Superb Health Care Article

Atul Gawande, a practicing surgeon, has written a brilliant article about healthcare reform for the New Yorker. Its basic thesis: while there are a host of theories about how to reduce the cost of healthcare in the United States, the greatest problem is over-treatment -- the prescription of medications, treatments, tests and surgeries that are redundant, unnecessary, and sometimes harmful.

To research the article, Gawande flew to MacAllen, a rural Texas county that's the most expensive health care market in the United States, despite having average or below-average patient outcomes, and residents who are, on average, as healthy as anywhere else. There's a sharp moment when he sits down with some physicians at a diner to talk it over:

“It’s malpractice,” a family physician who had practiced here for thirty-three years said.

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted.

“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.

I thought this discussion was fascinating, because it confirmed my little experience discussing the subject with my best friend, a neurosurgeon practicing in Nashville. Back when he was going through medical school, we used to talk about the high cost of medical care, and he always insisted the problem was malpractice suits; insurance against malpractice was bankrupting doctors and forcing them to add extra testing. When I pointed him to studies showing that malpractice awards were dropping even as insurance costs skyrocketed, he shrugged it off. It was the lawyers, plain and simple.

I have a feeling that now, after many more years of practice and experience, he sees things differently (and I'm looking forward to asking him at my bachelor party next week). My guess is that the malpractice canard is a commonly-held but superficial excuse that one would encounter early on in medical education -- especially while interning and doing early rotations. But as doctors gain more experience, they gain a richer, more nuanced understanding that complicates that reassuring but misleading perspective. And that's what is reflected in the exchange above: initially, the doctors offer the comforting excuse that it's the fault of lawyers and court cases -- not their own. But when push comes to shove, they recognize the problem lies closer to home.

Which isn't to say that insurance reform, digitization, universal coverage, prescription cost controls, etc., aren't key to moving forward. But a huge component is getting physicians to recognize that, despite excellent medical skills, their daily decisions contribute incrementally to the national health care problem.

Read more of "Superb Health Care Article"

Video of HIV Infection

This is remarkable. Scientists have captured video of an HIV-infected T cell transferring the virus directly into a healthy T-Cell through a virological synapse -- basically a tunnel from the interior of one cell into the interior of another. This is a huge development, because it shows that once the virus has infected a host, it can spread without ever leaving its host cells, and this means that the immune system's antibodies, which float around outside the cells, are never given a chance to recognize and attack the virus as it spreads.

This suggests part of why and AIDS vaccine has been so difficult to develop; not only does the virus change the proteins on its surface in order to prevent an effective immune response, it looks like any vaccine targeted at the virus itself can only function as a first line of defense -- attempting to recognize and destroy the virus before it infects any cells. This is a huge problem, especially because the immune system requires some spool-up time, even after vaccination to ramp up antibody production once an invading wave of viruses has been recognized. The lag in "secondary response" combined with the virus' ability to hide in host cells means that, by the time the immune system is up to speed, it's probably too late.

Of course, there are other avenues of treatment; it should now be possible to target the specific proteins which infected cells coat themselves with in order to capture healthy cells and create the virological synapses (in the video below, you can see how the healthy cell becomes stuck and is unable to separate, while other healthy cells bounce off each other). By recognizing those proteins, the immune system can target and destroy infected cells. And this approach, if we work it out, should be vastly more effective than attempting to catch the virus before it infects any cells.



Still, it's a lesson in how much we still have to learn about the mechanics of basic microbiology. We have a tendency to see viruses as stripped-down machines, little boxes of infectious badness that float around and overwhelm us with their lethal efficiency and sheer numbers. But this sometimes overlooks how active and innovative viruses are. It's stunning what HIV can do with only a handful of genes. And it's amazing that after two decades of research into HIV we are only now starting to unravel its mechanisms of transmission.

Read more of "Video of HIV Infection"