Sunday, May 20, 2007

paJAMA Blogging

There is an editorial in the most recent issue of the Journal of the American Medical Association which purports that the American medical system is no longer, in the author's own words, "the best in the world." His argument is that it's quite broken. I read a few panicky news articles about the JAMA editorial, and thought I should see what the guy has to say. Thankfully, we subscribe to it here, so I was able to read it. (Update: Found a posting of it)

In short, the author, Ezekial Emanuel, states that the American healthcare system is broken. He cites as proof statistics which rate the American healthcare system as #45 amongst countries while we pay the most for our health care (16% GDP, more than any other western nation). Additionally, he cites ours as having only mediocre rates for lifespan and infant mortality compared to other countries, even Cuba. Not that I'd worry about how we compare to Cuba; Castro's government could tell me the sky is blue and I'd be skeptical.

These statistics are all alarming at face value, but I've no idea what went into forming them. Emanuel does cite his sources, so I could always chase those down and see what the methodologies were. We'll call that a "rainy day" project.

The problem, however, is that Emanuel jumps straight to his conclusion from there. He goes on to argue rhetoric and anecdote to further his case, that Americans feel like they're getting diminished returns for their money, that many would rather spend the money on food and shelter. The latter strikes me as a bit of non-sequitur for his general point, but that's not really important.

Only briefly does Emanuel attempt to identify any cause for our healthcare system being sick. He notes that American physicians are fast to adopt innovation and invention, whatever new (i.e. expensive) treatment, medicine, or technology is being developed. Additionally, he states that American physicians will make a lot of off-label use of medicines and implants.

So, I'm left unconvinced. Emanuel tells us that America's healthcare system needs drastic health due to the statistics above, but nowhere does he attempt any explanation for those statistics aside from cost. So we're ranked 45th in the world . . . why? Our life expectancy is lower . . . why? We have slightly higher infant mortality rates . . . why? It's a terrible mistake to try to find solutions without first identifying the actual problem.

I'll concede that, since it was a three page editorial, I shouldn't expect a great deal of policy and scholarship from it. However, given the "doom and gloom" tone of the article, I'd have expected at least something resembling a coherent approach to the topic. Instead, as I said, it was mainly rhetoric with pleas for solutions to unidentified problems.

I'd have expected more from JAMA.

Update 2
Had an interesting conversation with my sister this evening, a 3rd year medical student. Based on what she's had in her classes, she postulated that the infant mortality rates may be due to the incidence of drug use ("crack babies") among mothers, as well as a failure to get proper pre-natal care, for whatever reason, and that the life expectancy is due to the rate of obesity in America.

If these were true, then I think it'd invalidate everything Emanuel posits in his piece. Changing what we spend on obesity is going to have no effect on life expectancy, since health care won't take the food out of your mouth. Similarly, no change in medical spending is going to make irresponsible mothers see a doctor or prevent them from using drugs during pregnancy.

At this point, it's reasonable to ask where we are spending all of that extra money. I'm wagering a guess that it's partly in cosmetic surgery, and partly in cancer therapy. Cosmetic surgery is a huge industry in America, and one that would have no effect on mortality rankings. Now, I remember reading something a while back saying that cancer patients have a much longer lifespan in the US due to their access to testing (earlier detection) and newer or more effective treatments. I can't remember where I read it so I can't cite it, but if it is the case then it would explain to me how we might be spending so much more.

None of this is meant to put a firm seal on it, but I'm left even more unsatisfied than before with Emanuel's case.

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