U.S. Politics: Wile E. Coyote edition

[AutumnEvenings]

This is what most people do, and often it is a huge mistake. I'm glad things worked out well in your case, in terms of the health outcomes for your son. Maybe there was only one surgeon qualified in your area, or maybe there were four or five and one has performed that procedure 5x more than the others. It's your money - it should be your choice. They're not doing you a favor because they are nice.

Well, it did and it didn't. I mean, my son is alive, which is awesome. I assume the procedure he had (a Ladd procedure: http://en.wikipedia.org/wiki/Intestinal_malrotation) worked and hasn't come "unstuck". However, when we later tried to place an NJ or GJ, it turned out that his duodenum had been placed too high, which he will almost certainly outgrow. And like, how many kids need an NJ or GJ? Hardly any. So is this a "bad outcome"? I don't even know. It was sure a disapointment...but it didn't stop me from choosing the same surgeon when my son needed yet another abdominal surgery (http://en.wikipedia.org/wiki/Fundoplication), as I figured he knew my son the best?

Which brings me to:

I thought they were two exclusive questions with no relationship between them. Fortuitous that those were the ones I asked though, because I do understand you now.

You are asking: How can I, the layperson, choose the best orthopedic surgeon? Right?

For one, we face this question everyday. How can I, the layperson, choose the best auto mechanic? Hair stylist? Or, one I hear often: lawyer. It's all pretty much the same.

1: Referrals. If you know someone who had a great knee replacement, who did they go to? It's not any worse of a strategy here than anywhere else.

2: Reviews and recommendations. The Washingtonian publishes lists of the Best Doctors by specialty. I found my current primary physician by a referral from a coworker, but then I actually checked out his Yelp ratings, of all things. They were great. I was convinced.

3: Interviewing the doctor.

A: With many procedures, the number of times that procedure was performed by that surgeon over the last year is far and away the best predictor of post-operative outcomes. Check out the data on nih.gov for your procedure and you can find information on what to look for.

B: What type of procedure are they going to perform? Is a laproscopic procedure available for your surgery? Is your doctor going to do it that way? If not, why not? If the answer is "because I'm not familiar with it" than maybe you want to go to someone who is. If the answer is "because, for this surgery, the outcomes aren't any better and there is evidence that outcomes are better with a traditional open procedure because x, y, and z, then maybe that's okay.

C: What is the expected recovery time? Why? What is there approach to physical therapy and why? (Research shows that earlier is better and many poor outcomes from orthopedic surgery are from post-surgical scarring, which is reduced by early physical therapy, so I wouldn't go to a doctor who was going to start me on physical therapy at the outside of the range.) What is the approach to pain management?

D: Cost. If you could know it. I'd probably pay $500 for an open procedure before I'd pay $5K out of pocket for a laproscopic procedure, even if my recovery time was two weeks less, or more.

What would have I looked for? I mean, it's "my money", as you say, but more importantly, my son's life. I really would not have sought out the cheapest surgeon, or factored cost into it at all. I would prefer medical bankruptcy over the Supercuts of Surgeons...but who does that benefit?

Anyway...would I have sought the surgeon most experienced with Ladd procedures? I don't know a single person whose had one, by the way. But I suppose that's what the internet is for? The surgeon would have needed privledges at my son's hospital, as insurance wouldn't cover a transfer to a "lesser" NICU, and anyway, I highly doubt a pediatric surgeon who didn't have privs at the Children's Hospital would be worth his weight.

Or do I figure open ab surgery is more or less the same, and go with the peds surgeon whose done that the most?

Or the one who has worked on the most four pound babies?

I don't care about bedside manner, but it was nice how his nurses called us every hour during surgery for an update...but was that the surgeon's call or not?

.

I'd still suggest doing your research before you undergo any medical procedure. You don't need to know everything - you just need to be able to ask informed questions. And we should consider expanding the role of the patient advocate - this is a person who does all of this information gathering and physician interviewing for you.

It's really hard to even know what questions to ask. I mainly wanted him to not die, you know?

[Guest Raidne]

...assuming everyone is able, is unrealistic, especially in healthcare, with its desperate/sick/drug-clouded consumers.

Assuming everyone is able to make a fully informed decision is unrealistic in choosing any professional. It doesn't follow, however, that eliminating choice is the answer.

Instead, where having information that would help to make that choice more readily available would lead to more people making good choices, the law should mandate that the information be made available.

The biggest obstacle is getting health care consumers to feel like consumers - people with a choice. Instead, people seem to have a psychological barrier against doing anything other than going to the specialist recommended by their primary care physician - and without even asking why that specialist is being recommended.

[Fez]

The Healthline article excludes deductible amounts. As far as I can tell, Dartmouth-Hitchcock is a Medicare-participating hospital, and so the amount they can charge the patient should be statutorily dictated by the fee schedule, i.e. is unlikely to vary widely. It's probably just a matter of what is being counted.

Again, no. The Medicare deductible for inpatient hospital stays is $1,156 for the first 60 days, only if someone was in the hospital beyond that would their costs start shooting up (and if they do, odds are they are also eligible Medicaid, which, outside of some very specific instances, doesn't have any deductible). I don't know if the healthline article includes deductibles, however bear in mind that for dual eligibles, Medicaid pays Medicare's premiums and deductibles and I would not be surprised if a lot of DC Medicare beneficaries were dual eligible.

And this cost would be included in the overall out-of-pocket costs figure mentioned earlier. So again, the average Medicare beneficiary pays a total of $4,241 out-of-pocket in a year (most often due to events not covered by Medicare at all), less than the $5,000 you proposed people should pay for a single procedure.

[Brienne the Beauty]

Assuming everyone is able to make a fully informed decision is unrealistic in choosing any professional. It doesn't follow, however, that eliminating choice is the answer.

Who is recommending that choice be eliminated? Not me nor anyone else on this thread.

The biggest obstacle is getting health care consumers to feel like consumers - people with a choice. Instead, people seem to have a psychological barrier against doing anything other than going to the specialist recommended by their primary care physician - and without even asking why that specialist is being recommended.

The knowledge gap is just too great for most people to do this. I have a better chance of understanding how a car engine works than how surgery works. It is hard. Most people, if they did this, would judge on how kind the surgeon was at their interview, and if he was a good listener. All of which has F all to do with how good he is with a knife (thank you Doctor House!) Look at the ads for plastic surgeons if you want to know what makes Joe Average go for a doctor - how many of them have meaningful stats?

You can say people should be informed consumers until you are blue in the face, but the fact remains they are not. Take for example the process of choosing a nice neighbourhood restaurant. I look on Yelp, check the restaurant's food hygeine ratings, read the menu and look in the window to see if its nice. If all this is good I try it. But half the time the restaurant sucks. That's fine, I just try a different place next time. (But if this was a surgery, there may not be a next time!) If I was an informed consumer (say a chef or had chef friends) I'd know that the restaurant had a bad rep "in the biz" and ordered from the cheapest and worst suppliers, and I'd look at the rubes flocking in the doors and think "Geez, do a little research, people." But this would be unjust.

[Mlle. Zabzie]

Actually, I know that this is a very emotional issue, and I've been that patient, first in the maternity ward, then in the NICU. Leaving aside "emergency" situations (like AE's), I think it is an EXCELLENT idea to "shop" for doctors.

I talked to several MFM's before I settled on my doctor, and also took a look at the hospital ratings before I decided knowing that if I were in the NICU, I'm stuck with the Neonatology team there (I had that luxury, though). I've talked to more than one Hemotoligist and rheumatologist as well. We interviewed 3 different pediatric practices. I read as much information as I could find about ll of them. My dad interviewed 4 spinal surgeons before he had (elective) back surgery. A friend talked to 5 cardiologists before having heart surgery. In my case, each of the doctors that I spoke to I chose in part (but not in whole) precisely because (s)he didn't treat me like an idiot and actually explained what was going on. Just throwing up your hands and saying "it's complicated! I can't be informed!" doesn't seem to me to be a good way to go about making decisions about my own health.

[Guest Raidne]

Well, it did and it didn't. I mean, my son is alive, which is awesome. I assume the procedure he had (a Ladd procedure: http://en.wikipedia....nal_malrotation) worked and hasn't come "unstuck". However, when we later tried to place an NJ or GJ, it turned out that his duodenum had been placed too high, which he will almost certainly outgrow. And like, how many kids need an NJ or GJ? Hardly any. So is this a "bad outcome"? I don't even know.

I hear you. It's completely overwhelming. An NIH search brings up a few articles that suggest that complications include ongoing feeding difficulties and chronic abdominal pain. The most common complication seems to be the need for additional surgeries within six months after the procedure (26% of the sample of 46 children), mostly for acute bowel obstruction, either small bowel or adhesion-related (I've read about surgical adhesions before and asked the doctor we keep on staff here at my office for medical advice about them - in my layperson's understanding, this is the body's tendency to start attaching tissues that were previously unattached before you started cutting into things and are impossible - seemingly - to completely avoid where there is any surgery).

If none of that happened, I'd say the outcome was good? I don't think you could have done anything more than look at the number of procedures that doctor had performed, and even then, in that particular case, all the studies I see are generally very positive about that kind of surgery, so I probably wouldn't have been overly concerned?

When it came time for the Nissen fundoplication, I suppose you could have asked for a copy of your son's records, including the operative report and taken them in for a second opinion - ostensibly to see if this doctor also recommended full fundoplication, but also just to get an opinion from him on what the other surgeon did before?

I would've wanted both surgeries performed laporascopically, which I bet they were? The doctor on staff here said that adhesions are particularly a problem in abdominal surgery, so minimally invasive techniques are probably best?

Weighing the desire to have the surgery done at a particular hospital that is close to you vs. by the best surgeon available is a tough choice for everyone. Say the best surgeon is across the country. Are you willing to travel and stay at a hotel for the period of recovery? Or not? I think that if I was looking at a surgery with varying outcomes, I'd travel for a surgeon who had done it 50 times over the last year with a great record of successes versus one who had done it 10 times ever.

And I agree that where it is your son's life, money is much less likely to factor into it, unlike a situation where you are looking at two different procedures with varying recovery times and corresponding cost differences.

You can also get basic information to help you understand the issue out of the doctor. I think in any situation where surgery is involved, I'd ask the doctor:

(1) What is the problem - what happens if we do nothing?

(2) What are you recommending - what is this expected to accomplish?

(3) What are the risks of that procedure? What complications are the most common? What factors predict those complications?

(4) What are the other options - other possible procedures? Why do what you recommend over one of those?

I may be wrong about this, but where feeding tubes are involved, I think asking about them and the complications they can cause is a good litmus test. I'd be comfortable with a doctor who really, really lectured me on proper feeding tube care at home.

I don't care about bedside manner, but it was nice how his nurses called us every hour during surgery for an update...but was that the surgeon's call or not?

Generally not - that's usually the hospital, I think? US News and World Report does hospital ratings on those criteria - level of nursing care, etc. They rate surgical departments also. I honestly don't know about which rating to look for - GI surgery, NICU departments? I think you'd have to ask around. There are a ton of message boards these days for the experiences people have had with particular procedures and they full of a ton of useful information on what questions to ask doctors, experiences with particular procedures, etc.

It's not like doctors should be perfect, and we shouldn't expect the same results at a rural hospital as you might expect from the surgeons staffing the country's top department in that specialty. But we should be able to ask questions and get answers. You shouldn't have a problem getting an hour of the doctor's time before he performs a surgery on you or a loved one. There's no reason to be hostile or rude to doctors, but I think it's fair to treat them like people who are performing a service to you that you are paying tens of thousands of dollars to, where you are in fact doing that, no? You should see what people demand of lawyers for tens of thousands of dollars. :)

[Guest Raidne]

I talked to several MFM's before I settled on my doctor, and also took a look at the hospital ratings before I decided knowing that if I were in the NICU, I'm stuck with the Neonatology team there (I had that luxury, though). I've talked to more than one Hemotoligist and rheumatologist as well. We interviewed 3 different pediatric practices. I read as much information as I could find about ll of them. My dad interviewed 4 spinal surgeons before he had (elective) back surgery. A friend talked to 5 cardiologists before having heart surgery.

In my experience, and from what I hear, I have been surprised at how many of them are absolutely willing to do this.

I imagine it's because patients who are fully informed up front don't file medical malpractice suits nearly as often, participate more effectively in their own care, etc.? What do you think?

ETA: Brienne, to me, understanding how a car works is harder. Fortunately my best friend is a mechanic and he will explain things to me in layman's terms. Mechanics, unlike doctors, don't seem as willing to take the time to do this - probably because they are not getting paid $25K for the procedure and don't have to carry malpractice insurance?

[Brienne the Beauty]

I don't think you understand that a lot of people are not as well informed as you, Raidne. You clearly have a high intelligence and a great deal of knowledge. Expecting everyone to be able to match this is as unrealistic as a keen, fit cyclist in a well-designed city wondering why most people won't cycle 30 miles to work. After all, it's easy for him - are most people just lazy?

[naz]

So, even the dumb are deserving of proper health care? Isn't that against everything Darwin stood for?

(I jest, of course.)

[Mlle. Zabzie]

I am still really struggling with the notion that it isnt a worthy goal and helpful thing to give consumers of healthcare more information about service providers and services available to them.

[Seli]

I am still really struggling with the notion that it isnt a worthy goal and helpful thing to give consumers of healthcare more information about service providers and services available to them.

It is a worthy goal. As is making sure that consumers have information about, houses, schools, cars, phones, insurances, food, electricity, safety, clothes, the environment, law, their rights,

The list goes on and on, in the best interest of actual people it is probably best to build a system where gaining information is optional, and not gaining information probably results in a sub-optimal -but never bad- solution. But that means lots of regulations.

[aeu]

We haven't even established whether or not Cyr is an immigrant, or if he's been on a non-immigrant visa the whole time he's lived here.

If I had to guess, I would say that Cyr came to US on a student visa (F1), switched to H1B during postdoc at a university, then continued on H1B when he switched to industry. He probably applied for / obtained a green card somewhere along the way.

If that's correct, he is right that such a path would not have changed all that much since 1996. But it is also true that it applies to a relatively low number of people.

With regard to the H1B, I can tell you that in 1996, the cap for the number of H1B visas was rarely met. In 2008, the entire quota was met in the first day. For the entire year. It didn't take more for the additional 20,000 spots for those with advanced degrees (misleadingly termed "exempt") to be filled either.

The H1B / work based green card system is a huge mess and this is a good example. In 2008, it did not matter whether you had a PhD from a U.S. university and already had a job. Even if you applied on the very first day, you still went into a lottery for H1B visa. They did some temporary fixes after that (like creating extra quota for technical fields), so I think it no longer fills in a single day, but I believe it still fills in a month or so.

I would look at it from a different angle.

I'd say that if someone is willing to bring some capital into my country to start a business, they're welcome to try. What do we have to lose? Give them a temp VISA, like the equivalent of H1B, and let them try for 3 to 5 years. If it takes off, we'll get the tax. If it doesn't, the expenditure pumped money into our economy and we deny his/her application for permanent residence status at the end of the temp VISA. Seems like a win-win to me.

If we are talking about actual capital (as opposed to human capital :)), this is already happening through Investor visas. I believe they are called E2 visas? Basically if you can show that you have a hundred thousand dollars or two, you can set up a company and apply for the investor visa. From what I understand, they are relatively easy to get as well.

[Brienne the Beauty]

I am still really struggling with the notion that it isnt a worthy goal and helpful thing to give consumers of healthcare more information about service providers and services available to them.

Sure. You also need to make sure that consumers of health care who can't take advantage of that don't get terrible care/massive bills. "Caveat emptor" should not be the only principle in healthcare. It should be transparently obvious that a lot of healthcare consumers are unconscious/drugged up/panicking.

[Brienne the Beauty]

They did some temporary fixes after that (like creating extra quota for technical fields), so I think it no longer fills in a single day, but I believe it still fills in a month or so.

The main "fix" here was a massive recession that made not so many people want to go to the USA! When the economy recovers it'll be the same old story.

[Mlle. Zabzie]

I don't think anyone is advocating caveat emptor. I think what Raidne is advocating and certainly what I would advocate is greater information available about procedures, their costs and the people that perform them. That is EQUALLY beneficial on the back end when being charged. That is, if you were drugged, etc, knowing standard or average costs would be relevant in knowing if you were overcharged and/ or taken advantage of. I personally think that more information is only part of a solution, but I do believe that it is an important part.

[Guest Raidne]

I don't think you understand that a lot of people are not as well informed as you, Raidne. You clearly have a high intelligence and a great deal of knowledge. Expecting everyone to be able to match this is as unrealistic as a keen, fit cyclist in a well-designed city wondering why most people won't cycle 30 miles to work. After all, it's easy for him - are most people just lazy?

Okay, read in conjunction with your answer to Zabz, I think you're assuming that more available information = caveat emptor system for healthcare.

But that's not the case. Nobody is suggesting that we do away with the minimum standards in place. I'm not even a proponent of medical malpractice reform. The proposal is that a law be passed obligating your physician to provide you with certain information, including pricing.

I don't think any system should be premised on perfectly informed consumers making perfectly rational decisions. Or even well-informed consumers making well-informed decisions. I do think, however, that where information can be made available to help consumers make well-informed decisions, it should be. That's all I'm saying here. Not that everyone else should be stuck with Dr. Nick.

Right now, finding this information is ridiculously difficult. I honestly have no idea how to find out how many of X procedures a surgeon has performed, or what would be considered a high volume for any given surgery, and I think that information should be readily available. Further, I don't think a person should have to request it to get it - it should be made available to you before you have to sign that "informed consent" form, in order for that form to take on any legal meaning (which I assure you, it certainly does).

In the meantime, healthcare consumers need to learn that it is in their best interests to see themselves as consumers with a right to this information. They need to ask their doctors questions. And expect to receive answers, explained in lay terms. You don't need everyone to be a perfect consumer of healthcare to see better outcomes, just a critical mass of people.

I, personally, have no medical background or training, or even any noteworthy college science courses. Medical stuff also, unfortunately, grosses me right out. The only advantage I have is that, because of my job, I've gotten used to reading medical terminology. That doesn't mean I understand anything that much better; it just means that I'm not intimidated by seeing a bunch of words that look like a foreign language anymore. When I'm working on a case, I can't ask follow-up medical questions to the doctors in many cases, so I have to look things up, but if I could just ask, that is what I would do, and I guarantee you I'd get at least as good of an understanding of the issue from talking to the doctor - and if I couldn't, I'd look at getting another doctor.

[Brienne the Beauty]

Sure, people should have more information, who could argue against that? But it wouldn't make much difference to the many healthcare consumers who are incapable of doing high quality research for whatever reasons. These people need good care too.

[IheartTesla]

Just to clarify, I did mess up what I wanted to say about visas, but in my defence I was typing just as I was ending my lunch break...

Anyway, yes, my own journey was F1-visa to H1B visa and then self application for a green card that involved lawyers and money, but in the end took 4 months to process and paid itself back when I went in to industry.

H1B visas do need a job (here is where I messed up since I never thought of my post-docs as a real 'job'). However, academic and non-profit H1B visas are technically infinite and can be filed anytime in the year (this is not the 20,000 advanced degree cap). For-profit organizations, yes, all the visas are snapped up within a day.

There are many things to be said about the H1B process (like the 6 year clock), but proving an American cannot do a similar job is trivially eay through the non-profit process (or at least, I never had any issue). As for numbers, I am still trying to find numbers for visas through the cap-exempt process, but I want to re-emphasize that they can be as numerous as possible.

[Brienne the Beauty]

It is good to know that academics are not impeded from immigrating due to petty visa caps. However, it is not the issue most people are concerned about, due to most people not being academics.

[IheartTesla]

Then you should be pleased with the US immigration system as it stands, since it is very strict, more so than most countries. If you are OK with the strict system while acknowledging it is very strict, that's your view, no problem. I do get annoyed at people who assume that the USA is as easy to emigrate to as Canada, or even easier, and arguing on that basis.

Canadian immigration is probably easier than US immigration, although anecdotally my brother (who will become a Canadian 'permanent resident' soon) isnt facing much shorter wait times. But at the same time, they need more people. They have vast unoccupued spaces and low birth rates, while the US is keeping up with replacement rates based on birth rates and immigration. Apart from that, Canada doesnt have the same problems that the US has with illegal immigration.

All those are mitigating factors for the US being more strict than Canada. In the end, Canada has 20% foreign born citizens while the US has 12%. Whether the factors above are enough to explain the difference is something I am agnostic on.

But yes, the US situation can be improved. There is no question. But there are mitigating factors.