I’ve been following Dr. Gawande since his first piece in The New Yorker. He’s the clearest thinker and writer on these topics I’ve read anywhere.

He’d be a natural for Surgeon General in an Obama administration.

I’m in agreement, Richard. But Surgeons General don’t get to practice, and Dr. Gupta is a good choice for a mostly PR related position. I’d love to see Dr. Gawande in a position in which he can continue his good work.

Supporters of single payer plans such as hr676 understand that the profit motive in both the payment and delivery side must be controlled. Profit motive has a place in selling rugs and cars but the doctor should have his interest in providing good care to the patient as the only goal. the media is ignoring this great plan whereas most doctors, union members and the population want it. The leadership in all these groups lack the will to represent the opinion of their respective members. a It would help if the media demanded the congressional budget office compare the current plans in the senate with hr676.
At the VA where i work levofloxacin is dispensed for $120 dollars per month. the same drug is almost $1000 per month in the private sector. Controlling profit motive for all is important and the Baucus plan will not do it and neither will Kennedy plan that just looks at the payment side

I cannot understand how the U.S. is one of the only industrialized countries not to have socialized medicine

I am Canadian and I get just as good care as an American for less cost and I do not worry about getting sick and going bankrupt.

I am horrified,but I somehow knew this. I do not have insurance, I pay out of pocket. Many of the services you have discussed I cannot have because of the cost. I must use common sense and the least expensive ways to obtain my health care. If there were a single payer system I would not change how I keep down health care cost. I do not use an of the new drugs because there are older drugs available to treat my issues and I can have those prescription filled for $4.00 at a number of local drugstores. I have to save money for months to have any special procedures.

Why didn’t Dr. Gawande look at models from other countries in his search for medical reform? We don’t have to reinvent the wheel…

The high cost of health care is a direct result of how education & culture affect one another in defining (& distorting) what it means to be a doctor. The advertising & selection process for future healthcare professionals in schools & in the media cultivates & reinforces the assumption & expectation that doctors are supposed to make a lot of money. This culls too many of the worst people that are driven by neurotic greed to become doctors.

In addition, there are either not enough doctors or, oppositely, too many people getting sick at one time. The solution is to either increase the number of doctors or to decrease the number of people getting sick at one time. Either halves of the solution would decrease the cost of healthcare.

In addition to a negatively stressful medical school training environment, doctors are overworked so naturally they would feel entitled to more money. There is also an incentive to intentionally keep the relative supply of doctors low which is to keep the cost of healthcare high – so that those that make it can make more money. This is determined by the politics behind education. The downside is that not only do the costs become too high but not enough time is spent with each individual patient.

Similarly people don’t learn how to take care of their health in school. Rather people are trained to become fodder for the healthcare industry. Bad habits are facilitated and the assumption is taught that problems can be fixed with a pill presented with a white lab coat. Future patients are unwittingly taught from an early age in school that doctors are about treatment rather than prevention.

The healthcare industry should be renamed the “sickness industry.” This is capitalism at its ugliest.

I am a primaty care doctor. I am proud to be a representative of that group. If I wanted to design a health care system that is effective and inexpensive, I would want it managed by people who aren’t profit driven. They are your primary care doctors. All you have to do is look at the what they spend, look at what they are reimbursed, and look at their outcomes. If you need more data you can also look at every other nation’s heatlth program in the world

I’m very curious about why OnPoint would not have included Jon Skinner, Elliot Fisher, or Brenda Sirovich on the program. It is their work that Dr. Gawande used throughout the New Yorker piece. This is not an area that Dr. Gawande has published on in the scientific literature and he’s not actually an expert on this very complicated topic. He’s really more of a health journalist. The discussion could have been much richer if OnPoint had included some actual experts.

I hope that Dr. Gawande can discuss Intermountain Health and Medicare incentives for quality vs. fee for service.

It was my understanding that Intermountain Health was able to cut hospital acquired infections tremendously, and it hurt their bottom line, because they weren’t being paid for readmissions. It was only because of the strong Mormon culture of the institution that they pushed ahead.

I believe that over utilization of tests and treatments exist, but that personal responsibility for one’s health is sorely lacking for many people. As a health care provider,I have seen many people over the years who have never exercised, eat whatever they want, are obese, some smoke or at least did in the past. They refuse to change, and expect health care to diagnose, treat and save them from the consequences, often in a very entitled and demanding manner. This is not to say that those who take care of themselves are always healthy, but they usually have less of the preventible complications.
As adults, it is difficult to change life long unhealthy behaviors. Current programs that help parents to teach their young children to eat better diets, exercise, and realize that they have some control over their health may be the best long term solution.

My 92 year old mother lives in McAllen and I have witnessed some of her medical care. Although many people in McAllen are poor and uneducated and would never question a doctor, many are also retirees who have a sense of entitlement to the most possible care, whatever the cost. The doctors are happy to oblige and Medicare or insurance will pay. Does your knee hurt? Get an MRI and arthroscopic surgery. You’re 85. Your knees are going to hurt. My mother has pancreatic cancer. The first doctor recommended a Whipple procedure, which would have killed her and she would have gone along with it if we had not stopped her and made her leave McAllen for a second opinion elsewhere. She returned to McAllen and got chemo and radiation, which have been ineffective. She spends all her time going to doctors and they give her the attention she craves. After she broke her hip at 89, they told her to get used to the idea that she would spend the rest of her life in a wheelchair. Within 6 months, she was walking again, but that was due to her stubbornness and her children’s intervention in finding a new rehab place. After 3 stents were placed near her heart, the hospital staff told me that they would look in on her every 8 hours through the night (no EKG was connected as she slept). We had to intervene again. Not only is the “care” expensive, it is appalling. I live near Boston, but I can’t get her to come here because the doctors in McAllen treat her “as if she were their mother”.

I listed to the program just now. At one point, Dr. Gawande noted that putting doctors on salaries wasn’t feasible because “they’d walk out at noon, saying, okay, I’ve done my share for the day.”

What?!! Outrageous! Can you imagine any other profession behaving, or being allowed to behave, that way? Lawyers? Policemen? Teachers? What on earth makes doctors feel such entitlement. A doctor friend of mine once told me that in their minds, M.D. stands for “Medical Deity.”
Apparently so.
I’ve long suspected that the health care crisis’s dirty little secret is greedy, overcompensated doctors. Dr. Gawande appears to have at least partly confirmed that.

sadly it is not that well wont have health care for all but all people in the u.s. be required to have health insurances with high cost and punished if u dont have health insurance like in mass.

The first things that will be passed is not savings and cheaper health care, but how to get people on and force them to stay with these private insurance companies.

even know once u have it u cant use it, and it still puts u in debt it is the preception of having it.

Main reason why the private insurance companies jump on the band wagon with the whitehouse, esp after all the money and capture market they got from Mass. and laws and rules that even if u found cheaper insurance in mass. u still have to pay the state cause it below a certain level the state and insurance companies agreed on.

even last week in congress they said they wouldnt make it cheaper if it would effect the private insurance companies, and the insurance companies will still make it worth it for doctors to do what your guess stated.

I hate to disappoint you Mike but Gawande considers what Massachusetts did a good thing. At least that’s what I heard him say during another NPR program.

ON YOU PRESENT PROGRAM: I AM ONLY SON, IN MIAMI, MY MOTHER WAS CONSIDERED “DIABETIC DEPENDENT ON INSULIN” BEEN AFRAID FOR HER HEALTH, I TOOK HER TO ANOTHER DOCTOR THAT CONFIRMED THAT SHE WAS NOT NEITHER EVER BEEN A DIABETIC.
TO HAVE MY MIND CLEAR I TOOK MY MOTHER DOWN TO ARGENTINA WERE I CAN PAY FOR ALL HER EXPENSES AND ALSO I HAVE A DAUGHTER THAT IS A PHYSICIAN.
AT PRESENT I AM EXPENDING A LOT OF TIME IN ARGENTINA TO BE SOME TIME WITH MY MOTHER AND EXPENDING A LOT OF MONEY.
I EVEN CALL THE FBI, SOMEONE SAID THEY WERE TO CALL ME BACK, NOBODY CALL.

The Massachusetts plan is not working, it’s imploding as I write. We can’t sustain the cost and the premiums keep going up. It’s a real scam if you ask me.

Great topic. Just as it was 30 years ago when first described by John Wennberg at Dartmouth!!

The goal of “managed care” was to require patients to see, or at least give a “referral” for any patient to see a specialist. This experiment worked for a while but is failing primarily because patients don’t want to be restrained. I have many patients who push to have every test and see every specialist.

You miss entirely the point that the under-reembursed primary care is dying off. New doctors are not chosing Internal Medicine, Pediatrics, or Family practice but instead the higher paid specialties. Primary care docs are routinely cheated by our “system” Why are doctors the only experts that aren’t paid for their telephone advice?? Yet I can be sued if someone alleges that my FREE advice was bad!

We have doctor friends in both the U.S. and England. The difference in their lifestyles is enormous. The English doctors are middle-class, not much different than other highly-educated professions. In contrast, our medical friends in this country who are specialist seem to live in another stratisphere…three homes, boats, world vacations, art collections, etc…closer to hedge fund managers than say professors. Bottom line is this “wealth over health” group give no better medical care than their English counterparts. In fact, the latter offer more personalized, common sense care for their patience. The outcome? Just compare the mortality rates for countries with socialized medicine to our own for-private system and the result is clear – they live longer!

Having read some of the comments and being a lifelong skeptic, I am concerned that Dr. Gawande’s observations will be misused by those who oppose health care reform. What I see here is that McAllen is a place where doctors who are interested in a profit motive have congregated. Apparantly El Paso ran them out, or more likely, they saw that McAllen was a place where they could make more money. I suspect that doctors whose first language is Spanish see this as a refuge for them where they can get patients that will do what they say. Could be similar to Miami. But my main point is not that these are bad doctors because of their conceivably poor English language skills but that the existence of the poor practices of these doctors in McAllen should not stand in the way of a new system, which may not be perfect, that covers more people. I see this report as being misused by those who oppose health car reform similar to the “Harry and Louise” commercials. I say reform first and fix it later. The present system cannot be worse that what will come later. I’d like to hear from some of the experts that Dr. Gawande relies on mentioned above to see if they have the same take on the situation that he does.

I only listened to part of the show, but question whether Medicare has “nothing” to do with the cost of medical care. My private insurer pays for two days in the hospital after major abdominal surgery (C-section). Yet, my in-laws, who are in their 80′s and are good people who listen to their Dr.’s, invariably have hospital stays for “tests”, with little resulting afterwards, and their stays always seem to last 7 days. Call me cynical, but I assume that the Medicare plan pays for 7 days in the hospital. They also have 4 physicals per year. This is clearly Dr.s taking advantage of the system (for their own income purposes) which the taxpayers support. How many children could get one physical per year if we weren’t paying for 4 physicals and excessive hospital stays for folks in their 70s, 80s, and 90s? Where are our priorities? Unfortunately, 4 year olds don’t vote, and don’t have AARP behind them.

As a primary care physician, as I wield my trusty pen to write orders which generate healthcare costs, I intuitively consider 5 factors:
1) What is medically appropriate/necessary?
2) What does the patient want?
3) What will the patient’s malpractice attorney expect to see done if I were taken to court for unlikely events outside of my control?
4) What are the financial costs to the patient/society?
5) Will I make enough money to stay in business and continue to employ my office staff?

In order to solve the healthcare crisis, 3 of the factors need to be modified by:
2) Stop direct-to-consumer advertising by pharmaceutical companies. Start Health Savings Accounts where patients pay a meaningful percentage of their bills and get to keep a small percentage of the money that’s left over each year. Patients need to have more “skin in the game.”
3) Malpractice reform to limit frivolous law suits and excessive damage payouts.
5) Pay less for expensive procedures. Pay more for quality care and good outcomes. Pay me for managing the health of my age/gender/illness-adjusted population of patients. And get rid of unpredictable and stupid billing rules that require exhaustive unnecessary documentation.

“You must have profit. If there is no profit, no reward, then talented people will choose another profession. Don’t kid yourself. People aren’t altruistic, and that is why communism will always fail.”

Doctors receive a government granted monopoly on the practice of medicine. Medical school slots are limited. Immigrant doctors must go through rigorous testing. Now all these probably increase quality of care. But they also restrict supply – to the point where a Doctor can make a very comfortable income and still put their patient first. Doctors that abuse their protected profession status by putting profits first are abusing the social contract that make their high incomes possible in the first place.

As a primary care physician, I truly doubt that the vast majority of physicians are running up our health care costs in this country. Our out of control costs have 4 major contributors: the pharmacy industry and the insurance industry are obvious culprits. But technology also plays a role (just because we “can” do a test/procedure, doesn’t mean we “should” do a test/procedure). And patients are the other component, whether that be in their lack of healthy lifestyles which contribute greatly to disease processes or their expectations for “more” health care. The fact that over 50% of health care dollars are spent in the last year of life neccesitates us to start making some decisions, again about what “should be done” as opposed to what “can be done”. We need to ask what is the cost and what will be gained. Our health care system also needs to change to invest/compensate primary care for prevention and early disease management, rather than trying to play catch up with much more expensive/intensive specialist care late in the disease process. Until these issues are addressed by health care leaders and congress, little change will be possible to rein in current expenditures.

I live in the US, and I work in the medical field. My sister has been living in Spain for over 8 years and I am horrified to see the care they have in their socialized system. Some examples she has experienced are as follows, just to name a few:
1) She was admitted for observation over the weekend while suspected of having an ectopic pregnancy (this can be an emergency), without having an ultrasound. The plan was waiting for it to rupture to send her to surgery because there was nobody to do an ultrasound because it was friday 3 PM and all radiologists were already gone for the weekend. In the US she would have had an ultrasound and the question answered in 1 hour. Of course, if docs cannot get sued in a socialized system, why would they care providing a fast and accurate diagnosis?
2) She has a daugther with rheumatoid arthritis and had to wait 6 months to have an MRI in the only hospital that was available to do it in a young kid. She flew to the US and had the MRI done next day. Note that she is instructed and educated and had struggle with the system; imagine what would happen to an noneducated, poor patient…..
3) She lives in a town with a population of about 100,000, 30 minutes from Madrid; there is no emergency room or surgical facility!!! If she has an emergency or urgent consult, they have to go first to a “general doctor” in local “offices” that do not have emergency, x-ray or laboratory facilities. These are usually crowded, doctors are usually not well prepared and not motivated, and if anything “medium tech” (such as an appendicitis) would be needed they are transferred to the general hospital downtown where they are treated in a very “impersonal” way.

Of course this is cheaper than American Medicine, but is also poor quality of care. Is this what we want?

Let’s not be idealists. Motivation is everything in life. If docs are not motivated (they are not well paid and cannot get sued) they would not care as much as they should.

I could go on and on for a while, but my conclusion is that we cannot get good and cheap at the same time.

Another thought is that we, Americans, have a different mentality than Canadians and Spanish. We are more demanding. We expect faster and better service. If we don’t get it we complain, we sue, etc. Forget about complaining in a socialized system. And get ready to wait………….

It’s easy to claim all the theoretical benefits of socialized medicine when we are enjoying the real benefits of the best medicine in the world that we have in the US. Everybody talks about the health care crisis, but over 70% of patients that have private insurance are happy with it. Uninsured patients are not denied emergency treatment in any hospital. Many counties have indigent funds that provide coverage for nonemergency services.

I’m sure none of us would go to Spain, Sweden or Canada to have a cardiac surgery, but thousands come every year to the US to have surgeries and other procedures.

I propose to all who claim for a socialized system to travel to any of these socialized medicine countries to have medical services so you will realize what you are willing to loose here in America.

@Richard C.,
I agree with many of your observations. However, comparing the U.S. to China, India or Indonesia is an apples to oranges comparison. A valid statistical sample is drawn from economically similar populations.

The bar graph in Exhibit 1 http://www.kff.org/insurance/snapshot/chcm010307oth.cfm
is the right comparison to make.

While Canada’s population is a fraction of ours the population of the OECD population exceeds ours.

Finally, Gawande is comparing behaviors of physicians and not patient populations. During the show he points to another town in Texas with a similar population with much lower costs but very good care.

Richard C. – Medicare is being destroyed by the seniors that use it…look at those silly “scooters”..do you really think the taxpayers should buy grandma a scooter? or just pay for major medical care…I watched my parents use medicare like there was no limit…I lived in japan for 12 years..traveled throughout Asia…Japan has both private and public medical care…but YOU HAVE TO BUY INSURANCE..and they have people that TRACK YOU DOWN IF YOU DON’T PAY…as witnessed by a recent high level gov. offical who was not paying…China has public but it’s bare bones..you have to tip the doctor if you want care…otherwise you BUY MEDICAL INSURANCE or go to a PRIVATE CLINC. One good country was Thailand..they have very good public hosptials…but still have a private medical insurance market too…so for the USA a combination of both would be best…BUT YOU HAVE TO PAY…nothing is free…and Medicare needs to cut out the fat and just pay the major medical bills..forget the scooters…

It’s wonderful that some of the people posting here will use the worse examples of National Health Care such as Spain’s or Canada.

How about we look at Switzerland, Netherlands, France and Germany or Taiwan for that matter to get a better idea of how to redesign our failing health care market. We do not have a system, we have a market and that is the problem it’s run by for profit insurance companies and pharmaceutical companies. Lets also not leave out the lawyers in this mess.

I’m not against having private insurance companies, I just think they need to be regulated and costs need to be controlled as they do in Switzerland which I think would be a good model for the US.

It is the corrupt medical industry who is responsible for these shortages:
http://www.usatoday.com/news/health/2005-03-02-doctor-shortage_x.htm
They manipulate the supply of doctors, creating shortages so they can keep financially raping their patients.
The medical industry is a scam, and doctors are nothing but crooks who send patients into bankruptcy while buying more vacation homes and Lexus SUVs.
Do no harm? Think again.

Sorry former PCP, but there is no career choice which absolutely guarantees a six figure salary besides medicine. You may work hard to get there, but once you do, it is EASY MONEY with LITTLE WORK.

The whole “if I wanted money I would have gone into finance” is a crock argument. Finance and banking are not guaranteed 6 fig salaries and you don’t have job stability as you do in medicine. There is no comparison. In America, MEDICNE = MONEY = RESPECT. This is why people do it.

As for all the time it took, face it, Residency is nothing but PAID TRAINING. Don’t expect such sympathy because of that. You got paid to learn. Not many jobs will offer years of paid training.

And please stop complainig about loans. You can usually pay those off within the first couple years of financially RAPING your patients

I know many doctors, residents, and med students. While they love to complain, just like you do, I can get them to admit that they have it GREAT –> overinflated salaries with flexibility and manageable hours.

Your industry is CORRUPT, thanks to the AMA and other organizations which work HARD to LIMIT the supply of doctors.

“Do no harm” is a crock. Medical bills RUIN PEOPLE’S LIVES so doctors can maintain their hedonistic lifestyles.

I grew up in california “beanerville” and culture, is based on LOCATION! and “prime case” relief . circulation of aliens [average european-americans"]

my grandpa was a 3rd gen doctor in milwaukee wi , who “never raised his rate$” and was confident with basic german and french language skills to help most all, in ’70s or 80′s spanish overcame immigration “Standards” exchange students often went to “latin amer” not euro-lingual standards…

mani-”festering” destiny may need a critical medical quantification to prevent defeating ourselves. and fooling ourselves by-proxy!!! location, youth, beliefs , subtrafuge , sweet conspiracy. make ones own culture rise above THE LOCATION!!! OF FOLLY!!! UN-REALITY by-PROXY . microscope sociological intervention, unbelievable , salvation quick quiet. location is fixable, but shameful to take flight without wit-hout WINNING and proving you are good enough and heroic to leave for heavy culture [YOUR CULTURE! that is definately the fix! but seems awkward to even think about, cultural normative values and provable statistics, and historic new-amer-bastard...FAMILY-"COP OUT",=irish/Eng...X...euro=Amer! soc-econ, class GEOGRAPHIC INTERVENTION....invisible pathogen of fundamental normative solution and perfect flow [exchange 1% quantified teens] and manifest destiny vs “THE child left behind” assure mental “”fair-play!!!”" health in love not by destiny but geo-science, poli-geographic CULTURE VACCINE!!! by-proxy, 1% effects, affects, offects, infects, insects??? “rats”? it’s a jungle in latin-U.S.A. where, who, when, why, $$$HOW, teen, cultural normative value, location most critical PREVENTION OBLIGATIONS…$,i.Q.phy$eek…. zen in atlantic? hari-kari?
writing on the wall’s, is for the bravest of readers only! to find civil societal , peace that has no conspiracies bigger than the “stereotypical gods”[quetzal] , obligation to prevention A.N.N.Y.T. is a fundamental quantification adaptable to both ocean regions of u.s.A. [“P.O.W. victim of cultural location of theoretical confrontation; 1% that must go! at YOUTH TEEN!!! emotional norm.:,. high quality case studies . very effective intervention A.N.N.Y.T…. Dr. Doogy Hauser MD, Boy genius!”go!”

What “surgeon/author Dr. Atul Gawande” provides is an inaccurate, non-scientific diatribe based upon misleading data. His primary hypothesis centers on the following statement: “Nevertheless, if you have the patience to pore over nationwide Medicare data…In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average,” Gawande notes. “The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.”

AND THIS IS EXACTLY WHERE Dr. Gawande is misled, and carries forth with a cacophony of error.

Nowhere in his article does he address the “Winter Texan” aspect of Healthcare provision in McAllen, nor how this fact skews the Medicare data upon which he bases his over simplified analysis. The fact that each winter McAllen sees a near doubling of its Medicare age population certainly accounts for this differential. Maybe in his next analysis, he could understand the data before jumping to his predetermined conclusions.

It is no wonder that Dr. Gawande seems to favor the non-scientific literature, and “Imperfect Sciences”.

He also failed to disclose his conflicts of interest relating to his personal bias for Clinton Era socialized healthcare.

Bob, do you live anywhere near the border with Mexico, or have you lived near the border in the recent past?