Just read this again. So much for us to learn here in the way we education physicians in America. Indeed, in the way we practice medicine. Putting an honest price-tag on care is fair. What we do is say 'you need this to save your life,' they agree, and then the family is bankrupt because they had no idea the cost would run into six or seven figures. (All complicated by our nefarious malpractice system.) Great interview.
A very interesting interview, thank you. I think Shetty is 100% right about the importance of long hours during training, the importance of a certain level of dedication (which one finds more often in ambitious young people from scruffy backgrounds[1]), and the value of phone-based software[2]. The overall impression I get is that so-called medical tourism, which one might more charitably frame as the practice of visiting speciality clinics overseas, should be much more encouraged, even by regulatory agencies and the American medical establishment itself[3].
One observation, however: Shetty's approach seems extremely powerful when it comes to medicine that is well-established, what one might call medical engineering practice. But I doubt it will work as well for medical innovation, what one might call medical science. If you want to discover *new* ways of fixing this or that, or new combinations of therapies, then you actually need all the American inefficiency in the system[4]. You need bus drivers (physicians) who are indeed steeped in aerodynamics and how to fix the engine. Only generalists working within a system that has significant inefficiencies, which spends more time and money than it absolutely must, can come up with new paths to treatment. In part because you have to have a more general perspective along with your gobs of practical experience to try coloring outside the lines, and in part because most new paths investigated will *not* be better, that being the nature of the Second Law, one might say -- there are always far more ways to be plausibly wrong than right. You have to be working within a system where "wasting time and money" trying "dumb" (according to the conventional wisdom) stuff that couldn't possibly work better is tolerated.
Which leads me to conclude there should be more regional and national level specialization in medicine: there should be places where performing well-understood medicine as efficiently as possible is the priority, and other places that focus on innovation. (And yet more places in which rock-bottom price, even at some cost in skill and safety, is the priority, for the benefit of the very poorest for whom that tradeoff is worthwhile -- but that's another story.)
---------------
[1] I don't think this is limited to medicine. Certainly in the sciences my experience is that the most creative individuals (cf. Feynman) come from scruffy backgrounds and are working to escape that, and will overshoot, to some extent -- become great in their ferocious attempt to escape sub-par. I think there's some truth to that in business and entrepreneurship, as well. We humans are not at our best when we are comfortable, alas.
[2] In defense of the software industry, part of the problem might be that phone-based software is inherently faster-changing and less reliable, because of the fast pace of phone hardware (and OS software). With desktop hardware, you can lock down some combination of hardware and software that meets the high reliability needs of medicine for a decade. For phones, not so much. And software developers may quail at the reliability needs of medicine for a platform that may change in 18 months with Apple's newest tweak to iOS or Samsung's new chipset. Or rather, they won't quail so much as shake their heads in astonishment at the price they're going to charge you for Apollo 11 level reliability in a Tik Tok video app world.
[3] I mean, BMW doesn't work to prevent you from buying a Hyundai, and Saks doesn't work to prevent you from shopping at Target. It's madness to insist that everyone buy the same kind of medical care, even for the same medical situation -- because all *else* in their lives will often be different. Restricting consumer choice rarely optimizes consumer utility, one would think.
[4] You also need a good regulatory regime, too, which encourages a certain level of innovation without exposing people to recklessness or charlatans. Something between the complete stultification of the nuclear industry by the NRC and the carelessness that gave us lobotomies and Elixir Sulfanilamide.
I don't disagree with anything you've said here. My writings are loaded with similar observations. I could go point by point, but I'll just say that all of this is insightful and valid.
I wonder how much medicine would change, for the better, if insurance companies were prohibited by law from setting arbitrary limits on medical facilities (and physicians), for the services of which they would pay? That is, United Healthcare, those ratfinks, could write a contract saying "We will only pay if you go to our stable of kept MDs (an HMO), or we will only pay if you go to an MD with this or that certification, or get your surgery in a center with this or that kind of instrumentation" but they could *not* write a contract saying "we will only pay if your doctor graduated from an American medical school, and only if the facility that does your appendectomy is in an American state."
One imagines an increased level of specialization, the way we see in cars or computers. China makes the actual iPhones, but the design and software is done in California. Maybe people will very routinely go to Mexico for routine surgeries, and go to Stanford Medical for something really hairy, desperate brain surgery. Economics would seem to suggest this will benefit everybody -- Mexico has a new lucrative service industry opportunity (and smart Mexican kids can get good jobs without emigrating), consumer prices are lower, high-price stuff stays with the fanciest facilities, which would perhaps have to charge more without subsidies from routine operations, but overall one imagines medical costs fall. Plus, competition at the dividing line keeps everybody on his toes...
Probably wouldn't work in the real world, since people are highly irrational about life 'n' death stuff like medicine.
I wrote another piece about Narayana's Caribbean hospital. I asked whether American insurers had considered reimbursing them. They said they had had many such discussions. But, always, they said, the discussions broke down when the insurers found they would only be given one all-in price, and not a detailed breakdown of expenses. Narayana would tell them, look we can give you a flat price of $30,000, or we can set up a new system to do the cost accounting you want, in which case, you'll get the breakdown, but the procedure will then cost $100,000--including the cost of the accounting, software, etc. THe insurers would walk away, saying they needed the breakdowns.
I wrote my dissertation about the idea of health insurance that paid for a diagnosis, not for a treatment. Just as car insurers pay you for the loss from an accident--not for what you do with the money.
Loved the angle of the influence of Mother Theresa! I’ve missed reading your essays for the last several months (life), but happy to return to reading your thoughtful excellent work. Thank you!
I'm fascinated by his excellent point that young people drift away from medicine as the economy gets better. I can tell you that they also leave medicine earlier and some recent data suggests that many medical students around the world don't see patient care as their ultimate destination. I'm not sure what they hope to do, or who will ultimately take care of our sick (like me as I get older). Thanks for sharing!
You must be familiar with the book by Richard Selzer, Mortal Lessons: Notes on the art of surgery. If you are not, I highly recommend as worthwhile to read and ponder. Selzer's prose at times verges on excessively complex but there are passages that are inspired. It is one of my favorite books and I have read it multiple times. The chapter on the examination of a patient by Yeshi Dhonden, physician to the Dalai Lama, always makes me think of how superficial and shallow many of our patient/physician interactions too often are and how little time we spend in preparing ourselves spiritually to practice our art.
Rick, Thanks for the recommendation. And, no, I don't know the book. I'll have a look once I reduce my current pile of not-quite-read books. :) It sounds great. A few years after my undergraduate years at the University of Virginia, Dr. Dhonden lectured on Tibetan medicine at the Med School. The school invited him back, and he did a three-month visitation in 1980, and the school studied Tibetan medicine for years, as a result. From an obit:
"In the mid -70′s, Dr. Dhonden was invited to the University of Virginia for the purpose of lecturing about Tibetan Medicine. Sitting in on the series, one of the university’s research professors was so impressed upon hearing Dr. Dhonden that he asked Dr. Dhonden to join him in conducting a laboratory study using Tibetan Medicine to treat mice with sarcoma. The fact that the information they discovered through this study could help a multitude of people encouraged him to proceed. Dr. Lobsang Tenzin, working for years with Dr. Dhonden as a Tibetan pharmacologist, and Professor Jeffery Hopkins, translator, completed the Tibetan team. ... The outcome was big. It showed that the response of the mice to the Tibetan formulas was equal to chemotherapy and appeared to be without side effects. However, the results of the study were never published by the university. Because the professor did not judge the results important, this discovery went unknown."
Makes you wonder how often in Western we have failed to properly investigate other cultures and ignored alternative therapies that have no promise of a big payday because they are not patentable here. I am, by nature, a skeptic, but if there is one thing I have learned in 45 years of medical practice, it is how complex the humany body is and how interwoven our physical and spiritual natures are. The mind/body connection is very real.
Another amazing post. The story of Dr. Shetty makes me simultaneously proud to be a surgeon and truly humbled, wondering if I have upheld my responsibility to honor my oath as a physician and the adequately carried on the legacy of the surgeons who trained me and those going back generations.
I don’t know enough, and frankly, Bob, I don’t think you do either, to select the single most interesting or (let alone and) important professional of any profession, certainly including medicine. (It is just barely possible that there is an exception for our own professions respectively.)
However, I am certainly willing to agree that Dr. Shetty is a very interesting physician indeed, and potentially a very important one.
My superlative is on the Internet, so therefore, it must be true. :) Speaking seriously, I have often opened lectures with that line to both grab attention and to make a serious point. If you offered me a choice--10 new miracle therapies or a business model/policy environment that can cut the cost of currently available procedures by 98%, I would almost certainly choose the latter. In terms of lives saved, lifespans increased, pain relieved, and suffering averted, I suspect that massive cost savings would do considerably more than any ganglion of new therapeutics. And Shetty's institution is arguably the superlative organization in that realm. Add in the Mother Teresa angle, his strategy of recruiting O.R. personnel from desperately poor villages, his development of health insurance for subsistence farmers, and his monomaniacal devotion to his craft, and my superlative becomes quite defensible--at least in a speech or a blog, if not in a journal article. Netflix found him a compelling subject for a documentary, and the right screenwriter could easily turn his life into a feature-length biopic. Glad you enjoyed his story.
“If you offered me a choice--10 new miracle therapies or a business model/policy environment that can cut the cost of currently available procedures by 98%, I would almost certainly choose the latter. In terms of lives saved, lifespans increased, pain relieved, and suffering averted, I suspect that massive cost savings would do considerably more than any ganglion of new therapeutics.”
In the immediate sense that’s certainly true, but taking a longer view, it might depend on the time frame you use to measure the results.
Fair enough. I should then apply an “Internet filter” to everything you say here?
I am a bit sorry you emphasize his exceptional personal qualities. To that degree his experiment may be difficult to replicate, especially at scale. Which would be a great loss: you are right about a 98% drop in costs.
Finally (? I keep editing this post so I can’t be sure it’s finally) I cannot endorse “ganglion” as a neologistic group noun for therapeutics. It refers to the body rather than to therapies, and it isn’t an adjective-ish or plural-ish noun. If not “cocktail,” how about “market basket”?
If I said not to apply said filter, would you honor my request? :) I emphasize the personal characteristics because I believe they matter. I find that most great discoveries emerge from some intensely personal story. And I believe such stories are essential components of persuasion and inspiration.
I should have said that I’m a bit sorry not for your emphasis, but for the exceptionalism. Will other surgeons practice similarly? If not, this is not a revolution, but a curiosity.
He’s an iconic example, but he’s not alone. While Westerners prattle on about Canada, UK, Sweden, and—God forbid—Cuba, they ought to be looking at India, Costs Rica, Singapore, etc. There are lots of Shetty-types. He is simply the most prominent face and, perhaps, the most successful in this realm.
You may well be right. But it is—alas, no it isn’t, but it ought to be—unusual for an economist to expect a significant change in behavior of a large group without a significant change to incentives.
Just read this again. So much for us to learn here in the way we education physicians in America. Indeed, in the way we practice medicine. Putting an honest price-tag on care is fair. What we do is say 'you need this to save your life,' they agree, and then the family is bankrupt because they had no idea the cost would run into six or seven figures. (All complicated by our nefarious malpractice system.) Great interview.
A very interesting interview, thank you. I think Shetty is 100% right about the importance of long hours during training, the importance of a certain level of dedication (which one finds more often in ambitious young people from scruffy backgrounds[1]), and the value of phone-based software[2]. The overall impression I get is that so-called medical tourism, which one might more charitably frame as the practice of visiting speciality clinics overseas, should be much more encouraged, even by regulatory agencies and the American medical establishment itself[3].
One observation, however: Shetty's approach seems extremely powerful when it comes to medicine that is well-established, what one might call medical engineering practice. But I doubt it will work as well for medical innovation, what one might call medical science. If you want to discover *new* ways of fixing this or that, or new combinations of therapies, then you actually need all the American inefficiency in the system[4]. You need bus drivers (physicians) who are indeed steeped in aerodynamics and how to fix the engine. Only generalists working within a system that has significant inefficiencies, which spends more time and money than it absolutely must, can come up with new paths to treatment. In part because you have to have a more general perspective along with your gobs of practical experience to try coloring outside the lines, and in part because most new paths investigated will *not* be better, that being the nature of the Second Law, one might say -- there are always far more ways to be plausibly wrong than right. You have to be working within a system where "wasting time and money" trying "dumb" (according to the conventional wisdom) stuff that couldn't possibly work better is tolerated.
Which leads me to conclude there should be more regional and national level specialization in medicine: there should be places where performing well-understood medicine as efficiently as possible is the priority, and other places that focus on innovation. (And yet more places in which rock-bottom price, even at some cost in skill and safety, is the priority, for the benefit of the very poorest for whom that tradeoff is worthwhile -- but that's another story.)
---------------
[1] I don't think this is limited to medicine. Certainly in the sciences my experience is that the most creative individuals (cf. Feynman) come from scruffy backgrounds and are working to escape that, and will overshoot, to some extent -- become great in their ferocious attempt to escape sub-par. I think there's some truth to that in business and entrepreneurship, as well. We humans are not at our best when we are comfortable, alas.
[2] In defense of the software industry, part of the problem might be that phone-based software is inherently faster-changing and less reliable, because of the fast pace of phone hardware (and OS software). With desktop hardware, you can lock down some combination of hardware and software that meets the high reliability needs of medicine for a decade. For phones, not so much. And software developers may quail at the reliability needs of medicine for a platform that may change in 18 months with Apple's newest tweak to iOS or Samsung's new chipset. Or rather, they won't quail so much as shake their heads in astonishment at the price they're going to charge you for Apollo 11 level reliability in a Tik Tok video app world.
[3] I mean, BMW doesn't work to prevent you from buying a Hyundai, and Saks doesn't work to prevent you from shopping at Target. It's madness to insist that everyone buy the same kind of medical care, even for the same medical situation -- because all *else* in their lives will often be different. Restricting consumer choice rarely optimizes consumer utility, one would think.
[4] You also need a good regulatory regime, too, which encourages a certain level of innovation without exposing people to recklessness or charlatans. Something between the complete stultification of the nuclear industry by the NRC and the carelessness that gave us lobotomies and Elixir Sulfanilamide.
I don't disagree with anything you've said here. My writings are loaded with similar observations. I could go point by point, but I'll just say that all of this is insightful and valid.
I wonder how much medicine would change, for the better, if insurance companies were prohibited by law from setting arbitrary limits on medical facilities (and physicians), for the services of which they would pay? That is, United Healthcare, those ratfinks, could write a contract saying "We will only pay if you go to our stable of kept MDs (an HMO), or we will only pay if you go to an MD with this or that certification, or get your surgery in a center with this or that kind of instrumentation" but they could *not* write a contract saying "we will only pay if your doctor graduated from an American medical school, and only if the facility that does your appendectomy is in an American state."
One imagines an increased level of specialization, the way we see in cars or computers. China makes the actual iPhones, but the design and software is done in California. Maybe people will very routinely go to Mexico for routine surgeries, and go to Stanford Medical for something really hairy, desperate brain surgery. Economics would seem to suggest this will benefit everybody -- Mexico has a new lucrative service industry opportunity (and smart Mexican kids can get good jobs without emigrating), consumer prices are lower, high-price stuff stays with the fanciest facilities, which would perhaps have to charge more without subsidies from routine operations, but overall one imagines medical costs fall. Plus, competition at the dividing line keeps everybody on his toes...
Probably wouldn't work in the real world, since people are highly irrational about life 'n' death stuff like medicine.
I wrote another piece about Narayana's Caribbean hospital. I asked whether American insurers had considered reimbursing them. They said they had had many such discussions. But, always, they said, the discussions broke down when the insurers found they would only be given one all-in price, and not a detailed breakdown of expenses. Narayana would tell them, look we can give you a flat price of $30,000, or we can set up a new system to do the cost accounting you want, in which case, you'll get the breakdown, but the procedure will then cost $100,000--including the cost of the accounting, software, etc. THe insurers would walk away, saying they needed the breakdowns.
I wrote my dissertation about the idea of health insurance that paid for a diagnosis, not for a treatment. Just as car insurers pay you for the loss from an accident--not for what you do with the money.
Loved the angle of the influence of Mother Theresa! I’ve missed reading your essays for the last several months (life), but happy to return to reading your thoughtful excellent work. Thank you!
Welcome back, then! Glad to have you.
Wonderful article. His efforts remind me of the Oklahoma Surgical Hospital. https://www.oklahomasurgicalhospital.com/
I'm fascinated by his excellent point that young people drift away from medicine as the economy gets better. I can tell you that they also leave medicine earlier and some recent data suggests that many medical students around the world don't see patient care as their ultimate destination. I'm not sure what they hope to do, or who will ultimately take care of our sick (like me as I get older). Thanks for sharing!
I don’t know that hospital, but shortly, I’ll be posting a similar piece on Surgery Center of Oklahoma.
Oops! My mistake! That's the one I meant to reference. I look forward to reading your thoughts on it.
Fantastic point. Quite profound. Just the sort of pushback I used to love from my students.
Gifted man of high integrity who i saw profiled i believe in Netflix documentary some years ago called The Surgeons Cut.
Bob,
You must be familiar with the book by Richard Selzer, Mortal Lessons: Notes on the art of surgery. If you are not, I highly recommend as worthwhile to read and ponder. Selzer's prose at times verges on excessively complex but there are passages that are inspired. It is one of my favorite books and I have read it multiple times. The chapter on the examination of a patient by Yeshi Dhonden, physician to the Dalai Lama, always makes me think of how superficial and shallow many of our patient/physician interactions too often are and how little time we spend in preparing ourselves spiritually to practice our art.
Rick
Rick, Thanks for the recommendation. And, no, I don't know the book. I'll have a look once I reduce my current pile of not-quite-read books. :) It sounds great. A few years after my undergraduate years at the University of Virginia, Dr. Dhonden lectured on Tibetan medicine at the Med School. The school invited him back, and he did a three-month visitation in 1980, and the school studied Tibetan medicine for years, as a result. From an obit:
"In the mid -70′s, Dr. Dhonden was invited to the University of Virginia for the purpose of lecturing about Tibetan Medicine. Sitting in on the series, one of the university’s research professors was so impressed upon hearing Dr. Dhonden that he asked Dr. Dhonden to join him in conducting a laboratory study using Tibetan Medicine to treat mice with sarcoma. The fact that the information they discovered through this study could help a multitude of people encouraged him to proceed. Dr. Lobsang Tenzin, working for years with Dr. Dhonden as a Tibetan pharmacologist, and Professor Jeffery Hopkins, translator, completed the Tibetan team. ... The outcome was big. It showed that the response of the mice to the Tibetan formulas was equal to chemotherapy and appeared to be without side effects. However, the results of the study were never published by the university. Because the professor did not judge the results important, this discovery went unknown."
Makes you wonder how often in Western we have failed to properly investigate other cultures and ignored alternative therapies that have no promise of a big payday because they are not patentable here. I am, by nature, a skeptic, but if there is one thing I have learned in 45 years of medical practice, it is how complex the humany body is and how interwoven our physical and spiritual natures are. The mind/body connection is very real.
Bob,
Another amazing post. The story of Dr. Shetty makes me simultaneously proud to be a surgeon and truly humbled, wondering if I have upheld my responsibility to honor my oath as a physician and the adequately carried on the legacy of the surgeons who trained me and those going back generations.
Rick
It is quite a story. Knowing you, I'm certain that you've adequately honored your predecessors.
I don’t know enough, and frankly, Bob, I don’t think you do either, to select the single most interesting or (let alone and) important professional of any profession, certainly including medicine. (It is just barely possible that there is an exception for our own professions respectively.)
However, I am certainly willing to agree that Dr. Shetty is a very interesting physician indeed, and potentially a very important one.
Thank you for drawing him to our attention.
My superlative is on the Internet, so therefore, it must be true. :) Speaking seriously, I have often opened lectures with that line to both grab attention and to make a serious point. If you offered me a choice--10 new miracle therapies or a business model/policy environment that can cut the cost of currently available procedures by 98%, I would almost certainly choose the latter. In terms of lives saved, lifespans increased, pain relieved, and suffering averted, I suspect that massive cost savings would do considerably more than any ganglion of new therapeutics. And Shetty's institution is arguably the superlative organization in that realm. Add in the Mother Teresa angle, his strategy of recruiting O.R. personnel from desperately poor villages, his development of health insurance for subsistence farmers, and his monomaniacal devotion to his craft, and my superlative becomes quite defensible--at least in a speech or a blog, if not in a journal article. Netflix found him a compelling subject for a documentary, and the right screenwriter could easily turn his life into a feature-length biopic. Glad you enjoyed his story.
“If you offered me a choice--10 new miracle therapies or a business model/policy environment that can cut the cost of currently available procedures by 98%, I would almost certainly choose the latter. In terms of lives saved, lifespans increased, pain relieved, and suffering averted, I suspect that massive cost savings would do considerably more than any ganglion of new therapeutics.”
In the immediate sense that’s certainly true, but taking a longer view, it might depend on the time frame you use to measure the results.
Fair enough. I should then apply an “Internet filter” to everything you say here?
I am a bit sorry you emphasize his exceptional personal qualities. To that degree his experiment may be difficult to replicate, especially at scale. Which would be a great loss: you are right about a 98% drop in costs.
Finally (? I keep editing this post so I can’t be sure it’s finally) I cannot endorse “ganglion” as a neologistic group noun for therapeutics. It refers to the body rather than to therapies, and it isn’t an adjective-ish or plural-ish noun. If not “cocktail,” how about “market basket”?
If I said not to apply said filter, would you honor my request? :) I emphasize the personal characteristics because I believe they matter. I find that most great discoveries emerge from some intensely personal story. And I believe such stories are essential components of persuasion and inspiration.
I should have said that I’m a bit sorry not for your emphasis, but for the exceptionalism. Will other surgeons practice similarly? If not, this is not a revolution, but a curiosity.
He’s an iconic example, but he’s not alone. While Westerners prattle on about Canada, UK, Sweden, and—God forbid—Cuba, they ought to be looking at India, Costs Rica, Singapore, etc. There are lots of Shetty-types. He is simply the most prominent face and, perhaps, the most successful in this realm.
You may well be right. But it is—alas, no it isn’t, but it ought to be—unusual for an economist to expect a significant change in behavior of a large group without a significant change to incentives.