The Ether Way

More on the performance of nationalized health care

As the election season draws nearer, health care reform continues to vie for position as a leading issue amongst the presidential candidates. Once again, the public should expect to be regaled with stories of the compassion and fairness of such systems, as well as their potential for efficiency. Peer reviewed studies and surveys that portray such systems favorably will be widely quoted.

The recent bill to dramatically expand health insurance for children, vetoed by President Bush, is likely to evolve into a defining campaign issue. Why?  Because it is trivially easy to cast opposition to such a well intentioned program for the innocent as mean.  Bush, and many of those opposed to the bill, believe that it was another step in the gradual expansion of federal control over health care in the USA. Be certain, the language of this particular bill laid down the scaffolding for the extension of this entitlement by subsequent legislation.  Bush may or may not be mean, but he is opposed to nationalized health care.

How are nationalized health care systems doing since I last blogged about them?

Below are a few pointers to interesting stories, and what they mean to me.

Britain's NHS continues to be under-funded to a substantial degree. Like many such organizations, they have shifted resources from longer-term objectives to deal with shorter-term crises.  One way this is accomplished is to 'defer' maintenance and replacement activities.  The NHS, whose standards for physical plant and equipment are substantially lower than the US's, has done this:

http://news.bbc.co.uk/2/hi/health/7060379.stm

4 Billion pounds - about 8 billion dollars - in a country with about 1/6 the population of the US - would scale up to about $ 48 billion here.  Why the backlog? The story makes the reasons obvious:

1. There was a bureaucratic imperative to demonstrate a surplus.  They did it by shifting all of their maintenance and capital budget to the future. The shadow health secretary quoted in this article refers to this as 'a sham.' I believe he is being generous.

2. They are so over capacity that they cannot close any substantial structure for renovation without causing serious disruption of service at a regional level.

To be fair, $48 billion dollars is a small amount in US dollars relative to the US health care budget - but it is also enough money to build 48-100 new hospitals…. which is a lot of capacity.  The real problem is that they have absolutely no excess capacity in their system, largely as a consequence of previous efforts at 'cost containment.'  But parts of England are much poorer than most people realize, with > 20% of the homes in places like Liverpool, Birmingham, Portsmouth, and Leeds not having central heat (or not being able to afford turning it on):

http://news.bbc.co.uk/2/hi/uk_news/7063120.stm

The British spend over $ 3 billion a year helping these people stay warm.

Spin, the modern synonym for propaganda, continues at the political level for Britain's NHS, as demonstrated by these items:

http://news.bbc.co.uk/2/hi/uk_news/politics/7063430.stm

http://news.bbc.co.uk/2/hi/health/6725725.stm

http://news.bbc.co.uk/2/hi/health/7061590.stm

   

I could be derisive, but it would be hard to surpass the language of the usually sympathetic BBC in these stories.  There are several features of nationalized health care systems that are self-evident in these stories:

- progress is announced (sometimes untruthfully) in synchrony     with election schedules
- failure is not an option (propaganda can be used to obscure all     substantial failings)
- the leadership of such systems are those who are most  politically pliable, not the most competent
- this in turn permits fantasy planning, with outrageous     under-estimation of the time and expense of major projects (3 years vs 10, 2.4 Bn vs 12.4)
- budgets must conform with legislative allocations (requiring the layoff of a mere 17,000 healthcare workers) and are completely disconnected from demand, and
- politicians can divert vast sums for publicity stunts. 

The reduction in personnel is causing a crisis independent of problems related to maintenance:

http://news.bbc.co.uk/2/hi/health/7064398.stm

To me, the most important message of these stories is that there is now profound skepticism, at every level, of all information disseminated by the NHS.  A nationalized health care system in the US would likely arrive at a similar relationship with its press and public very, very quickly.  The major difference is that the US press would gladly vilify practitioners at the behest of politicians, a practice that the BBC is now too wise to engage in.

While the US press is usually a venue for fluff pieces which portray Britain's NHS quite favorably, the BBC publishes stories that create a completely different impression:

http://news.bbc.co.uk/2/hi/health/7062473.stm

Think about it - less than a third of diabetes receive the testing that the NHS mandates they should.  If you read the article, it's clear that the NHS does a lot of things related to diabetes care well, and is making a concerted effort to make almost everything better. Once again, failure is not arising from incompetence or lack of motivation at an individual level, but rather from a system whose resources are generated by coercive taxation and redistributed at the pace of elections and governmental fiscal cycles.  The successes and failures here are both arising from the structure of the NHS.

How is the NHS doing? Well, the truth is that it is hard to tell.  One thing is certain: medical tourism is thriving and growing in parallel with the NHS, with increasing numbers of Britons willing to pay cash out of their pockets to receive care in dozens of countries (most of which would have been inconceivable as alternatives even 15 years ago).

http://www.treatmentabroad.net/

Ultimately, it may be that our most reliable indicator of how well and nationalized health care system is functioning will be the number of such 'refugees' that it generates.  Using this as our metric, it would seem that while its leadership represents that everything is getting better, things in Britain's NHS are in fact getting much worse.

While composing this post, I felt like I was shooting fish in a barrel.  The bad news about Britain's NHS isn't hard to find.  All of the above pointers are to news stories from 2007.  Of course, bad news sells, and sells well.  The good of the NHS (like its care for the indigent with chronic diseases and cancer) isn't news. Sadly, the thrust of all of the news is that the NHS is failing by almost every measure.  This matters, as the British have the greatest experience of any western country operating a nationalized health care system.  They know how to do this - they understand the planning, the logistics, the personnel issues, the oversight, and the regulation.  On a large scale, this is likely to be as good as it gets.  Think about that.  Is Bush wrong to reject this? Is he mean? Or is he prescient in supposing that nationalized health care will work about as well as nationalized farming did in the Soviet Union?  Only history will know for sure.  Mere mortals must make their best guess using the information at hand.

Finally, it is worth mentioning that most of our information about nationalized health care comes from the press of English speaking countries.  Why? Because they generate English language documentation and news coverage.  Both the good and bad of other nationalized health care systems receive less coverage because of this language barrier.  Every once in a while, a story appears that hints at how things might be going in other countries.  Take this one from Japan as an example:

http://news.bbc.co.uk/2/hi/asia-pacific/6970192.stm

I am certain that Japan's system, like England's, has many good features. But, like every system, it's not all good, no matter what its' propagandists and spin doctors say.

Should physicians be the leaders of anesthesiology?

Not everyone thinks so, especially the AANA.

There was an editorial on this topic in the ASA newsletter by Doug Bacon.

http://www.asahq.org/Newsletters/2007/05-07/crowsNest05_07.html

I had responded to Dr Bacon's comments with a recitation of several articles in the AUA newsletter  which support his musings that the AANA is  actively working to diminish the training programs that are at the core of our specialty.

The ASA newsletter chose not to publish my comments so I post them here.

Letter to the Editor, ASA newsletter

I agree with Dr Bacon’s evaluation of the evidence suggesting that AANA, by its actions, is working aggressively to defeat fixing the anesthesiology teaching payment rule.  As such they are actively hurting our future. With better funding nurse anesthetists have opened 22 new training programs since 2000, whereas 8 anesthesiology residency programs have closed (30 since 1994). The ASA’s efforts at reconciliation with AANA may be for naught.

I refer the interested member to recent issues of the AUA Update, the newsletter of the Association of University Anesthesiologists (http://www.auahq.org/newsletter.html). In the Summer 2006 issue the AUA President Roberta Hines outlined the financial impact of this legislation emphasizing the importance of it to the future of the specialty. In that issue also was a report of a speech by the then ASA President Orin Guidry who presented clear evidence that AANA was effectively undermining efforts of the ASA to promote legislation that would correct the payment reductions for teaching residents. Notably CMS includes AANA as a stakeholder in this physician-related legislation.  One may speculate how this came to be. Indeed the AANA position paper on the topic ends with:

Message to Congress: Oppose teaching rules changes that disrupt fair payment treatment between nurse anesthetists and anesthesiologists. The rules should not unfairly advantage one type of provider over another.

This continues their theme, promulgated to legislators, that nurse anesthetists, despite not having undergone the rigors of premedical education, medical school, and residency, are equivalent to anesthesiologists.

The Fall 2006 issue contained an overview by James Hall of the status of anesthesiology assistants programs, perhaps an alternative that organized anesthesiology could promote to provide alternate members for the anesthesia care team who would be less likely to work against us.  Anesthesiologists should work with their state legislators to develop licensure pathways for AAs and academic programs need to support and develop AA schools. Also in that issue was a report on a NY Times article on the movement of nurses from the third world to the US such that every new nurse anesthetist translates into one less bedside ICU nurse, which in turn further contributes to the nursing shortage in poor countries, despite the fact that there are non-RN alternative anesthesia providers.

The Winter 2006 issue contained a report of Jerry Reve’s Rovenstine lecture with his analysis of problems with anesthesiology research, many of which can be addressed through the financial impact of the teaching rule. The problems he identified may be construed as a symptom of our difficulties providing proper academic support of anesthesiologists in training.

The Summer 2007 issue includes an article by Robert Johnstone, an ASA Director, who describes efforts by the AANA to promote a competing bill that would include direct Medicare funding of student nurse anesthetists. He describes his chagrin, upon talking to his legislators, of learning that the nurse anesthetists had already visited with a competing message. Finally, Johnstone’s article prompted a comment by me:

The following can be found on the Webpage of my state society:
“On May 2nd, the Pennsylvania House Insurance Committee met for testimony on Governor Rendell’s health plan. Representatives from the Pennsylvania  Society of Anesthesiologists (PSA) and the Pennsylvania Association of Nurse Anesthetists (PANA) were present to testify. Dr. Erin Sullivan, President, PSA and Dr. Joseph Answine, President-Elect, PSA, testified that the anesthesia care team is time-proven and safe. Furthermore, they testified that the anesthesiologist is an acute care physician that diagnoses and treats illness during the peri-operative period. Dr. Arthur Zwerling (Doctor of Nursing Practice, DNP), President-Elect, PANA testified that the PANA seeks independent practice for Certified Registered Nurse Anesthetists and that an anesthesiologist is not necessary in most settings.”

The evidence appears compelling that AANA is actively working against the efforts of the ASA to ensure the future viability of Anesthesiology. The AANA is a large society, and most of the nurse anesthetists we work with belong to it and thus can be assumed to support its activities, daily collegiality notwithstanding. Chamberlain is widely thought to have blown it in his disregard of the evidence that he faced. I wonder if we are doing the same?

W Andrew Kofke MD MBA FCCM

Editor AUA Update

Professor University of Pennsylvania

 

Submitted to ASA Newsletter June 25, 2007

 

 

on Memory and Reminiscence

We have, in the next place, to treat of Memory and Remembering, considering its nature, its cause, and the part of the soul to which this experience, as well as that of Recollecting, belongs.  -Aristotle 350 BC

The clinical Anesthesiologist's interest in memory and its formation is that of a lmberjack to the forest. Anesthesiologists are clear-cutters, ad not typically too engaged in the niceties of the eco-system. In this case we might reasonably be forgiven, since the failure to abolish memory during a general anesthetic is at least a therapeutic failure and at worst, a terrible (actionable) trauma for the patient. Fortunately for us, memory formation/consolidation is eliminated far more easily than movement, which means that the anesthetic depth (related to the concentration of anesthetic) required to keep the patient "still for the knife" is much greater than the concentration required to interrupt memory formation. So far, so good. An interesting digression; movement during surgery can be initiated from the spinal cord in the absence of any brain activity. (Think of A chicken running around its  head cut off; well, maybe don't...) We know this from experiments involving isolated head and body perfusion experiments, (not human!) where the body and the head are separately anesthetized. So when the surgeon yells "the patient is awake," the wise anesthesiologist knows that non-purposeful movement under anesthesia does not imply awareness, (but certainly doesn't preclude it...)

Of all animal traits, the three most philosophically intriguing are awareness, consciousness and memory. Of these, memory is certainly more derivative; Invertebrate worms demonstrate memory (they can learn) without any sense that they are conscious or aware. The taxonomies of memory, while being the subject of heated intellectual conflict, all seem rather comfortable, even intuitive, to the casual spectator. Memory is most superficially parsed into short-term and long-term, which we know have different physiological mechanisms (we know this in great measure due to the work of Dr Eric Kandel, which won him the Nobel). When you remember a phone number long enough to dial it, you are using short term memory. This involves chemical changes in synapses. If you remember your home address and telephone number from last year, you are using long term memory. That involves changes in synaptic connections. Long term memory gets sliced and diced lots of different ways, based mostly on our human classification of cognitive function. Explicit memory is memory which is subject to conscious recall (like the name of your high school sweetheart, or your anniversary). Implicit memory is not (for instance, riding a bicycle, recognizing a face or voice). Explicit memories are further sub-divided along various functional lines; intellectual memories, memories of events, etc, etc. WIkipedia has an unusually good introduction to the science of memory.    Here also, is a link to a video introductory lecture on the neurobiology of memory from the MIT Distributed Intelligence project:  http://mitworld.mit.edu/stream/146/

Saving the Brain

“My Brain – it’s my second favorite organ” -  Woody Allen in Sleeper

(Readers please note: this post is inspired by the preceding posts of Mitch and Andy.  It's much more hard-science oriented than my other posts, but consistent with Mitch's vision for this blog.)

The central objective of all of anesthesia and critical care medicine is to save the brain, and to spare it as much injury as possible.   Sadly, brain injury is epidemic and largely unavoidable in much of modern medicine.  For those few who survive a CPR event in any setting, it is the presence of brain injury that distinguishes meaningful survival from all of its ugly alternatives.  I have no doubt that most patients and their families would give up their kidneys (if they had them to give) in preference to losing even 5 IQ points.  Anything that we might do to decrease the rate at which we discharge people NQR (Not Quite Right) would be worth princely sums to our patients, their families, and us as caregivers.  Brain injury is the difference between mere survival and meaningful survival.

The annals of anesthesiology, neurology, neurosurgery, critical care, and now emergency medicine are filled with the scrapheap of failed ideas for neuroprotection.  Moderate hypothermia at the time of an event is not nearly as helpful as moderate hypothermia for 24 hours subsequently.  Most of the explanations of this entail far more hand-waving than solid science (see Yenari below).  What little solid science there is seems to be a better held secret than most of the US government’s activities in the GWOT.  Deep hypothermia provides protection, but at temperatures that can only be achieved with a cardiopulmonary bypass machine.  There is some evidence that suggests that erythropoietin provides a benefit, but not sufficient evidence to drive widespread use for this purpose – yet.