Five hopeful trends in medicine and healthcare

Enough with the gloom and doom!

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I feel that I have been spending way too much time as a “chronicler of the decline,” to use von Mises phrase.  The secular trend in healthcare (literally spanning the last 100 years) is one of increasing centralization, consolidation, and reduced choice.  Nevertheless, there are some promising developments that gives me hope for a better  future.

Here are five notable trends, in no particular order:

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Shortages and price gouging

Healthcare microeconomics on the brink

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The shaming campaign that followed the news of two generic drug prices somersaulting into the stratosphere after being acquired by private companies is not too surprising.  The idea that a drug which cost $13.50 one day can cost $750 the next, seemingly on the whim of greedy Wall Street investors and pharma start-ups, is fodder for the outrage machine.

But what the outrage machine does not realize is the extent to which the generic healthcare supplies are constantly on the brink of shortage.

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One hundred years of managed care

A tragedy in five acts (and the triumph of progressivism)

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This is the wrap-up to the series on the economic history of the American healthcare system, the first installments of which can be found here and here.

The term “managed care” entered the common lexicon in the 1990’s, when contracted arrangements between physicians and hospitals on the one hand, and insurance entities on the other, became standard means to try to control healthcare expenditures.  The origin of the concept is frequently credited to Dr. Paul Ellwood and his influential Jackson Hole Group, who introduced the idea in the early 1970’s.

But in our 2-part series on the economic history of American medicine, we saw that healthcare has been “managed” from its inception in the late 1910’s, when the Flexnerian reforms and the ensuing medical licensing laws began to influence (and limit) the type of medical care Americans could choose to receive.

Since that time, an ever-growing managerial class of academics, industry leaders, technocrats, and private foundation believers in “systems” and in a “scientific” approach to organizing society has been guiding the various government interventions which have shaped American healthcare as we know it today.(1)

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An economic history of the American health care system – Part 2

From the Great Depression to the present time

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This is the second of a 2-part series. You may find part 1 here.

Q: What alternative models of health care payment were sought during the Great Depression?

A:  Taken aback by the sudden surplus of hospital beds, and realizing that patients and families were not willing or able to use hospital services at the prices demanded, leaders of hospital associations and of medical associations, such as the American College of Surgeons, began to look for models of collective health care payment.

They remarked that European countries which had adopted government-funded health plans did not seem to have the same problem of surplus capacity.  The apparent ability of European systems to coordinate supply and demand reinforced the belief of these American leaders that a similar plan would be desirable for the United States.  But political opposition to a national health care system was strong, and the medical community itself was divided on this idea.

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What cardiologists can teach economists

A tribute to Kanu Chatterjee

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I wrote an earlier version of this post in 2011.  In light of the current economic and financial turmoil, it seems all the more relevant.

I had the great fortune and pleasure of studying under the late Kanu Chatterjee during my cardiology fellowship at the University of California San Francisco.

In the early 1970’s, Dr. Chatterjee was among the first to understand the benefits of “afterload reduction” for the treatment of congestive heart failure:


Prior to that time, giving medications that could lower the blood pressure was often seen as heretical.  In fact, during the 1950’s and 1960’s, the treatment of heart failure sometimes consisted in applying measures to raise the blood pressure and increase the work of the heart.

The concept of afterload reduction introduced by Dr. Chatterjee and his colleagues was revolutionary.  With such a treatment, mortality rates in heart failure were improved for the first time.

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An economic history of the American health care system-Part 1

From the pre-Flexner era to the great depression

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This is the first of a 2-part series. You may find part 2 here.

Q: What is the starting point in the history of the American health care system?

A:  The American health care system was born in the 1910’s out of the so-called “Flexnerian reform” in medical education and the resulting licensing laws.

Q: Why is that the starting point?

A: Prior to that time, medical care in the United States was essentially unregulated.  Anyone could open up a medical practice, and many did so with little training.

Patients had complete freedom to obtain medical care from whomever they wished.  When such complete freedom exists, one cannot realistically talk about a “system.”

Q: What were the main features of this “pre-historical” period?

A: There were competing forms of medical care.  “Regular” medicine continued the tradition emanating from European institutions and medical schools.  It was ostensibly represented by the American Medical Association (AMA).

The regular form of medical care tended to be more disposed toward aggressive interventions (blistering, bloodtletting , and toxic purgatives), but over time, it also increasingly incorporated scientific knowledge into its mode of practice.   Surgery was part of regular medicine, and surgical techniques were improving rapidly in the latter part of the nineteenth century.

Other forms of medical care, such as Eclecticism, herbalism, and homeopathy tended to be less inclined toward aggressive treatments, and each had its own diagnostic and therapeutic philosophy.

There was a multitude of medical schools, and most of them were privately owned.  In many cases, the curriculum lasted one or two years after high school.  Given this large number of schools, the United States had the highest number of physicians per capita in the world.

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Reduced posting frequency and Amazon affiliate status

Since A&O was revived 4 months ago, I have tried to post twice weekly (and sometimes more frequently).  Due to other writing commitments, I must now reduce the posting frequency to once a week, aiming for every Thursday.

Also, to help support the effort of maintaining this website, I have signed up to become an Amazon affiliate, which means that if you enter Amazon through this website to make a purchase (say, by clicking on a link for a reference or by using the widget in the sidebar), Alert & Oriented will receive a small portion of the price of your purchase from Amazon.

Thank you for your support and continued readership!


5 must-read articles about what good medical decisions are all about

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I told you before that I would do my best to avoid bringing up phronesis, but a superb essay by Lisa Rosenbaum, national correspondent at the New England Journal of Medicine, is forcing my hand.

In “The Paternalism Preference — Choosing Unshared Decision Making,”  Rosenbaum calls into question the gradual shifting of the burden of decision-making onto patients in the name of informed consent and autonomy.

The essay begins by examining the issue from the patient’s perspective, but Rosenbaum’s reflection then turns to the role of the physician.  She remarks:

But science cannot answer a question at the core of our professional identities: As information-empowered patients assume greater responsibility for choices, do we assume less?

The answer to that question has to do with our understanding of what constitutes good medical decision-making.  Clearly, the prevailing notion assumes that good medical decisions come after a rational approximation of an objective biological reality, a “predictive analysis” that forms the core of “evidence-based medicine.”

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Evidence-based mania: an intoxication of the intellect

And an attack against reason

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For many years, thoughtful commentators have highlighted the shortcomings of evidence-based medicine (EBM).  Among them was Alvan Feinstein, one of the great pioneers and theoreticians of clinical research, and arguably one of the founders of the EBM movement.¹  But despite the increasing discontent with this mode of thinking, EBM remains an extremely prevalent intellectual vice that has captured the mindset of the medical community.

In the last few days, I came across some particularly striking examples of how EBM dominates the medical psyche.

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Prohibition: Then and now

Arguments against banning or taxing our way to health

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The following editorial was first published in September 2014 on the blog of the San Francisco Medical Society. At the time, a ‘soda tax’ was on the ballot for voters to consider. The measure was defeated but the debate continues, as seen in these recent BMJ editorials. Note: the version below is slightly modified from the original.

Nearly one hundred years ago, the eighteenth amendment to the United States Constitution made it illegal to produce, transport, or sell alcoholic drinks. The prohibition was the culminating action of a “temperance movement,” a century-long grassroots effort aimed at curbing the consumption of alcohol. The movement arose in response to an epidemic of alcoholism and was guided by the compelling argument that alcohol is toxic and that alcoholism brings along serious social evils: chronic unemployment and family neglect or abuse.

Today, a similar movement is taking shape in response to the obesity epidemic. Excessive consumption of sucrose and fructose in ubiquitous “sugary” drinks has been identified as a main cause and found to be responsible for the high prevalence of diabetes and its associated health and socioeconomic complications: cardiovascular and renal disease, blindness, premature death, and exploding health care costs. The new temperance movement decries the excessive use of sweet beverages and calls for restricting their sale. These restrictions can come in the form of taxes or outright bans.

But is resorting to taxation and to the strong arm of government always a wise move? I propose some arguments to ponder:

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