How Doctors Die (2011)
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While the karma was a pleasant addition to an otherwise rough day, my intent was simply to pass on a thoughtful article to people I hoped would enjoy it. Perhaps an exponential decay on reposts would prevent abuse?
Abysmal in terms of having good medical outcomes, and being treated respectfully by hospital staff (who tend to be extremely overworked).
Plus, it's degrading to have no control over how much you will be charged, and whether insurance will cover it.
I personally have had one relatively minor medical issue, so the above comes more from experiences with family members in the hospital.
You can't just fix this problem at one level; it's pretty endemic. To start with, I'd love to be able to opt-out of unlikely-to-improve-my-outcome procedures, but even with those wishes doctors are likely to still act because of other pressures.
IF you really don't want CPR, or heroic measures to be taken on you, then get a DO NOT RECUSSITATE' or DNR tattoo on your chest or side, where the defib pads go (just in case) and carry around a copy of your advanced directives in your wallet.
For everything else, you will be conscious and thus have the ability to tell someone 'no'
I'm not interested in the debate as to why this is, just trying to inform people.
- a tattoo may be a strong indication that, some time ago, you had an opinion, but it isn't any kind of indication that you still are of that opinion (including a timestamp in your tattoo is an option, but impractical). A signed statement in a bracelet, on the other hand, can be updated regularly, and even if it is not updated, the fact that you still are wearing it can be seen as confirmation that your opinion hasn't changed.
- regulations.
I also think the system puts too much stress on relatives and the patient when it comes to choices and bureaucracy. Coming from Sweden, just having to choose between 7-8 different insurance plans is headache enough, but to have to choose your doctor, your hospital etc is just too much. I don't want to have to think about it. Americans seem to value choice and being able to shop around much more highly than I do. "Being a good consumer". I can intellectually understand why, but making choices all the time for everything is very taxing and energy consuming, and at some point I just want to be taken care of.
I wouldn't want to do away with the freedom of choice, convenient as it may be to have a default. Besides, once you've chosen all those things you can just stick with them for years on end.
I think it's difficult to imagine how much easier it can be, when you're used to dealing with heavy bureaucracy and insurance companies. I can't explain how much less stressed I was in that system. Then again, I'm even stressed about owning a car with all that entails in terms of check-ups, oil changes, repairs, insurance, expiring licenses, parking etc. Perhaps other people are better at dealing with this crap than I am.
I can imagine pretty well. When things are set up with good insurance coverage, it's hardly any different than what you described, maybe with the exception of preferred networks, but in my city I've never had any doctor fall outside of the preferred network for my insurance anyway. Everything is either covered from the insurance or you get a straightforward bill, and even then you can get an HSA to cover your out-of-pocket expenses with some insurance plans. I've never had to deal with insurance paperwork either, aside from collecting my insurance card from the mail and presenting it at the doctor's office. It can easily be much, much worse though.
We could stand to improve the quality of care for the poor in the US, but there's lots of room to do that in the existing system. For people who have health insurance benefits from their work, I think having a little bit more paperwork is better than waiting for months for surgery.
I live in Denmark currently, and I do find the healthcare system here a lot more sane. I have some choice; for example, I can choose a doctor. On that angle I actually have more choice: I can choose any doctor, and keep him/her, whereas in the U.S. I had to give up the doctor I liked when I was a kid, because my dad's company changed insurance plans and my doctor wasn't covered by the new one. And I don't have a huge bureaucratic mess of insurances and plans and bills to deal with, or worry about how changes in my employment will affect my coverage.
In particular, I don't see how an unregulated system would solve the correlation-across-lifetime problems. A friend of mine was born with a congenital heart defect, a "preexisting condition" since birth. In a free market, it actuarially makes little sense to sell him insurance at any kind of affordable rate, because the uncertain event already happened (he lost a particular lottery at birth). And in a really free market, that would apply to many more people, because rational insurance companies would require genetic screening before allowing coverage (which they currently can't), allowing them to uncover all sorts of less obvious genetic lottery losers. Put differently, the random risk being insured is, in large part, entire lifetimes, which the insurance market cannot handle, particularly if you think individuals should have some kind of choice (vs. some kind of setup where parents have to buy their offspring's lifetime health insurance pre-conception).
Risk pooling across a large corporation's employees is sort of a hack to approximate the needed across-population risk pooling, in the absence of a true socialized risk pool. That hack has let he U.S. hobble through much of the post-WW2 era, since a large percentage of Americans had employment-for-life at large companies, but it's poorly suited to a world of freelancers and job-hopping.
In a free market, whenever it is financially rational to insure someone, it would happen. So, someone probably couldn't get insurace that covers their preexisting condition (which wouldn't be fair to the insurer), but they could get coverage for other things.
And that's the way it should be. Nobody should force someone else to take care of them. People are not owed anything by the universe.
If anything, it strikes me as exceptionally petty and greedy for people who have the misfortune not to need to undergo surgery for a congenital heart disease to be angry about having to pay for their 1/risk chance of it.
I mean, I'm not even arguing anything particularly leftist here: F.A. Hayek made basically this argument.
What's wrong with it is that you're initiating force against me, and making my life manifestly worse.
I mean, as someone who can pay for my own healthcare, this is what I get out of socialized medicine in the US:
(1) Less money to spend on my own healthcare issues (2) Regulations that prevent my doctors from taking care of me in the best possible way (3) Regulations that prevent me from getting the best medicine (4) Anything medical is done in an extremely expensive and wasteful way
That's what you're doing to me, in order to instill your notion of what is "perfectly fair."
The U.S. medical system does not work effectively for the same reasons that the Soviet economy did not.
It's likely only going to keep getting worse with Obamacare.
Am I rare in that I wouldn't mind paying a little more if it'd mean that the country would be legitimately happier/healthier? Whether that be socialized healthcare, single-payer, or any combination.
"...as someone who can pay for my own healthcare..."
What should be done about the people who cannot?
Your profile reveals that you're an Ayn Rand fan; I don't believe Rand provided an answer to this question, other than to posit that harnessing the collective resources of society to address it, in any way, destroys essential freedom. Do you propose that "The Virtue of Selfishness" would be an effective and moral organizing principle for modern society?
Then just do it. It is unfortunate that Obamacare is forcing you to get insurance, but I'm sure you can find a medical plan with a ridiculously high deductible (specifically for people who are wealthy[1]) that will cost you next to nothing[2] and, similar to life insurance, protect you and your assets if something catastrophic happens.
1. I'm making no judgement about whether you are wealthy or just choose to pursue no healthcare.
2. Assuming they are still available next year. http://www.dailyfinance.com/2012/07/13/obamacare-could-kill-...
Which is why healthcare-as-insurance is so perverse.
So, someone probably couldn't get insurace that covers their preexisting condition (which wouldn't be fair to the insurer), but they could get coverage for other things.
Would you perhaps like to volunteer at a hospital some time? Maybe you could explain objectivist principles to parents with children born with 'pre-existing conditions' like spina bifida or taysach's syndrome? Explain that they'll have to deal with a child's debilitating illness without financial aid? Maybe you could read Atlas Shrugged during storytime at a children's cancer ward? You could explain to all of those little 'Takers' how unfair their treatment is to their parent's insurance companies?
Say, "I demand that you practice altruism. I am going to force you to be good, by my definition of good, at the point of a gun."
I would want to help someone with spina bifida, but I would not want to do it because you force me to at gunpoint, while simultaneously creating a system where I myself can't get the healthcare I can actually pay for.
Naked capitalism and healthcare can't work together (and this coming from somebody who strongly believes the government has way too many fingers in way too many pies). The priorities are too far out of whack; but that doesn't mean capitalism shouldn't have a significant role to play.
I do think government regulation (in particular, the tax benefit for companies providing insurance) have made the situation far worse than it needs to be. I talked to an insurance broker after the Obamacare vote. He told me every insurance company in my state was dropping policies for 19 year olds, since they had no say who they covered. Talk about incentivizing good behavior...
In the end, it's an incredibly complex problem that should not be handled in at the Federal level, if for no other reason than there are too many competing needs.
In the end, it's an incredibly complex problem that should not be handled in at the Federal level
Then you are arguing on the wrong side.
You are like the Republican Party. You argue that one thing is practical, but another thing is moral. You cede the moral high ground to the other party. Ironic, since the moral high ground ought to be yours.
How do you "not cover" the result of a procedure that impacted every aspect of my life while covering everything else
If it's that important, why don't you just pay for it? Why do you point a gun at me and force me to pay for your procedure? If our medical system were free, it would be as efficient as the veterinary system, and the cost reduction would be commensurate. So, you see, the moral is the practical.
Naked capitalism and healthcare can't work together
Neither can capitalism and clothing, consumer electronics, toothpaste, food, transportation. I mean, everywhere we have tried capitalism, it has failed. Everywhere we have tried socialization and regulation, it has worked. Why don't we apply the model of the Soviet Union to our healthcare system? That is obviously a pro-healthy choice. </friendly_sarcasm>
I'm not asking "you" to cover my procedure. I'm asking to be allowed into a shared risk pool at any cost due to having had a procedure. Regardless, when you buy into a shared risk pool, guess what, you have to share the risk. You can't say "I'm not sick, so I shouldn't have to pay for sick people." Your option is to buy in or not. As a personal insurance companies have smiled upon, a person has their choice to not buy in or not; for those of us they frown at, we don't have choice to buy in (short of being part of a corporate plan).
And that gets back to where the regulation has caused problems: it's set the entire industry up to have insurance companies be the customers of medical care instead of individuals, leading to all kinds of weird incentives.
For healthy people and relatively rich people, naked capitalism would be fine for healthcare. However, government is (well, should be;) about more than just building roads and bombers. It should be an embodiment of a shared responsibility we have to each other. I put reasonable[1] levels of healthcare in that shared responsibility.
I think a single-payer system, especially in the US, would fail horribly. I think we need more competition and not less. I think, most importantly, the customer for medical care (ie the person who ultimately sees the bill) should be the individual (failure of any price consciousness is another part of what got us into this situation).
But I also think everybody should have access to good quality care at prices they can afford. Today, there is an entire middle-class (not "The Middle-class") that makes too much for medicaid and too little for insurance that are just screwed. Have cancer? Too bad if you want to fight it, because one dose of the medication costs more than you make in a day. That is just inhumane and pure capitalism doesn't care. So the alternative is to quit your job so you can qualify for medicaid, but even that sucks (for bureaucratic, lack of competition, and lack of price sensitivity reasons) and is worse for the patient and our economy both.
So I believe capitalism plays a very important role in this, but I don't think, by itself, it can solve it. My perspective on this shifted a lot after going to work for myself and not being able to provide healthcare for my children after my COBRA ran out.
1. Being kept alive for years on a ventilator is nowhere near reasonable.
"Hospitals Letting Patients Die to Save Money" [0]
"Top doctor's chilling claim: The NHS kills off 130,000 elderly patients every year" [1]
"I wanted to burn down the hospital that let my husband die like a battery hen: MP's heartbreaking account of NHS neglect" [2]
Of course, unlike the wicked free market, the NHS would never put financial considerations ahead of providing care:
"Nine out of 10 NHS Trusts are 'rationing operations' " [3]
And, what wonderful care the NHS provides:
"NHS death rates four times higher than US" [4]
And, it's great how the NHS protects patient data:
"NHS lost track of 1.8m patient records in a year with sensitive information found in public bin and for sale on the internet" [5]
And there is so much more that could be said... [6].
[0] http://www.telegraph.co.uk/health/healthnews/9385674/Hospita...
[1] http://www.dailymail.co.uk/news/article-2161869/Top-doctors-...
[2] http://www.dailymail.co.uk/news/article-2244912/Ann-Clwyd-MP...
[3] http://www.dailymail.co.uk/health/article-2161489/Nine-10-NH...
[4] http://www.dailymail.co.uk/health/article-195277/NHS-death-r...
[5] http://www.dailymail.co.uk/health/article-2224580/NHS-lost-t...
[6] https://www.google.com/search?q=site%3Adailymail.co.uk+NHS
Any health care system that does not aspire to that ideal is by its very nature horrendously biased against the poor.
(By the way, you should be more careful with the articles you choose to believe. For example, the research cited in the one titled "NHS death rates four times higher than US" did not show any such thing - it was a comparison between one UK and one US hospital, on a relatively tiny cohort of 1000 patients, showing a mere 7.5% difference in post-operative death rate. It is ridiculous to extrapolate this data to the entire health care systems of two countries.
This is typical of Daily Mail spin on such research - you'd be much better off not citing that newspaper at all due to its inherent bias against the NHS.)
But the government put some of those edges there in the first place. The biggest reason you have to have insurance in the US now is without it you're going to pay 5x what the insurance company pays for the same procedure. Because they're buying medical care in bulk and you're not.
One way you could deal with that is form a co-op to negotiate prices the same way insurance companies do, but without the insurance part. But you can't, because it's illegal.
Which is a product of government regulation.
Seriously. This is historically factual, and very clearly explained in [1].
[1] http://www.theobjectivestandard.com/issues/2007-winter/moral...
That seems shockingly lazy to me, and possibly dangerous.
On to choices, having many choices do not make people happier, but rather the opposite, there is plenty of research backing this up. Obviously having no ability to choose makes people unhappy as well. I don't think it's laziness realizing and acting on what makes us happy and what doesn't.
Even the simplest visit is an excruciatingly long, bureaucratic, kafkaesque nightmare where your bank account is drained, and the patient has little if any input or control over how they're treated. Hospitals just suck.
That was only the beginning. I received dozens of singleton bills for the co-pay amounts for dozens of separate procedures and tests, which each arrived in my mailbox over a period of seven months. Seven months of surprise bills for various different things they did in a period of a couple of hours. The charges totalled in the thousands. And of course, for each separate charge, I got mail from both the insurance company and the hospital.
The net effect being that I received nothing except doctors saying "we see nothing wrong" and being sent home. But I had to endure finding surprise bills in the mail, and doing the paperwork to pay and file them, randomly for the next seven months. Every one a reminder of how a system took advantage of me while I was down and couldn't answer for myself.
I felt betrayed, like could not one person have the sensitivity and take the time to let me rest somewhere and feed me food and gatorade or something? And no matter how much I wanted to move on from it and get on with my life, I still had to face the bills streaming in like randomized salt rubbed into the wound.
Lesson: Take outstanding care of yourself at all times without fail. Don't have medical problems. If you do, have amazing health insurance.
If you were so lightheaded and confused that you were unable to be your own advocate and get yourself some fluids and food then you probably should have gone to the hospital. If you just let doctors talk you into it and you didn't think it was warranted then you have a problem with your assertion skills.
As a UK citizen I've never had to endure such nonsense around health. I don't know what's weirder, that such a crazy system was allowed to evolve or that people defend it.
Still, I think the post I replied to above warrants criticism. Reading between the lines one might come to the conclusion that he went to the ER because he was out of shape.
I've known two people in the medical field in this position, late stage cancer with young children at home. Both chose to fight with drug cocktails and experimental treatments (such as sipuleucel-T when it was in trials) but stopped short of life debilitating treatments like chemo, although one was lucky enough to get laser based irradiation therapy (I forgot the technical term, but it uses an accelerator to irradiate a tumor without harming surrounding tissue as much as chemo: http://www.protons.com/protons/index.page). I never asked but I'm guessing that they've seen all too often what the family goes through with a loved one dying from terminal cancer and don't think it's worth the pain or suffering, for the family or for them.
It's a hard tradeoff. Maximize the quality time you have, and prepare for your family's future -- especially before the diagnosis comes.
But from where I sit, the dying doctors' point of view, as presented in this article, struck me as irrational.
Axiom: Being dead is better than being alive. Under all circumstances.
I personally believe this axiom, very strongly. I'd rather spit in the eye of death with my last breath than go quietly into the night.
It logically follows, then, that a treatment that has a 1% chance of working is better than doing nothing, if the latter has a 0% chance of working, no matter how extreme the treatment is.
Living longer, even in a state of constant extreme pain, is better than dying. Well, maybe dying peacefully would be less painful for my relatives, but again, I personally place a much higher value on my own life than my family's feelings of sadness or whatever.
The only question which remains is the validity of the Axiom. If this world is all there is, if when you die there isn't an afterlife or reincarnation or whatever...then the Axiom is clearly true.
If you have strong religious belief, then perhaps your afterlife is better. But only a perfect belief that you are headed to a better place makes it rational to give up. If you have a little bit of doubt -- if you're 99% sure you're going to Heaven but 1% of you whispers that maybe there's nothing and you'll turn into dust instead -- you still want to put off rolling that die as long as you can. Ditto if you're 100% sure there's an afterlife and 99% sure you've been good enough to get into Heaven, but 1% of you says that maybe Hell is where you're headed.
If your religion forbids suicide, and there's a chance that the Judge who will weigh your life will interpret not opting for the best available medical treatment as equivalent to suicide, then that affects your decision too. Although, to be fair, this cuts both ways: The suffering you cause your family by lingering beyond your time on Earth might count against you too. Literally "Damned if you do, damned if you don't." It's unclear enough that there should really be a few more commandments or something, to address all the corner cases.
Despite having no particular religious views, she would disagree with your "axiom" in the strongest of possible terms. So would I. I am not religious, but my preferences include not suffering horrible pain. I also am against causing severe emotional and/or financial distress for people I care about. Those preferences lead to there being situations where I am literally better off dead than alive, and I have made sure that my wife is aware of what those situations are so that she can make that decision for me if I am incapacitated and it needs to be made.
This is not about life being better than death. This is about the amount of pain and suffering you cause yourself and others while fighting off death.
It's easy to sit back and pontificate that you'd choose heroic medical treatment over whatever the alternative might be if you've never actually seen what that entails. It's a lot harder when you see that for most people, especially older people, it's an experience akin to being imprisoned and then tortured to death. A hospital is an awful place to spend the last moments of your life.
In many circumstances death is by far better than life.
You need to factor in the quality of life. Its really what's important.
Take diseases like Alzheimers and neurodegenerative diseases. If I can't take care of my activities of daily living, and do not mentate - why on earth would I want to spend another day on this earth.
We can keep people alive for a terminally long time with tube feedings, rectal tubes and catheters and IV medications. Doesn't make living better than death. It also doesn't not mean that one decided to go quietly into the night.
Suffering is suffering, sometimes its better to stop suffering.
With that in mind, do you really want to be physically and mentally tortured in the last few days, weeks or months of your existence? How about at some time in the middle of your life? It all amounts to the same thing, in the end.
Sometime after that I had conversations with my Grandmother and Mother about their wishes.
I now know their expectations, and they know mine. It's important to think about death, and these situations. It's even more important to express your feelings to those who have the power to impact how you will be treated.
Without that paper, hospital personnel may ignore you when you say what she wanted, in fact may feel they are legally required to ignore you.
And the paper needs to be accessible on short notice (not in a bank safety-deposit box). It's a good idea to have a copy filed at her primary care doctor's office.
I've seen two grandfathers of mine on which absurd medical care was given: one was seriously ill and maintained as a living mummy for months (he did look as bad as people who were rescued from extermination camp at the end of WWII) and another who, while in coma, had a leg cut off although everyone knew he wouldn't wake up. Who the heck wants to wake up with only one leg when one know you'll die in the next few hours / days of terrible cancers that spread throughout the whole body?
It's precisely what this article is talking about because it's really what's going on.
People dying in an environment they're not familiar with, experienced things they never experienced during their whole life: broken ribs due to overzealous CPR, one leg cut off, tubes everywhere.
I've had a girlfriend who was a doctor and the sheer number of crazy situation like this she was describing were insane.
Believe me: this is very real and you probably don't want the statistics.
Because the probability that you will notice, the day your day has come, that you're missing one leg while feeling your ribs being broken is very far from zero.
"And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little."
It should be easy to prove/disprove this, as doctors get surveyed all the time on different subjects.
Is that always necessarily true...?
Guidelines in the US and Europe recommend compressions which are four or five cm deep, and that's a pretty significant percentage of the distance from your sternum to your back. Remember of course that one of the things that your rib cage is supposed to protect against is blows to your heart and lungs, so it shouldn't be too much of a surprise that a procedure that is supposed to compress your heart is also going to cause damage to your ribcage.
He survived though and after a bypass op is fine to this day.
The speed with which you can be in specialist care is absolutely critical when it comes to cardiac problems - which is a large part of the reason why survival rates are far higher in places like Central London where you've got both fast response time for paramedics (for London as a whole, ~75% of 'immediately life-threatening' calls have a response time of under eight minutes) and multiple world class Hospitals with specialist cardiac centres.
Even so, that's one hell of a lucky break your father had and fantastic that he both survived and is fine still!
Very lucky, but not for the poor guy who got stabbed. Not sure what happened to him at the end of the day.
I did it wrong.
There's new technology that automates this and the incident of rib-breakage is, as I understand, drastically minimized. (http://en.wikipedia.org/wiki/AutoPulse)
As an anecdote, my 70+ year old dentist (i.e. not the demographic with the strongest bones) had a heart attack (clinically dead). The responding EMTs used the AutoPulse, which saved his life. It pumped his heart for 10+ minutes while 1 EMT gave him air and the other drove to the hospital. No brain damage, no broken ribs.
I still get shivers thinking about the crepitus :)
We need to understand the mechanics of cells down to the molecular level. Then maybe we can think of a fix. At this stage in society, we know just enough about cancers to do more harm than good in the remaining years of life for the worst forms of cancer.
For example, WILT / OncoSENS. Which is to say turn off all mechanisms for telomere lengthening and work around the issues that will cause by replacing stem cell populations:
http://www.fightaging.org/archives/2011/10/accumulating-the-...
http://sens.org/research/introduction-to-sens-research/onco
---
Further, even a robust cure for a specific cancer based on targeted cell killing (by surface chemistry or other markers) doesn't require a complete understanding of the cancer cell - you just need to identify a reliable marker, no need to understand why it's a reliable marker.
*: Before responding, read the still-highly-relevant: http://www.andersonlocalization.com/pdf/more_is_different.pd...
Metaphor: if you are fighting a fire, you don't kneed to understand the full composition of th various fuels and the exact molecular characteristics of the fire at every point, it is enough to know that water will quench it.
- I realise that many on HN have an aversion to metaphors so please forgive me and let me continue to elaborate.
Wole cell emulation is certainly not necessary, although it would no doubt be interesting to be able to do this at some long-distant point.
We don't need to do this because it really does seem as though it is enough to understand the mechanisms of unconstrained cellular proliferation through genetic analysis and surface protein characterisation.
This will allow targeted therapies through:
1) Find the genes that are Broken, or allow the final common pathway of cell proliferation to be stuck in the 'on' position, and work out how to block them.
-Initially this will be done by designed drugs following the model of glivec but one day soon (i hope) it seems likely that siRNA technologies will make it a lot easier and faster
2) characterise the surface molecules that are different in the cancerous cells and design targeted therapies for them,
- as with Trastuzamab for HER2 in receptor positive breast cancers; in the future it seems more likely that we will be able to achieve good efficacy with musing camel antibodies (smaller, high affinity), and by combining the antibodies to substances to deliver targeted radiation, chemotherapy and upregulate the immune response against the cells
3) immune system-boosting therapies which prime the immune system against specific cancers
- already shown in proof of concept for various leukemias, see New England Journal of Medicine 'Chimeric Antigen Receptor–Modified T Cells in Chronic Lymphoid Leukemias' , doi://10.1056/NEJMoa1103849
You say we need to understand the mechanics of cells down to a molecular level; in a very many cases we do:'we understand huge areas of cellular biology down to the atomic and molecular level. There are of course many things we don't understand or know yet, but emulation is not necessary for knowing them and it seems quite clear that proliferation pathways are very well characterised indeed, and have been for around 20-25 years; since all cancerous cells must proliferate by this pathway it is simply (I know, it is very difficult, but still, I say again, simply) a matter of determining which pathway is being used and blocking it, whilst also destroying the cell.
Not easy work, but I believe something that we are making good progress on.
- my 2c given a background in molecular biology and as a final year med student