• An empirical revolution

    I didn’t realize that Google Books only has the first 50 or so pages of Paul Starr’s The Social Transformation of American Medicine. So now I have to start typing what I want to share rather than extracting images. Here’s an excerpt from page 55:

    Empirical evidence rather than dogmatic assertions of personal or traditional authority became the grounds for assessing the truth. The early empirical investigations showed that accepted techniques had no therapeutic value, yet there were no effective alternatives available to replace them. Medicine had reached that difficult point in its history when leading scientists knew its limitations, but as yet lacked the means to advance beyond them. Ironically, as Richard Shryock writes, “the most hopeful period in the history of medicine was the one in which the public looked to medicine with the least hope.”

    As I read this I thought not of early 19th century medicine but of the U.S. health care system in 2010. It suffers from high cost, low to mediocre quality, and poor access. Assertions of remedies are abundant, empirical evidence about them is emerging and shared on this blog (and elsewhere), and many are uncertain that effective alternative arrangements exist. Like medicine in the early 19th century, we’re at a difficult point. We know the limitations of the health care system but, at this moment, lack the means to advance beyond them. Will this time be viewed as an ironically hopeful period too? It depends which way we go from here.

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    • Well, Austin, I think the key is getting beyond the idea of “Medicine”, Paul Starr’s title is one of the worst choices I thought he made in what otherwise is an enlightening and thoughtful book. You are trying to do that in your description, but I wanted to highlight it, we’re talking now about a health care system and not medicine as a focus. Medicine is probably now more a part of the problem than a part of the solution. Yet, we’ve only made the barest beginnings of a transformation in the thinking that we probably need to be able to write the new transformation book in fifty years or so.

      Jim

    • We know that empirical evidence is (mostly) worthless. We also have lots of good “evidence based medicine”. The problem is not one of science but that of political will and the current medical “culture”. These are difficult problems.
      We have the “means” in the form of payment. We are currently (in the US) paying for the wrong things and mostly getting the expected poor outcomes. However, those who profit handsomely from the current arrangement have the “means” to promote continuing the wasteful unproductive spending. In the current political climate, I don’t see a solution to the problem.

    • Mark, you don’t really believe that first sentence, do you, since if you did you would not want to support models, health information gathering, database formation or anything else that gathered data, since why have data if empirical evidence is (mostly) worthless? Realize that people working on the problems and becoming cynical about the progress are actually just not understanding the problem. I agree that many of the problems with USING empirical evidence appear daunting, but that’s mostly because the incentives for using information are way behind the incentives for producing it.

      Jim

      Jim

    • Sorry, Jim, you are right. I misspoke… (too much Thanksgiving distraction). I meant to say that “anecdotal evidence is mostly worthless.”
      (I’ll try to remember to engage my brain before putting my fingers to the keyboard.)

    • “It suffers from high cost, low to mediocre quality, and poor access. Assertions of remedies are abundant, empirical evidence about them is emerging and shared on this blog (and elsewhere), and many are uncertain that effective alternative arrangements exist. Like medicine in the early 19th century, we’re at a difficult point. We know the limitations of the health care system but, at this moment, lack the means to advance beyond them.”

      If the focus is on quality, quality, quality driven by empirical data, with changes based on wild or studied guesses on quality improvements, the progress will be rapid and surprising. in improved outcomes and reduced costs.

      As long as the focus is on magic bullet cost cuts, the quality will only decline and costs soar.

      One can do a simple empirical comparative study of national health care systems and conclude universal coverage will bring increases in quality and lower costs. For more than half a century the US has been trying to reduce costs and increase quality by systematically denying health care as a means of cost control, but the result has been an explosion in costs and greatly increased inefficiency.

      If we look at other nations with universal coverage, we see them constantly trying to improve quality by some empirical measure, or in some cases trying to reduce costs (which are far lower than the US) , with mixed results, but they respond by keeping the improvements while seeking to reverse the cost increase and quality declines. But none of those nations have fallen below the US on quality or above the US on costs.

      On the other hand, only before the 80s did quality in the US improve significantly as a consequence of many public health efforts that included greatly expanding access to health care.

      But with cholera in the news, let’s remember one of the most important advances from empirical medical science and health care delivery: mapping out the cases of illness and the public water wells, followed by the educated guess that putting a sign on a few wells would cut the epidemic.

      But just this month we have an empirical report on brain health – the critical early years of brain development – correlated with disease burden and inadequate food in early childhood development. The use of immunization and other pubic health measures like clean water, limited toxic exposure, and food sufficiency will boost life long mental health and development (proxy metric of IQ).

      But we know that immunization and clean water and limited pollution are only successful if done universally. Immunize only 10% of a community and provide only them with clean water will fail to protect them from disease – it the herd is carrying disease some of the immune will become infected with new strains.

      In our US health care system, the empirical work of long ago that introduced hand washing to cut hospital mortality is still applicable today – empirical studies of hand washing has shown that doing more to promote hand washing or equivalent in hospital or clinical settings will reduce costs as a side effect of the quality improvement of reduced disease and mortality.

      Another empirical advance is the (re-)introduction of checklists to such activities as surgery. That is essential rocket science.

      We know all we need to know to first increase quality and thus reduce costs.

    • “We know all we need to know to first increase quality and thus reduce costs.”

      I don’t think it is all that easy. Yes, there are a few things we can do that will obviously increase quality and lower costs. Most of the time it is not that clear. In general, I actually expect quality to cost a bit more. Our current problem is more, I believe, poor ROI. We spend too much on the wrong things and the right things. Still, I think it is fixable but Mark gets it right. Our politics is what holds us back now.

      Steve

    • I think that the US health system has proven conclusively that increasing the amount paid for health services has a negative effect on quality. The US spends more than twice the amount of the 21 developed countries and has the lowest health indicators.
      The US health system is very good at producing income for those producing goods and services but this is the only benefit and bears no relation to the quality of care.
      As an extreme example of cost/benefit, consider Cuba which spends approximately $186 per capita versus the US mean of $4500 per capita. The US and Cuba are neck and neck on most health indicators.
      I think we are doing something wrong.