Pyrrhic medicine

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February 23, 2015

It’s almost cliché that the U.S. spends more on medical care than any other country but still has the worst health outcomes in the developed world. The New Yorker’s “Why America Is Losing the Health Race” article opens with this claim and then continues:

The superior health outcomes achieved by other wealthy countries demonstrate that Americans are—to use the language of negotiators—“leaving years of life on the table.” The causes of this problem are many: poverty, widening income disparity, underinvestment in social infrastructure, lack of health insurance coverage and access to health care.

Which is probably true. But here’s an alternate (and perhaps contributory) hypothesis: what if U.S. health outcomes are so poor because our doctors are so good? After all, the U.S. has Harvard, Stanford, Johns Hopkins, Yale, UCLA, and UCSF—six out of the top ten medical schools worldwide, per this ranking—and besides, the U.S. attracts a great many foreign-trained medical professionals (“America Is Stealing The World’s Doctors,” the Times tactfully implies). These superb but debt-ridden doctors are incentivized to go into procedure-performing specialties instead of primary care: Orthopedists, Cardiologists, Urologists, and Gastroenterologists all make about twice the annual income of family doctors. Then the following occurs:

  • One morning, Mrs. J goes to get the newspaper, clutches her chest, and suffers a cardiac arrest. A family member starts CPR and another calls the ambulance.
  • The family’s orders are clear—do everything to save the patient’s life.
  • And through the ingenuity and heroism of a highly trained American ER physician and his team, Mrs. J gets Return of Spontaneous Circulation.
  • An EKG shows an acute ST-Elevated Myocardial Infarction (heart attack, the bad kind). Cardiology is consulted; after discussion, patient is sent to the cath lab for emergency angioplasty. By this time, she is intubated.
  • The Highly Trained cardiologist is able to stent the patient’s occluded artery. She is sent to the ICU for further monitoring.
  • The patient extubates and appears to be improving. However, two weeks into her hospital stay, she develops concerning EKG changes, and is rushed down to the cath lab once more to treat a stent reocclusion.
  • Sent back to the ICU. After three weeks, she is deemed safe for discharge, and is sent to a skilled nursing facility for recuperation.
  • Unfortunately, the patient develops a bad pneumonia, followed by septic shock and multi-organ failure. She is intubated and admitted once more.
  • Through the heroic efforts of Pulmonologists, Nephrologists, Infectious Disease specialists, and Intensivists, she pulls through. After a two-month ICU stay, she is discharged home.
  • The day after returning home, Mrs. J goes to get the newspaper, trips on a sidewalk crack, breaks her neck, and dies.
  • Total cost of medical care: $1 million dollars.

I totally made that number up; also, I’m not a doctor. But you get the point. Now here’s the same case in a Less Heroic and Patriotic country:

  • One morning, Mrs. J goes to get the newspaper, clutches her chest, and suffers a cardiac arrest. A family member starts CPR and another calls the ambulance.
  • The family’s orders are clear—do everything to save the patient’s life.
  • Unfortunately, the less heroic and ingenious ER physician fails to bring Mrs. J back.
  • She dies.
  • Total cost of medical care: $10,000.
  • The other $990,000 dollars gets spent on cost-effective preventative care interventions that require no heroism whatsoever, saving 30 lives.

And so the American doctors, best in the world, do better at every single individual medical crisis and thus have worse outcomes overall. Pyrrhic medicine.

Take home messages: a) no amount of clinical training is going to fix America’s healthcare system, and b) even though there’s a lot of anger/debate about “rationing care," we already do this. Our current rationing-care policy is "Spend whatever it takes for emergencies, and pay for that by decreasing primary care availability and increasing the cost of elective procedures.”

I’m not sure this is an effective strategy.