Seth's Blog

Atul Gawande’s latest article in The New Yorker (gated) is one of his best. It is about attempts to reduce health care costs by focusing on the most expensive patients. A tiny fraction of people produce something like 30% of the total cost. You can save a lot of money, it turns out, if you try hard to help them.

To help them, it turns out, you need to do things that aren’t obvious, such as hire someone whose last job was at Dunkin Donuts (as a “health coach”).  It turns out that not everyone is happy with what you’re doing.

[One high-cost patient] had seen a cardiologist for chest pains two decades ago, when she was in her twenties. It was the result of a temporary inflammatory condition but [the cardiologist] continued to have her see him for an examination and electrocardiogram every three months, and a cardiac ultrasound every year. The results were always normal. After the clinic doctors advised her to stop [having the tests], he called her at home to say her health was at risk if she didn’t keep seeing him. She went  back.

To me, the most revealing part of the article was about a young woman with persistent migraines. During the last 10 months she had required $52,000 of medical care (“twenty-nine E.R. visits, fifty-one doctor’s office visits, and a hospital admission”). Yes, dealing with a persistent migraine by going to the E.R. over and over isn’t getting anywhere. But here is what Gawande (a doctor at Harvard, who writes for The New Yorker) recommends:

She wasn’t getting what she needed for adequate migraine care–a primary physician taking her in hand, trying different medications in a systematic way, and figuring out how to better keep her migraines at bay.

During those fifty-one doctor’s office visits, the woman wasn’t prescribed all possible medicines? And, if she was, she needs a doctor’s help to figure out if they work — which they obviously don’t? How stupid does Gawande think that she and her doctors are?

I don’t think Gawande thinks they are stupid; I think he is unable to stop thinking like a doctor, which means thinking that every serious problem has a solution that includes prescription drugs or other medical care. (Unless it’s obesity, in which case the solution is the ancient advice to “eat less, move more”.) This woman needs to explore lifestyle solutions to her problem. She doesn’t need a doctor for that. But most doctors, judging by their actions, cannot imagine such a thing.

There exists in China a branch of law enforcement called economic police (I don’t know the Chinese name) whose job is to make sure government officials aren’t getting rich — that is, corrupt. Only government officials, no one else. The brother of a friend of mine is one of them. He has been doing it for six years. In college he double-majored in police work and economics. He carries a gun but has only used it once — to stop a government official trying to flee from Shenzhen to Hong Kong.

• misleading genetic tests
• Interview with Jane Jacobs about how the residents of Greenwich Village defeated Robert Moses. One of the most amazing uprisings in America in the last 100 years.
• introduction to umami

In an article about how law schools deceive prospective students, one way astonished me. Thomas Jefferson School of Law in San Diego reported that 92% of their graduates are employed 9 months after graduation. That 92% included the 25% of the students they couldn’t locate. Which is in accord with the guidelines, said the associate dean of student affairs.

I showed a Chinese friend of mine the famous Chinese Professor commercial. In Beijing, 2030, a Chinese professor tells his students about the fallen American empire. It is a commercial against “government waste”.

My friend said that in China you would be put in jail for making such a commercial. There is lots of waste in the Chinese government, she said. I asked her for examples. One is restaurant meals. Government officials go out for extremely expensive meals and eat just a few bites. I have heard that one quarter of restaurant spending in China comes from the government. There is a restaurant near my apartment with absurdly high prices; one of my students said that only government officials would eat there. Another example of government waste is cars. Government officials have big expensive cars.

Inside the Chinese Government.