The first day of internship fell on solstice. There is probably some symbolism in it, something about fertility. Ten days of orientation were certainly fertile on the amount of information and welcomes. Some smart folks were writing the names people they met in notebooks. So many times we were assured that by this time next year we will be pros. I really believe it when my program director said that whatever problem we would encounter, they have had already solved it. So, technically, there should be no problems.
Still I wanted to hear something else on the first day of internship and every time when things go south down in the trenches, why I volunteered for this. And this is why I am writing it down, so that when I am in doubt I can get back here and re-read it.
Seven hundred thousand people declare bankruptcy every year due to medical bills.
There are three types of care: necessary, preventive-sensitive, and supply-sensitive. Necessary care is care that is, well, necessary. It constitutes the smallest fraction of Medicare expenditure, but is under the heaviest regulatory oversight. Preventive-sensitive care is care that has more than one option, care chosen is determined by opinions. For example, PSA testing, mastectomy/lumpectomy. This type of care also makes up a smaller fraction, about 25%. Supply-sensitive care is the type of care that is determined not by specific treatments but by frequency of treatment. This type of care makes up 60% of Medicare expenditure and includes imaging, consults, ICU admissions. This type care sees the least regulatory oversight.
Some interesting observations: the more hospital beds, the more admission; the more cardiologists, the more angios; the more cath labs, the more catheterizations. This is what supply-sensitive care is about. When Atul Gawande talked about El Paso, TX vs McAllen, TX, this is what he meant. A larger number of doctors in McAllen made McAllen the most expensive town in the US to get health care. And by far not the best care.
One third of Medicare goes to care in the last 2 years of life. One sixth of Medicare goes to care in the last 60 days. "Medicalization of death." Google it.
Benefit vs expenditure plateaus, and even goes down.
The number of men needed to have their PSA checked to avoid one death due to prostate cancer is one thousand per ten years. While doing this, we will miss 4 prostate cancers that will result in death. At the same time, fifty men will be overdiagnosed. But can we talk this math with a patient? Success stories are what we hear and what shape our measure of chance of survival. How many people do you know who tell you about failures? This is not unlike playing a lottery. We all want to play a lottery because we only see winners. But how many losers are on the news telling that they lost? Watch Dan Gilbert.
Cancer. The same tumor has different cells. Cancer cells in mets are different from those in the parent tumor. Responses to the same treatment are different. Genetics of tumors and people matter more than ever. No longer can we apply the same treatment to people with the same disease.
How we track and understand health care determines implications for the heath of our patients.
Three are more than 6 billion cell phones. The wireless future of medicine.
Internship will be over by the next solstice. With these issues and promises, the question is why would one not do medicine?
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