This is probably the most devastating effect of the whole “healthcare costs are rising too fast, let’s all freak out” movement.

Instead of taking a holistic approach to solving the problem of healthcare costs, the absolute most cited reason for rising costs is too many “unnecessary” procedures. But if there’s even a remote chance that your patient has an undiagnosed health problem that can be diagnosed by a medical scan, in what way is that scan unnecessary? This is called preventative medicine, and tends to have negative repercussions on the profits of the healthcare system. Ain’t no money in keeping people healthy…

A better question than “why are so many people getting CT scans,” is “why the hell does it cost so much to get a CT scan?” See this Forbes article for more information on that second question.

This is an extremely odd analogy to give as far as success and failure goes. CT scans are a part of the diagnosis process, done before any therapeutic steps take place.

In other words, say you want to look at the health outcomes in the case of coronary artery disease. If you are trying to find the most efficient (i.e. highest success rate, relative to the cost) therapeutic practices, what on earth does the # of CT scans have to do with anything? It’s a diagnostic tool, and has absolutely no direct effect on the health outcome of someone who has coronary artery disease.

Sure, every time a CT scan comes back all clear, it’s easy to look back and say, “Well maybe I shouldn’t have ordered that $4,000 scan, since it was useless and all..” but this could not be further from the truth. In fact, they even have a name for this type of faulty thinking:

Hindsight Bias

This is probably the most important concept in this talk: efficiency. But how is it measured?

We don’t know, but one would assume that, by efficiency, Dr. Gawande is referring to the relationship between quality and quantity of services, i.e. “the extent to which time, effort or cost is well used for the intended task or purpose.” In other words, as healthcare gets more “efficient”, we would expect the cost to decrease, given the same # of patients, or else increase proportional to the # of new patients receiving this service. This has not happened in healthcare industry…

However, the argument can easily be made that the healthcare industry has come to see efficiency as the relationship between how long you work and how much money you make from that work. In which case the industry is incredibly efficient, and much more so than in the 1950’s, when the average salary for physicians was a mere $106,889.56 – adjusted for inflation – compared to the roughly $221,000 they now make.

Again, should doctors just stop being so selfish? No, that is not at all the point here.

Again, this whole question of WHY the cost of healthcare has increased in just the last few decades, without a proportional increase in quality, pretty much goes unmentioned in this piece.

Some things to think about as Dr. Gawande continues:

• For what reasons is “incomplete” care being given?
• For what reasons is “inappropriate” care being given?

If you think about it for a bit, these questions break down to two much more fundamental questions:

• Are doctors not smart enough?
• Do they simply not care about the patients health?

The answers to these last two should be obvious: of course they’re smart enough and of course they care (at least, in the long term). However, this talk seems to focus disproportionately on these questions and neglect the first two.

This statement seems to be getting at one of the core problems in healthcare costs: the cost (i.e. the unbelievable amount of personal debt one must take on) of becoming a healthcare provider in the first place. In 2012, the average med-school debt came in around $170,000 – excluding interest.. Including interest and depending on the loan agreement, a young doctor will graduate with a $234,763.65 mountain of debt chained to them.

If one wishes to keep a debt-to-income ratio below 1:1, paying this kind of loan off over the next 10 years requires an income of at least $234,764.40, about $13k more than the $221,000 per year average. Considering the fact that the average physician begins their career around the age of 29-30, many of these men and women are already married (avg. age for men/women: 28.9/26.9) and have at least one child (avg. age of 1st pregnancy: 25.1).

So, is it any wonder that so many doctors sacrifice quality of care for quantity of care?

To switch gears and discuss a stylistic issue…

This is a spoken piece, but the mixed metaphor (cowboys/pit crews) will still clang in some inner ears. Those inner ears are wrong. “We have trained…people to be race car drivers, but it’s pit crews that we need”–so much worse. The mixed metaphor has long been maligned as a cardinal sin of style. But in this post-posted-postal-modern world, the mixed metaphor has a meaning all its own. And a weight. It draws attention to the metaphor itself, suggesting that any metaphor will do because the point is fundamental (And because a metaphor that fleshes out what’s been put plainly in the preceding sentence is inherently remedial). We have trained a socket wrench when what we need is a gaggle of reluctantly barren aunts. “Reluctantly” in the preceding sentence is sinful in much the same way as as mixing metaphors. And yet it means something that couldn’t otherwise be expressed. Ya dig?

Primary care physicians play a vital role in our healthcare system. However, over the last few decades they have been forced to adapt to something unsustainable and contrary to the very ideals of primary care, leading to a full on crisis., as the non-profit group Primary Care Progress points out:

many practices are still using antiquated systems of care delivery. Patients are having a hard time seeing their regular clinicians or finding new ones. When they do secure a visit, it is often rushed…large surveys of physicians’ practices show that for some medical conditions, up to 50% of patients are not receiving recommended evidence-based care.

The “specialization” of primary care physicians has had a harmful effect on professional satisfaction (pg. 73), not to mention the danger it poses to delivering quality healthcare.

This all goes back to a very important warning that Adam Smith gave us about the division of labor:

The man whose whole life is spent in performing a few simple operations, of which the effects are perhaps always the same, or very nearly the same, has no occasion to exert his understanding or to exercise his invention…He naturally loses, therefore, the habit of such exertion, and generally becomes as stupid and ignorant as it is possible for a human creature to become.

This fact is perfectly demonstrated by the recent experience of Kim Little, a woman from Arkansas who had a tiny pre-cancerous growth removed.

After a physician’s assistant spotted the tiny growth just below her eye, Little set up an appointment to get it removed, which entailed much more than she had imagined:

1. Her dermatologist insisted on a special (and very expensive) method of removal (Mohs technique), which took about 30 minutes to complete.
2. Being told she had no choice in the matter, the dermatologist then sent her to the specialized plastic surgeon across the street to get the wound stitched up, despite the fact it would have undoubtedly healed on it’s own.
3. The plastic surgeon then had Ms. Little hooked up to an IV and even put under anesthesia before he performed the simple procedure.
4. She was then billed $1,833 for the Mohs surgery, $14,407 for the plastic surgeon, $1,000 for the anesthesiologist, and $8,774 for the hospital charges.

While there are some very questionable business practices attached to this anecdote, it demonstrates exactly why the cost of healthcare has exploded over the past few decades.

As Atul hinted at earlier (“this was a life as a craftsman”), it’s sometimes helpful to think of doctors – whose ultimate goal should be the production of health & wellness – as you would any other craftsman.

In this sense, the medical profession essentially underwent the exact same changes after the bacterial revolution that craftsmen went through after the industrial revolution; namely, division of labor.

In the highly influential work, Wealth Of Nations, Adam Smith describes the process of dividing labor with an anecdote about a pin-making factory. He correctly argues that one man could scarcely make even one pin a day, and certainly no more than 20. However, it took just 10 men to make upwards of 48,000 a day through the very specific process and technique of dividing labor.