Authors

  • Mitch Keamy Photo Mitch Keamy is an anesthesiologist in Las Vegas Nevada Andy Kofke Photo Andy Kofke is a Professor of Neuro-anesthesiology and Critical Care at the University of Pennslvania Mike O'Connor Mike O'Connor is Professor of Anesthesiology and Critical Care at the University of Chicago Rob Dean Photo Rob Dean is a cardiac anesthesiologist in Grand Rapids Michigan, with extensive experience in O.R. administration.

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Comments

shomama

why are anesthesiologist so adamantly anti-nationalized health care? Is it because they are worried it may poke a hole through their artificially inflated salaries? There must be some of you that believe health care is a HUMAN RIGHT. I especially liked how you conveniently excluded medicare/medicaid from your analogy of how bad it would be if the government ran things. Last time I checked, being poor with medicaid is better than being poor with a shitty HMO (I've had both myself). Just because the government has done a bad job running the VA or Walter Read doesn't necessarily mean that it would do a bad job running a national health plan. And maybe if the government did run our health service there could finally be some accountability from the people, the citizens. As it stands now the insurance companies are only accountable to their shareholders. I'm a med student going into anesthesiology. I hope that the field will not be full of republican idiots!

Mike O'Connor

First, I'm deeply grateful for the personal attack. Nothing inspires me to be more rational or considerate than the absence of both in others.

Socialized medicine and health care for the poor are both highly attractive to physicians as a group, myself included. While most people have a dog in this fight, my attention has been and remains centered on how to generate better health care across the spectrum, including the indigent. The question to ask and answer is: what it the best way to do this?

In theory, nationalized health care or socialized medicine create a perfect safety net, and establish a baseline of care for everyone in a society. On a small scale, it is very likely that this model works, and works well. Scaling it up and keeping it going is vastly more difficult than most people appreciate. Centrally controlled health care resembles the federal government's response to Katrina more than anything else. That's its nature. We all may believe that it could be done better, but there is no evidence that this is the case. Advocacy in defiance of all available evidence is either prescience or religious fervor: only time will tell.

Health care systems are like the proverbial elephant: your view of what you're dealing with is highly dependent upon where you happen to have hold. Insiders have widely disparate views of how these systems perform, but in most instances, they seem to be inferior to what exists in the US already:

Canada:

http://socglory.blogspot.com/2007/08/canadian-doctor-describes-how.html

England:

http://nhsblogdoc.blogspot.com/

Read the description of the Canadian system: in most instances, our public hospitals provide better care(but once again, have abandoned cancer treatment and the management of chronic disease). This matters, as once you scratch away the veneer of propaganda, these systems become less attractive. Adapting the Canadian or English models might make things worse for everybody; there is no evidence to suggest that they will be superior.

And of course, my post above advances the hypothesis that the US government struggles to provide adequate care on a smaller scale.

I remind you that I am employed as an academic. Outside of our local public hospital, the one I work at has provided more care to the poor than anyplace in the city, in some years, more than all of the other hospitals in the city put together. The consequence has been that my salary has been meager for most of my career. If you care, my counterparts in England and Canada are presently compensated more handsomely than you might imagine.... because anesthesia everywhere is more demanding than you might think.

If this problem were easy to solve, we wouldn't be having this discussion. Make no mistake: everyone wants to solve this problem, but have different visions of what constitutes an acceptable solution. As is often the case, our system may be bad, but all of the alternatives are worse.

mkeamy

Hi shomama. Thanks for coming by. While I think inflammatory ad-hominem attacks (look it up) are not conducive to a decent discussion, I'll give you the benefit of the doubt that you didn't simply come around to expiate some anger you've got at something else, but that you're asking a serious question. I have grave concerns about the whole healthcare finance system either way; private or public. (I am one of the author's co-authors, by the way; he may be the smartest guy I know...) anyway, the public financing option has the defects that you mention; excessive profiteering, de facto rationing, and overwhelming beaurocracy. A federalized system will have problems with resource allocation (matching need to supply) a politicized rationing system (everyone can't have everything they want) and perhaps a politicized delivery system (do you want to work for a George Bush right wing zealot-appointee placed in charge of your hospital?)For an example of a resource allocation mismatch as a consequence of government manipulation, you need look no further than the critical shortage of primary care doctors which is the consequence of a lopsided medicare compensation system that differentially rewards proceduralists.
Every path is fraught with risks now, although most feel something must be done to address mounting access to care issues in this country... Interestingly, I read (and just re-read) Mike's post-I didn't see any discussion of physician income there? Are you projecting some other feelings of your own onto this post? For a great discussion of physician income issues, which seems to be on your mind, go to Kevin MD's blog, where there is a link to a letter written by the (liberal) Princeton healthcare professor Uwe Rinehardt, in responding to a New York Times op ed piece attacking physician incomes, also with a link.

As for accountability, read Mike's post "Hiding the Bodies" Do you think that a government that could pretend global warming doesn't exist for seven years will be publicly accountable? I don't.

Anger is a very difficult emotion if you're going into anesthesia; it'll eat you up!


Cheers and good luck.

shomama

mkearny:
First off, there is no need for me to look up ad-hominem as I am well aware of its meaning. Perhaps you should look up the correct spelling of bureaucracy.

I'm glad for the discussion. I have been reading your blog for some time now and really enjoy it. I found your piece on the pre-op interview enormously inspiring and touching and I have actually tried to incorporate that thinking when I do pre-ops now.

I'm sorry if my comment seemed angry. I did not intend to disrespect any of you and clearly you all have much more experience than I do. However, it seems that everywhere I look anesthesiologists in particular are adamantly opposed to a single-payer system. I can't seem to understand why that is so. I thought that perhaps since anesthesiologists are so well paid, they fear losing that income. That is the reason I brought up income. I am not "projecting" other feelings so you can spare me the $.50 psychology.

I believe the original post makes a cohesive argument. And you both clearly acknowledge that the current system is broken; on this we can agree. But here is my point: How can the systems the original poster mentions be that terrible (i.e. Canada and England) but still rank above the United States in most ratings of health care. Furthermore, what about the French system, which is widely considered the best health care system in the world? Could the money we are pouring into this senseless war be better utilized to create a health care system modeled after the French. And not even the French...America has a history of ingenuity and creativity. Can we not come up with a national health system that provides adequate care to all its citizens without compromising on individual access or wait time. And one that doesn't grease the pockets of insurance companies. So the alternatives are not worse. They can be better.

The original poster claims that at his public hospital the poor are cared for without a problem. While I find this rosey picture hard to believe, he might want to consider visiting other county hospitals, like those in Los Angeles or New York. Patients waiting for hours without care or as was seen in LA, those who can't pay are put in a cab and sent to "skid row" sometimes with their IV still in place and only a hospital gown across their backs.

Hank Roberts

Do you respond to questions here? It's not clear.

Curious about whether the government's done the right thing as you see it in dealing with this news:
http://origin.mercurynews.com/breakingnews/ci_8439887
http://ap.google.com/article/ALeqM5i8B3EkgPbRHRxqB6l6BG6ZL1bn9QD8V69MQG0

Mike O'Connor

First, the obvious observations:
This is a disaster for these patients.
In a perfect world, this should never happen.


Truth: It has happened before and will happen again.

Now it's time for the less obvious....

I've spent a lot of time in the past ten years reading about, studying, and thinking about failure, especially recurring failure. Failure recurs when previous response to it was ineffective. Response is ineffective if it is predicated on an incomplete or incorrect understanding of the cause of failure.

Truth: In medicine, we have eradicated all (or almost all) of the simple failures. Those that remain defy our understanding, not our will. This is a critical insight: those problems which fester in medicine defy simple solutions, no matter what the pundits, politicians, regulators, and various experts say. More on this tangent in another post...

Wild Speculation: While these news stories point to re-use of syringes and vials, this is at the least an oversimplification. Further, my speculation is that there was minimal or no re-use of vials, and that all of the syringes that were re-used were glass, not disposable plastic. Hence the real problem: the processing of re-usable instruments in health care, including all surgical instruments, glass syringes, and endoscopes.

Fact: The processing of re-usable medical instruments is a logistically daunting and technically difficult undertaking in which minor failures have major consequences. It is profoundly more difficult to accomplish than outsiders appreciate, and failures far more common that casual newsreaders might believe. It is a problem that plagues all of health care, from its most prominent institutions to its most obscure. It almost certainly happens for more often than it makes the news. Like all recurring failures in medicine, our understanding of this phenomenon is poor, which is why it continues to happen. My colleague Richard Cook has been intensely interested in understanding this problem; unfortunately, there is no external funding available to do so. As for this response: it will be ineffective, as all previous responses have been, and it is likely we could have this dialogue 5 or 10 years from now, just as we could have had it 5, 10, or 50 years ago.

This area represents a real opportunity to make progress on patient safety, but it would take a substantial investment in a study by a competent investigator. There is no money forthcoming, and there are only a few investigators competent to understand this problem. Absent real understanding, progress on reducing the incidence of this disastrous complication will not happen.

If you're interested in the lab and understanding safety and failure, visit the homepage:

http://www.ctlab.org/

For more stories about failures associated with the processing of instruments:

http://www.newsobserver.com/215/story/181586.html

Canada:

http://www.thestar.com/News/Ideas/article/301896

England:

http://www.bio-medicine.org/medicine-news/Contaminated-Surgical-Instruments-Increase-Risk-Of-Infections-12072-1/

Hank Roberts

Thanks Mike O'Connor, that's helpful.
I've read (in a biofilms article) that it's actually impossible to sterilize the hollow inside of a colonoscope, they make a best effort. I'd wondered, seeing the lab with the problem did colonoscopies, if it could be transmission via the instrument rather than via the anesthesia injections. (And just now Google turns up quite a few hits, biofilm contamination seems to be a hot issue with a lot of research)

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