Monday, June 22, 2009

Blogging and Gender [Bryan]

I am usually fairly late in adopting new technologies. The Internet, though, has been an exception. I was on Prodigy before hardly anyone else knew what the Internet was. I began reading blogs around 2002 during the debate about the Iraq war. At that time, blogging was a rough and tumble world of flame wars and impolite ranting. It was totally a man's world.

Now, however, most of the bloggers I know personally are women. They tell me that I am the "only guy they know who blogs." It has been a strange evolution.

I think my perception of change has to do with the growth in LDS culture of mommy blogs and family blogs, which consist mostly in pictures and updates on family happenings. This type of blog is particularly popular among student families, who use blogs as a way of keeping in contact with family "back home" in Utah.

This, of course, is a completely legitimate way of thinking about blogging. I like to check in on family blogs, too. But I'm sure many people find our blog to be odd, with, for example, a series on posts on economics and health care. The reason for this difference is this: I was "raised" on the Internet during my formative years to see blogs as places to debate ideas and I can't quite shake that upbringing.

Saturday, June 20, 2009

Taking history into your hands [Bryan]

I've been following closely the hopeful/historic/troubling events in Iran. I don't know if the election was stolen, although I suspect that it was. I don't know much about this Mousavi guy, although he doesn't seem like much of an improvement. It has been hard, though, not to be deeply moved by what is happening -- to watch people with the courage and determination to take history into their hands and try to shape it into something better.

I watched a YouTube video today of a young Iranian girl bleeding to death in the streets of Tehran. It was horrific thing to watch -- a series of images that will stay with me for a long time. She was probably in her twenties or late teens, dressed as a more conservative Muslim. She was shot in the chest. One can see the blood spread. One can see the life drain from her eyes. One can hear the panicked screams as people realize how badly hurt she is. All for what? It could be for nothing. Or for everything.

Times like this make me feel small and trivial. Today, for example, I went to Walmart, went to the lake, and played Guitar Hero. It was a fun time, well spent with family. But I have never taken history into my hands. I have never left in the morning knowing that, during to day, I might be beaten or even killed for taking a stand. I have never really stood up to someone (or for someone) like that, fought for justice with everything on the line. What would I do? Would I find an excuse?

I pity people who face such situations. But, sometimes, I also envy them. They know something about themselves that I do not know about myself.

Friday, June 19, 2009

Why Was Our Healthcare So Expensive? Part II [Bryan]

I should clarify, I think, Dr. Gawande's position. His project is to explain why health care costs vary so much from city to city. He cites some studies about differential treatment between cities:
Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.
If doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.

Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and “adequate health insurance to cover tests and medications.” Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines. But when it came to measures of less certain value—and higher cost—the differences were considerable. More than seventy per cent of physicians in high-cost cities referred the patient to a gastroenterologist, ordered an upper endoscopy, or both, while half as many in low-cost cities did. Physicians from high-cost cities typically recommended that patients with well-controlled hypertension see them in the office every one to three months, while those from low-cost cities recommended visits twice yearly. In case after uncertain case, more was not necessarily better. But physicians from the most expensive cities did the most expensive things.

So, in cases where the science is unclear, doctors in high-cost cities tended to adopt a "more treatment is better" approach. He points out that this can't all be explained by differences in the doctors' training. In any given city, doctors come from many different medical schools. He argues instead that, sometimes, a culture of over-treatment arises in some cities. And, sometimes, that culture arises because some doctors develop an entrepreneurial spirit about the practice of medicine. Health care costs are explained, then, by some mixture of hazy science combined and the particular culture of medicine in some cities. It's the culture, then, not simply individually greedy doctors.

What this suggests is that better science can help us reduce costs. For this reason, I think the Democrats are wise to push "comparative effectiveness research" and the Republicans wrong to oppose it (the Republican strategy appears to be to stringently oppose reforms that would save money in medical practice, and then bitterly complain that health care reform is too expensive).

Tuesday, June 09, 2009

Why Was Our Healthcare So Expensive? [Bryan]

We recently added up the total hospital bills for the birth of baby Stephen. Remember, we had an emergency C-Section, plus a brief visit to the NICU. Ellie's bill totaled $20,000, while Stephen's totaled about $10,000. That is a lot of money. Luckily, we didn't have to pay these bills with our insurance, but it got me wondering: Why does health care cost so much?

In addition, I've been wondering why American health care performs so poorly against other health care systems worldwide. In other countries, they spend a fraction of what we spend on health care, but their health outcomes are usually much better than ours. Why does our health system do so poorly with all the money we put in?

I think I've finally found an answer, and it has almost nothing to do with malpractice lawsuits, greedy insurance companies, or "socialized medicine" or lack thereof. The problem is, unfortunately, doctors that have become businessmen (and women). Doctors make money on tests, surgeries, procedures, referrals, and so forth. It is in their interests to maximize the use of health care, which drives up total costs and, since all medical procedures have risks, this actually makes for poorer health outcomes. Or so this article (byAtul Gawande) claims. Go read it. Most interesting thing I've ever read about the health care cost problem.

A snippet from the conclusion:

When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

Sunday, June 07, 2009

A Little Better? [Ellie]

A few months ago, I read an article in the Atlantic Monthly by Hanna Rosin called "The Case Against Breastfeeding." I'm sure they chose that title just to be provocative, since its author was, in fact, a breastfeeding mother (eerily, nursing her third and last newborn, a boy--just like mine). Rather than actually arguing against breastfeeding, Rosin was more rebelling against the powerful medical and social coercion associated with it.

I can see why she wants to rebel. Breastfeeding is such a fraught issue. I have friends who can't nurse but dearly want to. I have friends who can but wish they had a reason not to. I have friends who've nursed for years and friends who've nursed for months. I have friends who've gone to extreme measures hoping that nursing would eventually work out and then been devastated when it never did. No matter the variation on this theme, no mother I know has escaped completely unscathed. We are judged if we do (she nursed her kids for how long?) and judged if we don't (she's so selfish).

In her article, Rosin contends that, while recent studies have found only modest benefits, if any, tied to breastfeeding, women are continually bombarded with the message that you are only a good mom if you breastfeed. She is irritated by what she sees as the constant yet unwarranted cheerleading of breastfeeding advocates. Rosin would modify the "breast is best" chant of La Leche-leaguers to "breast is only a little better."

A little better? Well. I'm not here to contest her point. I haven't read the research. She might be right. But I need to believe that the sacrifices I'm making to breastfeed are not just "a little better." For instance, I recently had to turn down the invitation of some friends to go camping because I didn't know how I would manage the breastfeeding issues (To vanish or not to vanish? If not, then I'll have to wrestle with a nursing cover. . .). I've had to interrupt the writing of this blog post on breastfeeding to breastfeed (no lie). I can't really take my kids to the zoo by myself this summer because I don't know what I'd do with my other two in such a vast public place while I breastfeed. Plus the whole nastiness of having to breastfeed in public, period.

Anyway, what I'm arguing for is this: I want to retain my mistaken belief that it is a LOT better to breastfeed. I want Stephen to be healthier, smarter, richer, better looking, and better behaved. I want his guaranteed admission to an Ivy League institution. And for me I want. . .a medal.

But I'll settle for the fact that despite its myriad inconveniences, I kinda like breastfeeding. I love the physical and emotional connection it builds between me and my son. While it might not be as beneficial as I'd like to believe, it still feels like The Right Thing to Do. And I'm a sucker for that kind of stuff.

Wednesday, June 03, 2009

What kind of world will Stephen have? [Bryan]

Last night I watched a show that really, really bothered me. It was called 2100, an ABC News special broadcast. The premise of the show was following a fictional girl, named Lucy, through life as it might play out if some of the projections currently being made about climate change and other environmental problems turn out to be accurate. The segment claimed that these were "worst case" projections, but they seemed relatively moderate to me (at least until the end, which seemed a bit far-fetched). The effects of climate change, judged by melting sea ice and glaciers, seem to be outpacing even the most pessimistic assumptions. They did the segment with some good graphic-novel type of animation, which had a surprising impact on me.

The segment stuck with me because this could be the life of my kids. Stephen, like the character Lucy, was born in 2009. I really wonder what sort of world we are leaving behind for Nora, Andrew, and Stephen. Not a good one, I think. We've really trashed the place -- and it wasn't our place.

The projections are relatively familiar: Gas shortages and riots as oil demand vastly exceeds supply. Outer suburbs become vast slums as people abandon them to live closer to the cities (can't afford to drive). Water shortage in the American Southwest (bye, bye, Las Vegas) and in cities that depend on glacier run-offs. Water shortage and soaring cost of oil lead to food shortages and mass starvation in other countries. Thirsty and starving people destabilize national borders, populations move as islands and low-lying cities flood, leading to war and civil unrest. It is all very grim.

Now, this isn't the only scenario, and certainly the human race has avoided disaster before. There was never a nuclear war, for example, which was a prospect that used to terrify me as a kid. But, in that case, it was obvious that our short-term interest was in not getting blown up. That created restraint and, to some degree, wisdom. With these sorts of problems, our short-term "economic" interest lies in doing more of the same. Humanity has never shown much interest in thinking about long-term problems. I like to think we can avoid this, but governments (and I am looking at you US Senate) seem resistant to even the most modest measures of restraint. I hope somebody proves me wrong.

Here is the opening segment.

Earth 2100: Civilization at Crossroads

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Nora Happenings [Bryan]

Nora's Kindergarten didn't do a graduation (thank goodness!). But they did have a little open house with punch and cookies on the second-to-last day of school. Here is Nora on the school playground with some friends.

Nora and her teacher, Mrs. P., on the last day of school.

Nora's school. Not much to look at, but we like it. The school district is very short on funds (the community refuses to pass a levy), but they do great things with their very modest resources.

Nora recently wrote a series of books we've taken to calling the "Haley series" -- Haley at the Park, Haley Goes to Wal-mart, etc. Haley, from what I understand, is the name of a friend of hers at school. Here she is showing off her work.


Nora's latest piano recital.