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13,600 diagnoses, Bob. 13,600.

From Atul Gawande's commencement speech at Stanford University's School of Medicine:

The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.

Half a century ago, medicine was neither costly nor effective. Since then, however, science has combated our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we’re struggling. There is no industry in the world with 13,600 different service lines to deliver.

It should be no wonder that you have not mastered the understanding of them all. No one ever will. That’s why we as doctors and scientists have become ever more finely specialized. If I can’t handle 13,600 diagnoses, well, maybe there are fifty that I can handle—or just one that I might focus on in my research. The result, however, is that we find ourselves to be specialists, worried almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people.


By Ezra Klein  |  June 18, 2010; 5:57 PM ET
Categories:  Health Reform  
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Comments

"...uncontrollable explosion..."

That only reminds me of BP Oil Well Explosion in Gulf of Mexico where it is pretty clear that our 'scientific, technological' abilities came short. So simply put, Atul's this call on 'scientific complexity' can at best be understood in a very narrow sense, specific branch of Medicine. Even there I doubt because when quite credible speculations are there about how 'human body and machine' at some point will merge - that is when immensity of our Medical Knowledge will dwarf today's doctors and their knowledge.

Also around 14K diagnosis, 6K drugs and 4K procedures; that seems peanuts when you have regular Databases handling Tera and Peta bytes of data. I am salivating by the opportunity presented here in applying standard Software Engineering techniques to the precise problem Atul talked - how to replicate this knowledge in every nook and corner of this country.

To pub bluntly, I think Atul is wrong here. I do not believe complexity in Medicine is 'bankrupting' us (if I understand the argument correctly, I can be wrong here). It is simply inane ways of Providers, Doctors, interests of Doctors in charging more money than other common services rendered in the society. Of course I know that Medicine is a noble profession and I have Doctors in my family too. But that cannot deny the comparative 'compensation' package differentials for Medical profession. Agreed not all get that much money, besides they toil for decades to get there (which is another horrible system in this country) and so on.

By trying to shift 'cost problems' on complexity of Medicine; I am not sure where we are going. We need to be ready to address the 'politics' of providing Health Care Service without bankruptcy in this country.

By the way - Dr. Atul Gawande is still one of the heros of that industry in this country and it is understandable that he will try to paint a picture where these newly graduate students get 'pumped up' by self importance. That is what might have prompted Dr. Gawande to paraphrase this issue like that.

Posted by: umesh409 | June 18, 2010 6:44 PM | Report abuse

This is a good reason why one of the best ways to advance medicine is indirectly, through the advancement of computer speed and artificial intelligence, things like basic scientific research into biological and quantum computers.

How to do that? Let me give you a fantastic quote from leading growth economist Paul Romer of Stanford:

As just one example, recall that the increasing returns to scale that is implied by nonrivalry leads to the failure of Adam Smith’s famous invisible hand result. The institutions of complete property rights and perfect competition that work so well in a world consisting solely of rival goods no longer deliver the optimal allocation of resources in a
world containing ideas.

-- Forthcoming American Economic Journal paper, page 8, at:

http://www.stanford.edu/~promer/Kaldor.pdf

Richard H. Serlin

Posted by: Richard722 | June 18, 2010 7:12 PM | Report abuse

Atul's formulation of thousands of diseases is precisely the wrong model to analyze our health and health care.

The vast majority of illnesses are either a) self limiting and need no treatment except symptomatic or b) more importantly are the result of a small number of common causes, causes which are obscured by our system of medical specialization, single bullet patent medications, and discrete diagnostic codes.

Two of many examples: inflammation is being recognized as a source of many illnesses - cancer, cardiovascular disease, arthritis and other pain syndromes and many more. By focusing on the individual diagnoses we guarantee that we will make limited progress in curing these conditions.

Vitamin D deficiency has been shown to contribute to osteoporosis, MS, autism, cancers, heart diseases and so many more. For $10 a year we could provide supplements to the 75% of Americans deficient in D and dramatically reduce the incidence of these multi hundred billion dollar causes of morbidity and mortality.

So Atul is contributing to the problem and not helping solve it.

Posted by: oderb | June 18, 2010 10:17 PM | Report abuse

So, Gawande is a chucklehead, like Klein. He spouts gobbledegook, or what he spouts is pointless, or, more likely, it's pointless gobbledegook, if there is such a thing.

--"There is no industry in the world with 13,600 different service lines to deliver."--

Has the man never heard of Wal*Mart, or Boeing?

Posted by: msoja | June 19, 2010 11:12 AM | Report abuse

"Half a century ago, medicine was neither costly nor effective."

That's an odd premise - that medicine was ineffective only fifty years ago. That was 1960 - not *that* long ago.

Major vaccines and antibiotics had been developed by then. Doctors were basically fixing what was wrong with you, unlike say, 150 years ago when medicine was truly ineffective.

Posted by: mcgutierrez31 | June 19, 2010 12:05 PM | Report abuse

"When we talk about the uncontrollable explosion in the costs of health care in America, for instance ...we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity."

Really? Is scientific complexity less complex in Canada, France, Germany, and every other industrialized country in the world?

Posted by: Bloix | June 19, 2010 2:35 PM | Report abuse

"Two of many examples: inflammation is being recognized as a source of many illnesses - cancer, cardiovascular disease, arthritis and other pain syndromes and many more. By focusing on the individual diagnoses we guarantee that we will make limited progress in curing these conditions."

You are an idiot. Inflammation is not the "source" of cancer. The source of cancer is multiple genetic defects picked up over time. To presume you can "treat" cancer by focusing on inflammation is idiotic, and shows you have no idea what you are talking about. I'm sure the cancer scientists at NIH would love to hear of your foolish ideas.

Cardiovascular disease? Wrong again, fool. Cardiovascular disease is caused by coronary artery blockage, and the source of CAD is not "inflammation" its deposits of cholesterol in the vessel walls. Inflammation plays a role, but it is hardly the central component of CAD.


"Vitamin D deficiency has been shown to contribute to osteoporosis, MS, autism, cancers, heart diseases and so many more. For $10 a year we could provide supplements to the 75% of Americans deficient in D and dramatically reduce the incidence of these multi hundred billion dollar causes of morbidity and mortality.

So Atul is contributing to the problem and not helping solve it."

Once again, foolishness abounds. The only disease you listed that Vitamin D plays a strong role in is osteoporosis, and even then VitD deficiency is only one cause among many for osteoporosis. Claiming you can give everybody Vitamin D supplements and make anything more than a modest improvement in osteoporosis rates is ridiculous. The central cause of multiple sclerosis is an autoantibody generated immune cascade that has very little to do with Vitamin D deficiency.

You're obviously not a doctor or a medical scientist, but I suppose you did stay at a Holiday Inn Express last night. Please take all your ridiculous hypotheses to the NIH Cancer Center, I'm sure they'd love to hear about it.

Posted by: platon201 | June 20, 2010 10:13 PM | Report abuse

The government is obviously the only institution that can handle a system with so much complexity. Good examples are the Post Office, the DMV, the oil spill, Katrina. You can clearly see why we need the government to handle our health care.

Posted by: kingstu01 | June 23, 2010 11:32 AM | Report abuse

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