Devil is in the details

(Note: this was also published at improvehealthcare.wordpress.com)

Harvard Medical School’s Department of Health Care Policy put an incredible event on this past Monday. The video and suggested reading are available on the website. The speakers were: David Cutler (Harvard), Allan Detsky (University of Toronto), David Goldhill (Media and Technology executive), and Daniel Kessler (Stanford).
Overall, I thought that the symposium was tremendous. Often speakers don’t want to disagree with either others ideas too much, or they disagree about minute details–at this event, there was no shortage of (very respectful) disagreement. I walked away feeling like I understand the nature and magnitude of the complexities of health care reform much better than when I entered and armed with some new language and frameworks with which to approach the issues. The longer I work in health delivery, the more I’m struck by the different sense of urgencies people feel: the speakers seemed intent of understanding the nature of the beast and saw it as a precursor to reforming health care. All except Cutler felt that the pending legislation was trivial or harmful, but failed to offer other actionable recommendations. I’m torn on this–I think history shows countless examples of how we’ve dug ourselves into a hole by not appreciating a problem fully. On the other hand, when the decision not to act may result in suffering and/or death, there does seem to be a moral imperative to get out of the ivory tower and get busy (recent post by Bill Easterly on the pointlessness of airport security makes me a little wary to assert this too confidently or with too much moral indignation).

doctors without borders

Human resources for health remains one of the most controversial areas of global health debate. Large numbers of medical practitioners, most notably doctors and nurses, trained in the developing world migrate to advanced economies, resulting in extremely inadequate levels of human resources in many parts of the world. Foreign medical professionals now make up an important percentage of our health care providers--my grandmother has commented that in her small town, none of the doctors at the hospital are U.S. born. By one estimate I found, 25% of health professionals in the U.S. hail from other countries.
As someone who spends most of the day thinking about the health problems facing developing countries, it can be a little jarring to open up the Boston Global or New York Times to learn that in fact, we in the United States are facing a "critical shortage" of doctors. These figures are a few years old, but the U.S. has roughly 1 doctor per 400 population. This of course varies regionally, but is the national average. Meanwhile, in India, where I traveled a few months ago, the ratio is closer to 1:1,700. I still can't even begin to wrap my head around Malawi, where there is one physician per 50,000 people. I have almost as many doctors in my office as they have in the entire country.