Scientific progress without humanity – Monty Python healthcare in New York

If you want enough medication to tranquilize an elephant, CSI-style forensic testing, or the highest standards of litigation-proof risk management, the healthcare system in New York is for you.

If you want to have sane conversations with sane people, or retain a sense of emotional or spiritual welfare…or indeed combine both of these things with preparing for the birth of a child, I recommend you give it a wide birth.

As with many things, Monty Python explained this situation many years ago better than I possibly can.

“OK. Take her into the foetus-frightening room”.

“And get the most expensive machines, in case the administrator comes.”

“Don’t worry, we’ll soon have you cured.”

“NOTHING DEAR, YOU’RE NOT QUALIFIED!”

Of course, this clip is from 1983, and needless to say it was a bit of a shock to me (to say the least) to see that this is still the prevailing approach in New York hospitals. (And rather worse…for example there are hospitals near hear with a C-Section rate of nearly 50%, and rising.)

Why is this?

Well, lots of reasons. The first is that actually, in lots of respects, New York is actually quite an old-fashioned place, its psychology laced with a strong dose of 1920 gothic ambition and a prevailing undercurrent of 1980s materialism – which combine to support an undercurrent of faith in the power of money and pharmaceuticals and surgery that can seem jarringly antiquated. Also, more obviously of course, this is the most litigious place on earth, and everyone is absolutely terrified of doing anything wrong for fear of having these guys after you.

Do you find you frequently need to sue people for personal injury? Like, often enough to need an App on your phone? Come to New York.

But there is something else going on as well. The single biggest difference in being treated by the NHS vs the New York health system is the bias that money puts on the care you receive. The NHS is of course constantly strapped for cash, and thus trying to minimize the care you receive – particularly when it comes to testing and medicine. In New York, the only people who want to keep your treatment costs low are the insurers and the patients.

Thus it is in the interest of everyone who treats you to test you as often as possible, to interpret those tests in a way that requires further tests or treatment, to give you as much medicine as possible…but at the same time to get you through beds as fast as possible (because you don’t pay by the hour.) Honestly, for those guys who haven’t experienced this system, you would not believe how scary it feels to require medical treatment but feel like a walking cash machine.

If you sewed your wallet inside your body, these guys would find it.

Throughout of course, this money-driven compulsion to treat is presented as evidence of the extent of progress and capability in the health system – and in some cases this is true. It is certainly easier to get some forms of expensive and useful treatment in New York than in London. But overall, the system stinks. Because it is driven by money, not humanity (my next post will be on some other aspects of the flaws of money as an incentive to progress.)

I wanted to end with a thought, which has occurred to me a few times – which is that resource in this kind of area is a neat balance. There is never ‘enough’ money for health. Having more money in your health service is generally better for patient outcomes. But there is also something to be said for what has been elegantly described as ‘the design constraint of ultra-affordability.’ Because we shouldn’t assume that the right thing to do and the most expensive thing to do are always the same.

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10 Comments

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10 responses to “Scientific progress without humanity – Monty Python healthcare in New York

  1. Buenosam

    A user experience designer would call it feature bloat. The NHS is a Linux health system: free, ugly, frustrating, and does everything you need in the most efficient possible way. Whereas it sounds like you’ve got something more like Windows Vista in NY…

  2. Fascinating post, particularly because I only know about the US healthcare system in terms of the political arguments we have in the UK where any change is presented as sending us hurtling towards the US system “where you have to present your credit card before they will let you in at A&E”. I.e. political hyperbole.

    There is a lot to be said for trying to do the minimum amount to solve any particular problem. For example, solicitors in the UK often make things far more complicated than they need to be so that both sides in any dispute have to shell out massive costs. I am guessing that solicitors in the UK and doctors in the US have the similar incentives and no wider restraints set by either competition or regulation.

    I do have to ask what you mean by this though: “an undercurrent of faith in the power of … science that can seem jarringly antiquated”

    Are you saying that the pursuit of knowledge and the scientific method are flawed or undesirable?

    • Hi Blue Eyes. Late night, emotional blogging…I of course meant ‘pharmaceuticals and intrusive surgery’ rather than ‘science’. The point is that the prevailing beliefs here are ‘more is better’, whether it is wealth and ownership or drugs and facelifts. And they are simply failing to keep up with the state of the art – which is to balance the capabilities of intervention with the wisdom of patient interaction. Thanks!

      • I assumed that’s what you meant, I would never have had you down as an anti-science person!

        When it comes to medicine I am definitely an active nihilist. Most of the little irritations we all get will go away without any intervention at all. The resources should be pointed at those which don’t!

        Nothing wrong with late night, emotional blogging :-)

  3. Marcus

    Yo Hooky, agree with some of your drift on this, but you’re doing that thing where you oppose using money to determine things, rather than whose money it is, which is really the problem here innit? Money isn’t good or bad, it’s just a unit of exchange – a transferable quantity of stuff.

    There is a problem in the US system that the people who recommend treatment have a financial interest, but there is equally a problem in the UK system that patients don’t. We have a tendency to view the most expensive treatment as the best one (as opposed to the docs in the US), and there is an outcry if a doctor recommends “wait and see” or “it just isn’t worth putting the patient through this procedure – medically or financially”. And sometimes that’s a really really valid opinion.

    Public understanding of medicine is always going to be poor. Even those who read up on their condition are unlikely to be qualified to understand findings in the Lancet. In particular, the UK periodically has insanely ill-informed arguments about screening programs, where it’s crucial to remember false-positive rates. (e.g. if a test gives 1% false positives for a disease that’s incredibly rare, it’s REALLY a bad idea to use it as you’ll tell more people they’ve got it that haven’t, than people that they’ve got it that have) .

    We do have an awful track record of massive unnecessary public expenditure on stuff that many experts will tell you is ineffective or even counter-productive, because the public will clamour for it because it’s “free”. (c.f. individual injections during the whole MMR idiocy)

    Basically, you can choose between public suspicion that US doctors are overspending, and public suspicion that UK doctors are cutting costs.

    • Hi Marcus

      Unfortunately I am not in a position to judge the overall system…if I did I would be blogging like nobody’s business, given the row over Medicare here and Lansley’s experimentation in the UK. The only bit I understand well is natal care (for obvious reasons) and the truth here is that the UK system rocks and the US system is both the most expensive in the world and the second worst in terms of outcomes in the developing world. But here I am seeing the US system at its worst – because pregnancy is a ‘condition’ (urgh) that we dealt with pretty well before the escalation of interventionism. I am sure that if we shifted the focus to, for example, transplant surgery, the US system would perform better.

      I think you are slightly askew on the US system…which does in fact almost always bias towards the most expensive treatment that in the UK would be the path of last resort, and that is utterly obsessed with screening tests. ‘Wait and see’ is a MUCH more likely course of action in the UK – to a fault sometimes (just try getting fertility treatment in the UK, a situation where the clock really is ticking.)

      But in any case, I’m not in a position to judge the whole system in terms of efficiency. I do know that in terms of emotional well-being for the individual, the NHS is much more benign. And I think this isn’t because of ‘Money’, but because in the NHS the financial incentives are relatively balanced (some people want to save money, others want to spend it.) In the US all of the financial biases tend to align on one side – let’s throw money at the problem. And the patient’s needs often get lost. At least hysterical public opinion gives a voice to public opinion – in the US system your opinion really doesn’t feel like part of the system.

  4. Rosie

    Hi Matthew – interesting post. Can I ask whether you have PPO or HMO style healthcare? I hear horror stories all the time about PPO style insurance coverage. But Dave and I use Kaiser Permanente, a Health Medical Organization in which all the doctors, equipment, buildings etc. are owned by the same company that is ‘insuring’ us… it’s a sort of communal organization to which we ‘contribute’ in order to ‘belong’. I’ve found that it works like a slightly more expensive but infinitely more effective NHS. I’m a really big fan. Because the same organization pays for our care and decides what care we need, it circumvents lots of the problems you describe, which are definitely a huge problem in a system where all the different parts of the mechanism (doctor, insurer, MRI scanner makers, drugs companies, etc.) are separate.

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