![]() We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists-but we’ve paid little attention to how to make them fit together well. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively. Among our most profound difficulties is making them work together. ![]() ![]() Medicine requires the successful function of systems-of people and of technologies. For those getting the best results-the hospitals and doctors measured at the top of the curve for patient outcomes-are not the most expensive. There is a bell curve for cost and quality, and it is frustrating-but also hopeful. Two communities in the same state with the same levels of poverty and health can differ by more than fifty per cent in their Medicare costs. There is remarkable variability in the cost and quality of care. For health care is not practiced the same way across the country. This is just what good medicine is like, we’re tempted to say. We in medicine have watched all this mainly with bafflement, even indifference. Our deficit problem-far and away-is the soaring and seemingly unstoppable cost of health care. But take both away and you’ve made almost no difference. One side says war spending is the problem, the other says it’s the economic bailout plan. By 2025, we will owe more money than our economy produces. And then there is the frightening federal debt we will face. State budgets will have to double to maintain current health programs. Health care will go from ten per cent to seventeen per cent of labor costs for business, and workers’ wages will have to fall. By the end of the decade, at the present rate of cost growth, the price of a family insurance plan will rise to $27,000. And the country is also struggling mightily with the costs. The result is that more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities. Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies. There is no industry in the world with 13,600 different service lines to deliver.īut this could not be further from the truth. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. And for each one we’ve discovered beneficial remedies-remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses-13,600 different ways our bodies can fail. Since then, however, science has combatted our ignorance. Half a century ago, medicine was neither costly nor effective. We’re talking about a problem rooted in scientific complexity. When we talk about the uncontrollable explosion in the costs of health care in America, for instance-about the reality that we in medicine are gradually bankrupting the country-we’re not talking about a problem rooted in economics. Worse, the fear is that the knowledge has grown beyond our capacity as a society. The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. This is a deeper, more fundamental problem than we acknowledge. I didn’t feel much better equipped when my wife had two miscarriages, or when our first child was born with part of his aorta missing, or when my daughter had a fall and dislocated her elbow, and I failed to recognize it, or when my wife tore a ligament in her wrist that I’d never heard of-her velluvial matrix, I think it was. The information was not anywhere in the textbooks. “So tell me: where exactly is the solar plexus?” I remember one time when a friend came with a question. And, inevitably, they turn to the medical graduate in the house for advice and explanation. Since I graduated from medical school, my family and friends have had their share of medical issues, just as you and your family will.
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