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Wondered when you'd come 'round to this. In my opinion and experience the medical profession really does deserve to be challenged much more. I am a Type 1 Diabetic. I have had this disease for most of my life. I adjust my own insulin levels very well, thanks. I keep my diet regular and healthy. Regularity and a bit of common sense in "good food" (less fat, more vegetables, the really basic stuff) do more than a dietitian ever does.

My doctor's visits now consist of "got any complications, how's your blood pressure, lets look at your bloodwork.... fine, go away." I take care of a good portion of the real work myself.

There is much that modern medicine can do. There is even more it can't and we really need to be honest with ourselves on what it can't do, like solve every ache and pain in an octogenarian. Sorry Granny, bugging the doctor for more pills really won't do anything for you.

Interestingly, there is an X-prize of $10 million for a medical diagnostic 'tricorder' (h/t Star Trek) that can test and diagnose a wide range of ailments with the same accuracy as a panel of board-certified physicians. It might be interesting to see to what extent medicine will be changed by the greater implementation of artificial intelligence techniques. Master systems have been touted in the past and largely failed to be adopted. There have been significant advances since then in AI and many orders of magnitude increases in computing capacity (see IBM's Watson). Maybe we'll see huge increases in productivity in medicine through these techniques to help avert the looming cost pressures. Law is another area that might be vulnerable to increased automation.

My doctor's visits now consist of "got any complications, how's your blood pressure, lets look at your bloodwork.... fine, go away." I take care of a good portion of the real work myself.

I've got a (luckily, quite minor) skin disease, which requires me to apply a special cream twice a day. The cream requires a prescription from the doctor, and each prescription entitles me to two tubes of cream.

The disease will never go away, and I've had the exact same treatment prescribed every time I've visited the doctor for at least the last 15 years. Even when I visit a different doctor, I just ask for the cream I need. The doctor never inspects me or asks how its going.

Each visit costs me $60. Its quite frustrating.

Here, I thought FIRE (Finance, Insurance, and Real Estate) was the new priesthood. Healthcare accounts for 17% of GDP, but FIRE takes in 21% (*)

(*) U.S. Figures. I would assume in Canada, with a more rational healthcare system and an even bigger housing bubble, FIRE would account for more.


Bbut they charge for access to public data up there. Therefore Canadian data is excluded from the public discourse.

I guess they don't know about price = marginal cost.

Someone should tell them.


Even Japan disseminates public data for free.

Andrew F: "Interestingly, there is an X-prize of $10 million for a medical diagnostic 'tricorder' (h/t Star Trek)" Fascinating.

I wonder whether a medical tricorder would challenge medical authority or reinforce it? I'm thinking of, for example, people who obediently follow GPS directions down backroads that lead nowhere. A key issue that Hobson identifies is the informational asymmetry - the medical specialist is the expert. Would computer-assisted diagnosis further centralize information, or empower consumers?

RSJ - "I thought FIRE (Finance, Insurance, and Real Estate) was the new priesthood." - It's about respect, prestige, and renumeration, not just % GDP.

Don't even get me started on data access. It's a scandal. All I can say is that it's better than it was 20 years ago.

Michael - I think this is the kind of thing that is less likely to happen in Canada, in part because the supply of physicians is more restricted so they don't have to drum up business to quite the same extent, and also because prices are controlled. The Ontario Health Insurance Plan's fee schedule lists a price for a minor assessment of as little as $15 (see H101 on the list).

Frances: what a great passage you quoted. I will have to go read it myself now.

I think that same passage could have been written today with equal merit. I would disagree, though, that there is less quackery. True, standards have risen and there have been innumerable advances, but if quackery means "using interventions known to be of little value", we still have that problem on a vast scale. We still have "embarrassing control over the nervous lay public", but whereas Hobson raised concern about unscurupulous practitioners hiding within the larger ranks of the competent, we now have a more serious problem of vast overconsumption of interventions that do far less to improve our health than we think. I like Karl Smith's description of medicine as one of the "engines of stagnation".

RSJ:
If you dont have access to CANSIM, you can access all the CANSIM tables online at E-Stat by claiming you are a student (http://www.statcan.gc.ca/estat/licence-eng.htm) . They are only updated once a year in the summer, but that's better than nothing.

It will not give you access to microdata, but that's better than nothing.

I gave it a quick glance and came up with the following numbers for March 2010 (in chained 2002 dollars):
Table 379-0027
Gross domestic product (GDP) at basic prices, by North American Industry Classification System (NAICS), monthly (dollars x 1,000,000)

All industries [T001] 1,229,992
Finance, insurance, real estate, rental and leasing and management of companies and enterprises [5A]2 257,867
Health care and social assistance [62] 82,608

FIRE was 20.9% of GDP, health care 6.7%

Great quote! It does seem sometimes that the gatekeepers to the medical profession could be holding back innovation that could automate or streamline the delivery of medical care. Though, as Hobson points out, they are hardly the only specialists engaged in rent seeking behaviour.

RSJ - "I would assume in Canada, with a more rational healthcare system and an even bigger housing bubble"

Could you explain why you think there is a housing bubble in Canada? I'm very interested in this issue and have been looking through data (Stats Canada and Teranet Housing Index and so on) and alternatively find evidence for or against the existence of a bubble: the CPI for rentals has not risen nearly as much over the last ten years as the CPI for house ownership (bubble!); but, the wages of construction workers (especially in Alberta) have risen with the cost of houses, suggesting new homes are now just plain more expensive due to rising labour costs (no bubble? Or because of rising speculative demand for houses?).

Simon C - I'm not sure that the 6.7% figure includes, but it can't be all health care spending. If you're interested: try this OECD data source: http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_1,00.html.

Great tip on the CANSIM tables.

Shangwen - "vast overconsumption of interventions that do far less to improve our health than we think" - yup, and I edited out some of the parts about hypochondriacs. I found Hobson's observation "Among all grades of workers with a rising margin of wages drugs are sheer fetishes" interesting - do you have any thoughts on the psychology of this? I found it fascinating that someone would make this observation 100 years ago, when I think of soaring pharmaceutical costs as a totally modern issue.

(Mostly unrelated aside: great-great-grandfather Woolley escaped from the Lancashire cotton mills by becoming a successful patent medicine salesman - probably he was one of the quacks Hobson had in mind...)

Frances: re "Among all grades of workers with a rising margin of wages drugs are sheer fetishes". Boy, do I have thoughts. (OK, I know plugging one's own, very inferior blog is annoying, but I have a relevant post on the issue here, using Canadian data, and some pontification.)

I think the psychology behind this is a combination of Robin Hanson (signalling to show that one has a valuable life), and the ironic fact that the vast rise in living standards over the past few generations has encouraged both excessive cautiousness and a desire to reward conspicuous achievement. The cautiousness leads us to be overly credulous of claims about prevention and early detection (both of which have dismal track records in mitigating disease burden, despite the hype). The reward impulse is expressed, I think, as the phenomenon whereby we want to attribute our relatively high status in the world to the very visible actions of a small group of individuals--the priestly class. In reality, our increased health is due to the invisible and incremental actions of hundreds of millions of people who slowly pushed up GDP, sought more education, built more livable environments, and demanded better food, but that is pretty mundane stuff. Far better to recognize the actions of those who bring about "scientific miracles" and "huge advances in medicine", and show our appreciation by consuming their rent-laden goods and services. Supporting them affirms that we believe we live well because of a supposed innate superiority, and not because of the boring, error-filled muddling-through of many many millions over the generations (including your grandfather).

Anecdote: I recall doing a brief rotation in an outpatient psychiatric clinic for kids (mostly behavioral problems). One phenomenon that I have never forgotten was that the majority of parents came in frustrated, fed up, and wanting impossibly fast change. However, the parents who were upper-middle class, educated, and more refined (managers, professionals, teachers, etc) were always careful to say to the clinicians something like, "We find this really difficult to live with. But we know there's no quick fix and our son/daughter may need to come here for a while before things change." On the surface, that sounds like--and is generally taken to be--the sophisticated, enlightened response, the sort of thing that Oprah viewers are told. But who on earth doesn't want a quick fix? I sure do, and so should anyone who values their quality of life. I think what those parents were doing was stressing their higher status by being willing to consume more while expecting less--like a ritual offering, but with their time on the altar instead of a white bull.

Shangwen - that's an excellent post. On psychotherapy utilization you write on your blog: "it would not surprise me if a lot of those well-heeled patients were also, to use psychologist Richard Walter's deathless words, "sitting down for an hour a week to talk about their cats and dogs"."

I don't want to be dismissive of mental health problems, which are often neglected and under-treated. Still, what I really want to know is this:

What is better for your mental health, talking to your psychiatrist about your dog, or talking to your dog about your psychiatrist?

Before I become the target of hate-mail, no, I was not being dismissive of mental illness in my post. What I was pointing to was the phenomenon, also very common in the US and pretty much anywhere in Canada, of "workers with a rising margin of wages" crowding out--in a very big way--those who are both poorer and more mentally ill.

So my remedy for that, and my answer to your last question, is that it would be cheaper for the health care system to buy rich people dogs and make them pay for psychotherapy. But then they might insist on purebreds with health plans....

Um, I've been in the Mental Health system too. Psychologists, who are paid for out of pocket in Ontario do "talk therapy". Social Workers do to, but with a different "take"; they are paid for by OHIP. Psychiatrists prescribe pills and leave the talk therapy to others. Actual psychiatrists are valuable enough that they have to be utilized efficiently.

For depression the latest research has shown that group-based Cognitive Bahaviour Therapy is effective and since it's group-based, efficient in both effect and cost.

For the dog, exercise is strongly encouraged for those with mental health problems. It's not so much talking to or about the dog as taking the dog for a walk. A Labrador Retriever of my acquaintance sees me and instantly things "walk" and jumps for joy. I have often joked that she should be a prescription in and of herself. If you forget to walk her she gets annoyed and reminds you, constantly, until you walk her. It's an effective counter to depression-based slacking.

As a point of fact, Bethlem Royal Hospital, aka "Bedlam", the world's oldest asylum/mental health hospital (it recently celebrated its 750th anniversary) found in the late 1700's that giving inmates pets like chickens made them behave better and feel better.

Dave,

I don't want to get into a big debate, but I would first look at aggregate price to rent ratios and mortgage debt/household income ratios.
I don't think construction worker salaries, size of home, increased desirability, etc., is relevant. Those are TTID arguments ("this time it's different").

If you have access to micro data, then you can (and should) look at the above by tenure. Bubbles may show up in the aggregate data, but they deflate on the margin.

Frances: (Apparently my previous comment got lost and I lost the links).
I had a quick glance at how they define health care spending and it is a much wider spectrum than simply the share of the GDP of the health care establishments, which is why my 6.x% figure is lower than the OECD's

I was surprised to see that the data was prvided by a NGO, the Canadian Institute for Health Information (CIHI) and not statscan.

From an anecdotal perspective, I know that my wife, who is an emergency doctor, often deals with patients that she refers to as the "worried well", and who she thinks probably do not need professional medical care - though, by definition, one must also treat these patients extra cautiously, because of the threat of lawsuits.

Overconsumption of health care doesn't just have to do with doctors pushing more and less effective treatments, but the demand for those treatments by patients - which is where I have trouble with relating it to the quote and the reference to a priesthood.

Another piece of that is actual quacks, like homeopaths, who seem to be able to get significant business treating people in a way that is wholly lacking in effectiveness. What is the portion of GDP that is spent on "alternative medicine" and other ineffective tools that are ostensibly about creating better health?

Whitfit: Good comment. I think it is essential in the healthcare debate to realize that overconsumption and overprovision go hand in hand. I suspect your wife, as an emerg doc, is not in a position to fruitfully encourage more consumption, but other types of practitioners are, such as psychiatrists and other mental health therapists, dermatologists, rehab clinicians, etc. It varies by situation. Nonetheless, patients also blame docs for being greedy or arrogant. One has to ask: what is it about our system that leads the two most important actors--clinician and patient--to so mistrust each other?

"One must also treat these [worried well] patients extra cautiously, because of the threat of lawsuits". This is a very unfortunate problem. Empirical research on defensive care shows that most practitioners have a very exaggerated belief about the risk of litigation, so their overprovision (or defensive underprovision) in such cases is many times more than the real risk. This is a small source of waste, but eliminating it has more to do with organizational structures, since it is difficult to simply exhort clinicians to act more rationally in that regard. Clinicians with the most accurate estimates tend to be those who are in the litigation league tables--especially obstetrics--because they deal with it routinely enough to have a reliable sense of risk. In other groups, it's all rumor and urban myth.

There are few reliable estimates of CAM (complementary and alternative medicine) spending, as the definition varies widely. However it is true that those with the greatest willingness to spend on such products fit the profile of those who demand the most from the mainstream health care system: the educated middle- to upper-middle classes. They are willing to spend significant amounts of money on gaining essentially 0 marginal health, just to show that they can. It's the group with "a rising margin of wages" yet again.

Shangwen:
"One has to ask: what is it about our system that leads the two most important actors--clinician and patient--to so mistrust each other?"
Lack of information. Most patient never go through enough procedures to be knoledgeable about the game. I totally trust my GP as I seeher regularly for my diabetes ( inherited, unfortunately, so the price mechanism won't work).
Most doctors don't see their patients often enough ( thankfully) to know them personnally.

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