and so the author includes a section about a person who thinks that a primary care physician helped him.

This form of the written word is generally known in English as "journalism."

It's a pretty standard journalistic anecdote to focus the narrative of the story. If you want the hard data, read the medical literature. He does refer abstractly to studies, but doesn't provide any links (though again, unfortunately, this is pretty standard).

What a great article. Thanks for sharing!

For this very reason, it bothers me that there is no adult equivalent to Apgar scores

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