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When last we left the village (about 2 weeks ago) whose entire existence was to support pulling babies form the stream, a search party had gone upstream to find out where the babies were coming from. Meanwhile there were still babies coming down the stream. As you may remember, a very sophisticated infrastructure had arisen to pull the babies from the stream. The folks who took the lead, the “baby savers,” took their job very seriously and were valued. They often had to jump in and save babies who were coming down or might have to manipulate the equipment to pluck one from the waterfall. As befits their importance, they were paid very well and had an honored place in the village.

The baby savers executive committee, already threatened by the fear that the search party might find where the babies are coming from and put a stop to it, began looking somewhat critically at the entire operation:

Baby saver president: As you know, we have been looking into the “babies in the stream” issue. We have a lot of folks who care a whole lot about babies and have been giving  there time to make sure the babies are pulled safely from the water. However, it seems there is room for improvement.

Village baby saver: What do you mean improvement, we work our butts off.

Village baby saver 2: Yeah, we are up all night. Often I have to jump in. The water is cold.

Baby saver president: Well, we have started to keep track of your work and, to be honest, we are not doing some of the things we should. As you know, we pay you by the baby.

Village baby saver 3: Your point?

Baby saver president: Not to name names, but I think we should have thought through this more carefully. I’m not going to name names, but one of you pulls out a lot of babies. Many of these babies are blue when they come out and the baby resuscitators are complaining. They say you (not to name names) are too rough and push others out of the way so that you can get the most babies.

Village baby saver 2: They are just jealous.

Baby saver president: And one of you, again I’m not naming names, is just too old to do this. Your eyesight is poor and you don’t swim well. The resuscitators have to jump in and grab your babies but then you take credit.

Village baby saver 3: They need to step back and let me do my job.

Baby saver president: I suspect the search party will be successful and there will be many fewer babies going forward. So we are going to start posting how well you do on the wall over there and it may well be that some of you won’t be able to be baby savers any more. From now on, everyone will know how many babies you catch, what percent are blue, and how many went over the waterfall that you should have saved.

Village baby savers (talking at once): wait, that isn’t fair. How is it my problem if they come down too fast? What if more than 2 people are on a shift? I have a wife and kids to feed. Those resuscitators can kiss my…

If you want to see how hospitals do in regards to preventable mortality and certain procedures and use that to pick your hospital, the government’s hospital compare website is for you (go to this site). If you want to see if your hospital or surgeon has an unusual number of complications or just doesn’t do a lot of the procedures that you need, Propublica has a tool that compares individual surgeons (go to this site). If you want to float along and let a random person pull you out of the water and hope they do a good job, enjoy the ride and I hope you avoid the waterfall.

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News item:

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On the NPR show “Wait, Wait, Don’t Tell Me” when this item came up one of the panelist suggested that this was an evidence-based decision. Perhaps a study of homeless people had been done and they had all sung the “Crayon Song” one too many times. Big audience laugh…

As a parent, we want a lot for our children. We want them to have a good life, to work hard but not too hard, to enjoy beauty and the company of others, and to have a family of their own to torture them like they tortured us. To this end, schools function to provide content that our children need to learn but also contribute to the rest of this as well. By ignoring any outcomes but college acceptance, we diminish the other aspects of education.

The two pillars that predict community success are educational and health care infrastructure. Measuring both has been fraught with peril.  Like Justice Stewart said about pornography, we know good schools and good healthcare when we see it. Unfortunately, that metric, like pornography, is difficult to quantify. In the Mobile   public schools that my children attended, there was a metric of “total scholarship money offered.” This was a particularly weird metric that encouraged the students to apply to colleges they had no intention of attending so they could receive a reportable scholarship offer. The healthcare metric, “Providence Hospital is MY hospital” is likewise not a good metric. If you go to the government’s hospital compare website (found here) you’ll swhat are good metrics.

Commonwealth has just come out with the latest report on the state of our county’s health (found here). We as a community once again fared poorly. Out of 306 health regions, we are listed at number 270. Of the 43 metrics that are used to assess our health system’s performance, we were excellent in one and very poor in 13. We were rock bottom in 3. What are we best in? Nurse response to call lights and home health wound healing. We are rock bottom in preventable mortality (people dying early) and people who have lost 6 or more teeth.

Mostly, it turns out that good schools reflect a critical mass of motivated parents who are willing to pay extra to attract good teachers and work harder to help their children achieve. When that happens, the halo effect tends to help others to achieve as well. Health care quality, it turns out, also is dependent on insurance status, educational attainment, regional income, and engagement of people in their own health. To improve education or health care delivery, it takes a village.

People want to live in areas with quality education and healthcare. I can only hope we can find a metric other than early ABCs to measure kindergarten quality with.  I also hope that our doctor governor accepts the health care metrics and charges us to work together to improve them, rather than force us to live in denial and in a broken system.

 

Have you ever watched television during the day? When I was much younger I recall staying home sick and one of the pleasures (aside from getting to eat Popsicles) was getting to watch black and white re-runs of 1950s television shows such as “My Three Sons” and “The Real McCoys.” Now, daytime fare seems to be geared towards ex-judges making pronouncements regarding the courtroom decorum (the favorite of the break room  this week is someone called “Judge Pirro”).  I don’t get to sit through much of the programming but if I did I understand I would see these commercials:

I now know all about Binder & Binder, America’s most trusted social security disability advocates. I know about Colonial Penn life insurance: they won’t reject your application because of age (even if you’re over 50), don’t require a medical examination, and is only $0.35 a day. And don’t forget the SunSetter retractable awning that makes it so you can enjoy the outdoors without baking in the sun.

Many of the daytime commercials (there are also a lot for medications related to osteoporosis, cancer, and erectile dysfunction)  contain the television commercial of equivalent of fine print, that rapidly read or speedily scrolled disclaimer that allows the advertiser to comply with the letter if not the spirit of what (I supppose) is a legal requirement to inform the public that what is being said in the ad is at best a half truth.

I bring this up because it surprises me that while lawyers are required to tell us that because they can purchase air time it in no way implies that they are any good at lawyering, medical professionals are under no such compunction. In fact, there is evidence that misrepresentation in ads for medical services is not uncommon and they are designed to:

  1. Manipulate patients’ ignorance and vulnerability; and
  2. Stimulate demand for unproven or ineffective therapies

Academic health centers were no better than their less academic colleagues:

In a study of advertisements produced for academic medical centers, Larson and colleagues found that more than 60% of the advertisements directly appealed to patients’ emotions. Further, the same study found that medical centers consistently promoted procedures or therapies with unproven benefits.

So what, you say. We are exposed to ads in a number of settings and for a number of products. Why not health care? Aside from the fact that many health care decisions are made under duress, the author of the article on medical advertising also points out that:

In the majority of circumstances, the consumer of healthcare services can’t truly be informed about what he or she is buying. Assessing the efficacy and safety of medical treatments requires time, reflection, and often expertise that most patients don’t have. Even if their sponsors’ intentions are honorable it is extremely difficult for medical service advertisements to convey the complex risks-and-benefits ratios that underlie intelligent medical decision-making. Complicating matters further, indicators of quality in medicine are extremely difficult to assess for the healthcare professional—let alone the layperson. As one author has put it, “the sheer complexity of medicine, and the quality measures it has available, virtually guarantees that any statement about quality that can fit comfortably in a popular advertising format will be deceptive … .”

What to do? One solution would be to require “fine print.” There is a web site where data for each hospital is available. Known as Hospital Compare,  it takes data from Medicare patients’ experience and uses it to compare hospitals to state and national benchmarks. It includes information regarding the process of care (how many patients get appropriate antibiotics), the outcomes of care (death rates for certain illnesses), the use of imaging studies (does you hospital order too few? Too many?) and patient satisfaction (would you recommend this hospital to a friend). Requiring inclusion of this type of comparison information in an advertisement would allow the consumer to compare hospitals based on information that is non-biased and data driven. Hospitals would at least have to use creativity to make their shortcoming appear as advantages, as Cialis did with a certain 4 hour problem. At the very least it would allow the consumer to make a more informed choice, like we do when we pick a lawyer based on the quality of the television ad.

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