electricland

Ah, nothing like The Rage first thing in the morning. (Courtesy Cousin Jen.)

The Health Care Crisis and What to Do About It, New York Review of Books

Haven't read it all yet, but it looks interesting. (And hey, Paul Krugman again!)

Very excited about this pilot study on wait times for knee and hip replacements from Alberta.

The average wait for a first orthopedic consultation dropped to six weeks from 35 weeks, according to an interim report on the program released yesterday.

In the project, which sends patients through a central-intake system and has its own doctors and surgical space, the average wait for surgery after the first consultation has plummeted to 4.7 weeks from 47 weeks.

And the average hospital stay has shrunk to 4.3 days from 6.2 days.

Andre Picard's commentary is very good -- it will probably disappear behind a pay-for-me barrier tomorrow, so ( here it is )

(The Alberta Hip and Knee Replacement Project's website has the full report [PDF].) Extremely promising -- and publicly funded too, whatever will they think of next? It sounds similar to Ontario's Cardiac Care Network, which is widely praised as an initiative that centralizes the bureaucracy, stays on top of patients' conditions and needs and moves them up and down the waiting list as necessary, streamlines the process of getting through the system, and generally Gets the Job Done. More, please. (Of course, I'm trying to figure out how to relate this to paediatrics for work, but I don't think the issues are really similar enough to do it -- so this is merely personal squee.)

And in cool science news from PNAS:

An Asian origin for a 10,000-year-old domesticated plant in the Americas

Grammatical Subjects in home sign: Abstract linguistic structure in adult primary gesture systems without linguistic input (language patterns developed by congenitally deaf people deprived of any speech or sign input)

First-hand account from an extremely pissed-off doctor.

(Thursday)

We discussed a plan to set up a triage station on the opposite site of the current one. Now our "hospital" had swelled to encompass both the East and Westbound lanes of Interstate 10. Helicopters still landing. About 3000-5000 people still in our location. I received word that the FEMA official said that they were pulling out. Until this point, FEMA was providing no medical assistance, but they were helping to obtain transportation for these people. The transportation was inadequate to say the least, and now they were pulling out? I approached the official and asked him whether it was true that they were pulling out and if so why. I was told that yes they were leaving, and he was unsure why. His comment was that the decision had been made by "people above my pay grade" as he shrugs his shoulders. Rumor was that shootings in New Orleans had spurred someone higher up in FEMA to pull back. This was ridiculous. We were 1.5 miles outside of New Orleans proper. At that time, we had no security problem. We did not have a security problem until later that day when transportation slowed almost to a standstill. No more FEMA, very little transportation. No coordination. It is Thursday -- 3 days post storm! There was no gunfire at our location. Only people in dire need of medical assistance and transportation. The lack of transportation for the people caused more of them to become medical patients. Dehydration and exhaustion. The FEMA official walked away leaving our crew, the local EMS crew from Austin City, and a mass of people -- patients lying on the Interstate in their own urine and feces. Supplies were still minimal -- oxygen, albuterol, IV fluids. I was rationing 2 bottles of nitroglycerin.

Absolutely appalling. Worth reading the whole thing, although you'll probably have to register (try Bugmenot).

Jim MacDonald is now my guru in this area. He published this a couple weeks ago, but if you haven't seen it, do read it, if only for the comparison.

archaica posted this New Yorker article on health insurance by Malcolm Gladwell. Very interesting indeed -- I recommend it. [ETA: I am also going to make a dentist appointment RIGHT AWAY.}

It put me in mind of this frequently referenced essay on "health care zombies", discredited ideas that will not die [PDF]. Posting the link so I can come back and read it all the way through one of these days.

Still simmering quietly over my ER visit. I don't mind so much about me -- I knew I wasn't in imminent danger of death -- but when nobody at all seems to be moving out of the waiting room, there does come a point when you start to think "OK, seriously. There are no doctors working at this hospital, are there?" For instance, waiting with me were a mother and her teenage daughter, who had cracked heads with another girl while playing soccer and was now woozy and vomiting. They'd been there since, I'm not exactly sure, but no later than 9 p.m., and they were finally called around 3 a.m. That is Just Not Right.

The triage nurse told me it wasn't that they were especially busy -- and I could see they weren't -- but nearly all their examining rooms were full of people waiting to be admitted. Which, I'm sorry, is just a sign of basic bad management. Not underfunding, not understaffing, nothing to do with how our health system is funded -- just inefficiency and a lack of will to change. Meanwhile, nurses are sitting over at the desk chitchatting. I should add that not one person came to check on the girl with the head injury while we were waiting.

At 9 a.m. they opened up a section (which to add insult to injury was called "Minor Treatment") and started calling us in batches of five. And it didn't exactly go fast, but as I mentioned it took a doctor all of 5 minutes to come in, ask me a couple of basic questions, poke and prod a little, measure the circumference of my calves and send me for a Doppler ultrasound. Are you seriously telling me that a doctor could not be spared for 5 minutes over the 9 hours I was sitting in that waiting room? Even if the vascular lab wasn't open at night, poke me and prod me, send me home to my own bed and tell me to come back in the morning or if I start to have chest pain or shortness of breath. I can do that. Same with the kid who needed a couple of stitches on the bridge of his nose. Same, I'm sure, with any number of people who needed to see a doctor but would really have preferred not to spend their night in that very un-urgent ER.

So I went hunting and found a couple of interesting sites -- I'm sure there are many more:

Institute for Healthcare Improvement (patient flow section)
Society for Health Systems (a lot of it is members-only, but they've got some good stuff in their newsletters)

Slightly related thought: on Friday at book club I was chatting with SS, who recently had an excisional biopsy following an abnormal Pap smear. She said the doctor was one of the best in the country for what she might have, but she didn't like his bedside manner -- he never said "S, you must be really nervous, don't worry, you're doing great," or anything of that kind. Which struck me because my response to any statement like that would be "Of course I'm nervous, you idiot, I might have cancer. Can we get on with this very uncomfortable procedure, please?" Mind you, I tend to prefer my doctors clinical with a side of flippant, so it sounds like this guy and I would get on just fine.

Bedside manner is such a fuzzy concept. As long as my doctor isn't actually insulting or belittling me -- which is why Dr. Gregory House and I would not get on at all -- my main criterion is competence. Likability is optional.