dispatches from the new world of work

Mother Lode!

The Atlantic this month (12.07) is loaded with my favorite sort of analyses; namely, those that reveal counter-intuitive truths (or decent speculations, at any rate). Consider:

*SLUMS ARE GOOD. Today's burgeoning slums are the product of people pouring into the cities from the countryside—in pursuit of jobs. (In 2008, cities' population will surpass countryside population.) While eyesores and cause of appropriate concern, said cities are in fact the source of jobs, and overall poverty reduction is significantly attributable to the migration—burgeoning slums notwithstanding. The assertion is that no nation has grown wealthy since the start of the Industrial Revolution until the country-city migration was in full flower. ("Bright Lights, Big Cities," Matthew Quirk)

*HOME OWNERSHIP IS BAD. There are indeed enormous benefits to home ownership. But the big drawback, especially in times of economic revolution, is that home ownership measurably slows migration from where the jobs were to where the jobs are. ("Housebound," Clive Crook)

*WE HAVE TOO MANY DOCTORS. The supply of doctors to an area is significantly determined by the wealth and insurance coverage of the population. Hence there are more docs per capita in well-off areas—where, in fact, medical problems are less intense per capita. This also leads in particular to an excess of specialists—lots of docs prescribe lots of tests and make lots of referrals. As to the "bottom line," healthcare, per several sound measures, is no better in places with lotsa per capita docs than in places that are doc-deprived. It gets more interesting: The more specialists, the worse the outcomes. (More or less.) Specialists trip over one another, give conflicting advice, and are notoriously bad at cross-communication. More on specialists: The glamour and pay accorded to specialists comes at the price of less and less well-paid primary care docs—it is the vanishing primary care docs who are primarily responsible for good healthcare outcomes. Dr Elliott Fisher, Center for Evaluative Clinical Sciences at Dartmouth Medical School: "If we sent 30 percent of the doctors in this country to Africa, we might raise the level of health on both continents." ("Overdose," Shannon Brownlee)

*Less AID, more aid. "Scents & Sensibility," by Sarah Chayes, is the saga of helping Afghans successfully build a soap and body-oil business. It's also the umpteenth repeat of the story of how such "on the ground," practical, human-scale efforts are slowed or halted by the ham-handedness of USAID. [Web-only slideshow]

*THE LATE-BIRD STARTS THE CREATIVE ENTERPRISE. From "How You Sleep Is Who You Are" [not available online]: "Early risers prefer to gather knowledge from concrete information. They reach conclusions through logic and analysis. Night-owls are more imaginative and open to unconventional ideas, preferring the unknown and favoring intuitive leaps on their way to reaching conclusions." Morning people are more self-controlled, more formal, respect authority, and obsess on making a good impression. The late bunch are more independent and have less respect for authority. (Research source cited by the Atlantic: "Morning and Evening Types: Exploring Their Personality Styles," by Juan Francisco Diaz-Morales.) (TP note: Sounds like we need a night-owl CEO matched by an early-bird CFO.)

Tom Peters posted this on 11/29/07.

Comments

Regarding â€“ we need fewer doctors.

I worked with a family doctor here in the UK who had spent a few years working in Africa. Richard tells me him and one other doctor (his senior - an African trained doctor) were the only two doctors in a hospital covering a population of 500,000 people. They dealt with everything that â€˜came through the door.â€™

Richard said it was the greatest learning of his medical career to date. When he hears doctors bemoaning staffing levels he usually smiles wryly. By the way this is not some old man looking back with rose tinted glasses. Richard is in his early 40â€™s.

I am certainly not advocating reducing the number of doctors but I am agreeing with the proposition that recruiting more doctors is not always the most effective way of dealing with increasing healthcare demand.

Posted by Trevor Gay at November 29, 2007 5:34 PM

More on docs...and healthcare in general.

Perverse incentives have led to an overabundance of specialists...and the studies demonstrating an inverse correlation between the number of specialists per capita and both morbidity and mortality are absolutely true from a public health perspective.

(Besides the "too many chefs in the kitchen" effect, there's a stronger effect: "If your only tool is a hammer, then everything begins to look like a nail." The number of unnecessary imaging tests, unnecessary stents, back surgeries, and other interventions so often begins a cascade of events that leads to harm! Beware!)

Primary care, wellness, and keeping patients away from hospitals and interventions is essential.

Our current system devalues these services. Faced with significant debt, many medical students pursue the more highly reimbursed (and interventional) specialties.

If you like data, take a look at this updated report from the Commonwealth Fund:

http://www.commonwealthfund.org/newsroom/newsroom_show.htm?doc_id=482616

Despite spending twice as much per capita than other OECD countries, the US ranks last or next to last on all indicators of health system performance.

Regarding the number of doctors, we need LESS specialists and MORE primary care physicians with appropriate geographic distribution for the population.

Among other things, this must ultimately involve reducing reimbursement for some entities to provide greater incentives for primary care physicians.

By the way, the dysfunctional market conditions we create for healthcare are a large part of the problem. Universal coverage is essential, and so is competition. Healthy competition can only occur if the consumer knows the value proposition...how much "bang for the buck?"

Manoj

Posted by Manoj Pawar at December 2, 2007 5:02 PM