I will always take my own history from a patient, but I use the previous records as corroborating records - I know what the general gist has been, but what might they have missed/what might the patient have told them?

It is a critical part of good patient care, despite its inefficiencies

This is just how records like this work, frequently contextually or globally incorrect, I don't think it's really a matter of malpractice, at least not in relative terms; though I guess they could do better, like recording that staff had witnessed me collapse (!) two times (one in the waiting room, one in the halls) before they left me sitting in some random chair in a hallway for a couple hours, during which time I passed out a third time, scaring the bejesus out of the others waiting there, none of whom were patients.

Hospitals aren't really all that great at paying attention anywhere, as far as I can tell; the U.S. has the most discerning customers (and to some extent, some of the last remaining customers in the developed world). In the U.S. you might have some hope of complaining about service like I received, for example how the triage nurse spilled what looked like about 200ml of my blood all over my arm and the floor while drawing a sample at intake, or that when somebody finally called me to the the first room, she didn't even wait for me to get to the locked door (which I failed to do, because I collapsed half way there and needed to be wheeled in, mostly helped by random bystanders) before turning and walking back to sit down behind the desk (not at the desk), where I saw her playing on her phone.

They take my urine, and three hours later they tell me my urine sample was "pristine". They were amazed at how clean it looked. Not even a single protein-- and as a female with a vagina that often discharges a proteinous substance, this was surprising! (And very good news! Doctor was astounded). The doctor concluded my kidney pain was "mechanical", that the muscle in that area had been bruised somehow I told her this was not the case, but she discharged me.

16 hours later (at home now) I'm running a fever of 104. My resting heart rate is an astounding 132 bpm. I'm scared of sepsis (infection of the blood) since I have experienced that before from kidney infections. I go to the hospital preparing for another 5 hour waiting time, but luckily they get me in an intake bed right away. I'm covering myself with a heavy blanket in my fever state-- something one shouldn't do, but nobody took it off me until I was about to be discharged. They come back with the results from another urine sample, and surprise, I have a kidney infection! I asked the doctor why my urine was "pristine" the day before and he said, "the lab tech probably didn't keep the dip stick in long enough" (which is why the test didn't register any protein in my urine whatsoever...) He acted like it was no big deal, like it happened all the time. They gave me 1/4 dose of morphine for the headache because I "look to be about 100 pounds" (I'm 5'10". That would put me at a BMI of 14.5-- ie. severely underweight, and cause for medical concern in and of itself! I'm 135 pounds, with a BMI of 19.4 Honestly, what the hell.) which doesn't help the pain at all, and I'm still wrapped in what amounts to a sweat lodge-- once again, nobody told me to take the blanket off. This is very common knowledge, but in my state of high fever and pain I did not think that it could be a bad idea. I would expect the doctors and nurses to be aware.

An hour later they suddenly tell me to get out of bed and they will move me to the waiting room with a chair and a goddamn television that I can already hear thumping through the walls, because this is an intake bed and "other patients need it". I'm sure they do, but I literally can't walk right now.

Long story short, the next time I get a kidney infection I'm staying home to die. The lack of care in that situation was astounding. To top it off, they treated me like a bad patient after I protested being moved to the waiting room.

edit: I also forgot to mention that they were going to give me pill antibiotics at discharge. I suggested they give me an IV instead, and set me up at an IV clinic. I'm not kidding, they said, "oh! That's actually a great idea". Ahhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh

They sent me home with like... "16 hours worth" of ultra-low-dose hydromorphone (I couldn't find any dosing guidelines which even reference 1mg tablets) and left me to choose which hours of pain I wanted them for; I missed my followup because the front desk folks couldn't send me where the surgeon's note said I should go.

The best part was the ambulance ride, which only cost me fifty bucks and was conducted excellently; the surgery itself also went well, as far as I can tell, though for an appendectomy that's nothing to write home about (not to downplay the work involved, but like flying in airplanes, it has become routine).

Likely not a coincidence, the ambulance ride is the one thing I had choice in as a patient, and the one thing I paid for out of pocket (although non-emergency rides somewhat subsidize emergency ones, by policy).

BTW, she had so many of these infections that her doctor eventually referred her to a urologist, who put her on a daily antibiotic (cephalexin, aka Keflex) as a preventative. She hasn't had another once since starting that, though there have been a couple of times that she felt like she might be getting one, and took an extra cephalexin, which was sufficient. I wish we had known about this option sooner.

Also: my pointing out that UTIs can sometimes fail to show up in the urine test was not intended as a defense of the way the hospital treated you. Quite the contrary: doctors should know that that can happen. My wife and I were not happy with the way she was treated on this occasion as well — it took hours to convince them to start the antibiotics, and she was in a lot of pain.

>Quite the contrary: doctors should know that that can happen.

Okay, thanks for clarifying. This is how I felt. It was silly to me that I could have all the symptoms of a UTI, only to have everything written off because of a clean urine sample. I think it was hopeful thinking on the doctor's part-- she just wanted me out of the bed so she could clear the waiting room.

How recurrent were your wife's UTIs, if you don't mind?

In fairness, I guess it really doesn't happen very often — the ER doc in my wife's situation commented that she had never seen it before. On the other hand, pulled muscles don't cause fever. I understand a little bit of reluctance to offer antibiotics, as they have been overused, but geez, you have a patient with a fever and in terrible pain, indeed with all the other symptoms of a kidney infection, what's really the downside to going ahead and starting the antibiotic to see what happens? That's how I see it, anyway; I'm not a doctor.

Really, she should have been referred to the urologist a lot sooner.

I had issues with bedwetting as a child and into my late teens. I went to sleep specialists, urologists, and psychologists but nobody could say anything about it. I think it's somehow related to what I've been experiencing lately but I don't know what to do about it. I was always getting infections as a kid too (ears, eyes, bladder, kidney) but not really flu or colds (despite not being vaccinated). Has your wife experienced any of these things in her youth?

My SO is a doctor, even here in Europe there are many flaws, but what I have learned over the years is that this system is way, way more complex and effective than people think. If you want to improve it, great! Step one: go talk to a doctor about your ideas. If you haven't done that, don't spread your unfounded assumptions, it only leads to more demonization of staff and systems and doesn't help anybody.

They asked me what happend and wrote down "was drunk" so everyone I met at the hospital was like "uhuu was drunk at the uni... one of those guys..."

[0] https://www.fiercehealthcare.com/it/study-docs-spend-more-ti...

Agreed. But that is because doctors are not easily accessible. You can't simply call doctor's cell phone or text him a message. Instead, you call the office, leave a message and wait for God knows how long. Some doctors do not even bother to call you back if they're not in the office.

> And how is this any different from reading a 'transcript' of the last interaction a patient had with a Doctor

You don't want to cancel the transcript-based approach. I was talking about improving existing processes, not replacing them altogether. Knowing that you're being recorded makes you more responsible for every note you take, it improves the kind of information doctors write down.

I'm sure you are aware that there are a ton of things to improve in the healthcare industry. It's just a matter of wise execution, which is the most complicated part.

watching body language, pauses, etc vs just reading can give different information. and multiple people reviewing that over a spell will yield different/new/conflicting insights. but it's different than reading a transcript.

What's the alternative? 24 hour shifts for the doctor and the new doctor each day needs to relearn everything?

Having to relearn everything might be a problem, depending on what it actually means, but as long as we want a normal human being as a doctor, they will cycle over time as people start and end shifts, and they will need to learn what happened before their shift started (and they may receive patients from multiple doctors leaving over their shift, making 1-on-1 hand-off infeasible).

It's easy to call this out as a problem, the question is what's the alternative that's better?

A good percentage still get frustrated. Can’t be helped. Patients reshape their narrative, remember new details, just plain open up more to some docs, etc. the repeated history taking really pays off in improving patient care.

Where I find patients get most frustrated is when docs come in for a specific job, and patients don’t have the health literacy to understand what that is or is not. “Doc, can I go home today?”

  “ I’m just the consulting cardio here to check out your heart for your primary doc, Doc McStuffins, I have no say in that at all, you need to ask McStuffins.”  

There’s no good response to that. No one wants to cough up cash to pay for health professionals time to repeat themselves all day long. But the patient that’s asking? They want that answer. They don’t -feel- like they’re asking an inappropriate or stupid question.

I think about this when it comes to providing a patient with "informed consent" for a particular treatment/operation. What does "informed" really mean in this case? A brief overview of the main risks and a couple of statistics? Or a thorough understanding of the pathophysiology of the disease and the trial data supporting the therapy? How long is a piece of string?

There is also an argument that, unless there is some sort of ongoing peer review (they did this during my Oncological Adventure(tm)), you're increasing the number of moving parts, and thus the chances of a breakdown. Charting errors are a significant source of medical mistakes.

The problem as I see it is not the intent of the procedure, it's the while (1) do x; mentality. There should be some "ifs" and mitigating functions instead of a hardcoded 1

Most patients get admitted under a DRG, which is a lump sum payment. It’s true that doesn’t apply to every patient, but enough of them that doctors habits aren’t going to be shaped by the minority.

For that matter, you can come in and see a patient without asking the same history as the guy before you, if you’re just checking a box for a billing.

This meme really needs to die. The NHS has massive financial incentives that impact clinical decisions. In fact, you literally go on to mention as such in your next sentence.

It turns out that having an incentive to "save the system money" results in a different set of clinical decisions. And no, those don't always work out in favor of the patient. (They're particularly problematic for the patient in cases of long-term care, which is why the NHS does rather badly on complicated and chronic conditions like treating cancer compared to the US and other countries).

It might be true that the NHS has poorer outcomes but I doubt that this is necessarily the cause. I live in Norway and have considerable recent first hand experience of the health system. I'm confident that they have incentives to save money too. In fact my wife's cancer nurse when explaining why there was a delay in starting the day's treatment said that preparations like Avastin would not be ordered from the pharmacy until the patient was both present and prepared for treatment because they could not afford to throw it away when the patient didn't turn up or turned out to be too ill for chemotherapy.

It is broadly speaking the same idea as the UK NHS but apparently has better outcomes for diseases like cancer. There are fees to pay, similar to an insurance excess or what the US calls co-pay; but those fees are affordable and capped to a couple of hundred pounds a year.

Not to mention that many if not most NHS-employed doctors run private practices on the side. Some only spend a day or two a week on their NHS duties. Others such as GPs are NHS-branded, but every GP practice is a private business that bills the NHS for time and materials.

I am certainly not saying the NHS system is perfect, and all private medicine is bad, so if that is the impression you got then perhaps I was unclear.

In almost every single clinical situations within an NHS hospital that I have seen or can think of, the clinicians treating you will not receive any extra money, bonus, promotion, etc. for the treatment they provide you or do not provide you.

I have lived in countries with more private systems, where there is a direct relationship between what treatment/investigations you receive and what money ends up in the doctors pocket. For example, a private doctor in HK referring for not-strictly-necessary-but-ultimatelhy-clinically-justifiable MRI scans at a private MRI clinic which, provides a percentage of the (expensive) scanning fee back to the referring clinician. Contrast that in the NHS, no one gets given money for sending a patient for an MRI scan, and in fact, if it isn't going to change the management of the patient, the request is likely to be refused to constrain resources. In the HK system, neither the doctor nor the MRI provider is incentivised to not do the scan, quite the opposite.

The NHS system is not perfect, but pointing out different the pros and cons of different incentivisation structures that do have an impact on patients is not something that is a "meme that needs to die"…

Right, I'm saying that the difference isn't simply a matter of private vs. public funds, the way OP claims. You can really trivially create a private system that has the same bad incentives with respect to costs and care as the NHS does. You can also trivially create a public system that has the same bad incentives with respect to costs and care as the US does.

That said, Germany and France aren't really publicly-funded as well the way people think. Both rely on a private network for care delivery (unlike the NHS), so it's a bit of a stretch to say that they're "public health care" systems. Even if you're looking at funding, in those two countries, taxpayer funds only cover 75% and 70% of expenses, respectively.

Just asking "but what are the alternatives" isn't productive in itself, and doesn't really carry the conversation forward. It more likely shuts it down as a hopeless problem. We can do better. It's not hopeless and we're not powerless as a collective.

I'm sure there are alternatives but we're not looking for them very well. We could start there. I'm doing my part by bringing this up in conversation whenever it's relevant and getting to know my state representative and state senator. I also make noise towards the hospital's admins in the meanwhile.

---------------

Also, the article discusses possible alternatives. Here are a couple of paragraphs from it:

"This begins with our own training. Certainly doctors must understand disease, but medical education is overly skewed toward the biomedical sciences and minutiae about esoteric and rare disease processes. Doctors also need time to engage with the humanities, because they are the gateway to the human experience."

"To restore balance between the art and the science of medicine, we should curtail initial coursework in topics like genetics, developmental biology and biochemistry, making room for training in communication, interpersonal dynamics and leadership."

It doesn’t require 24-hour shifts or even a medical degree to do this kind of coordination. I did it and I have no medical training whatsoever. But it was pretty important work, and my dad would have been lost without it.

Methodologies such as Kepner-Tregoe explicitly make handovers very easy, used very effectively in manufacturing, energy, and other industries. But God forbid that almighty doctors should ever take any advice from outside their profession.

That's not modern reality and its shameful.

My spouse is an MD and she spends a minimum of 45 minutes before her shift reviewing her patients' charts. After work, at home she tidies up patient notes to ensure the next person gets an efficient summary of the patient. Then after dinner she's answering a bunch of instant messages from patients on the hospital's patient portal and doing any prep necessary for the next day.

Programmers would be collectively rending our garments if we had to do anywhere near the amount of unpaid / off-the-clock work as doctors do.

More often than not, if I got someone on the other line that seemed to know a bit, skipping the questions ended up being counterproductive, as I would assume some knowledge about a specific item from the other end that didn't exist (but other knowledge did). I learned to trust the process, and glean the extra bits of information that weren't what the other side was trying to convey, but did nonetheless.

I think it's a mistake to assume that just because the doctor asks you questions and doesn't always seem to take into account a prior answer the doctor is not listing. I think it's more likely that they have learned that the small percentage of time that asking similar questions in different ways has led to new, important information has led them to be careful and methodical, even at the expense of patients thinking they aren't listening.

When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other.

I don't disagree with what I interpret as the intent of your message - that there is real value in process, question repetition, and not jumping to conclusions.

I do think it implies a false choice at the end though. A doctor can imply they care / listen / are familiar with your case, while still asking insightful questions and probing for relevant changes.

[Analogy] As there are many engineers here, consider this contracting example: how would most companies respond if, for a project, at each meeting, the contractor sent a new representative, who asked all the same questions as the first meeting, could provide no status updates, and many reps suggested apparently different solutions, platforms, or approaches?

This is an important point but I feel you're approaching it from a very short term view. Look at Pakistan, for example: after the CIA used a vaccination program as cover for a genetic testing scheme meant to find Bin Laden [1], there was (and still is) a significant impact on the Pakistani and other population's trust in their domestic healthcare industry [2]. Even if it was a real Polio vaccination program that saved thousands of lives in a purely utilitarian short term calculation, the damage that distrust causes long term can far outweigh the benefits. Worst of all, due to the nature of that distrust, measuring that damage becomes so much harder.

The point is, doctors don't just need their patients to trust them, but to trust the institution of modern medicine and healthcare as a whole. They need the patients to trust their nurses, pharmacists, specialists, and technicians just as much as the primary doctor. Given how critical patient cooperation/honesty and preventative care are to clinical outcomes, I don't see any convincing evidence that patient perception isn't just as important as the rest of the process.

[1] https://www.theguardian.com/world/2011/jul/11/cia-fake-vacci...

[2] https://www.scientificamerican.com/article/how-cia-fake-vacc...

That does sound rather concerning if that's the case!

As a medical student about to sit my final exams, I have shadowed hundreds of doctors of different grades and specialties in many different hospitals and family practices, and I don't recall ever seeing a doctor not review the notes before seeing a patient. Often here in the UK at least there is a large amount of time pressure and it would certainly be desirable to have more time to review further back, in more detail, etc. but given in general practice there is a 10 minute slot per patient, there are systemic limits on this (that would be nice to address).

On the other side, trying to figure out what is going on with patients is much more complex than catching up on notes and trying to get a "delta" update from them about what has changed in the shortest space of time/words as possible. The number of times I have taken a history from a patient and then less than half an hour later observed them add hugely important extra details that were omitted previously is pretty large. Often, it is far more helpful and illuminating to ask a patient to tell you what has been going on in their own words, even if you think you have read it all in the notes. I have often seen more senior clinicians pick up subtle clues that were missed by more junior clinicians, or ask a pertinent question that was not asked before.

And finally, on a more pragmatic basis, doctors take a lot of risk on board whenever they treat a patient. Patient's get tired of people asking them if they have any allergies for example, but when it's your name on the prescription, and your ability to sleep and your license on the line, you may well decide to ask the patient again rather than rely on what some previous clinician in some previous setting has written down on the patient's file. In a similar vein, a lot of practice is not black and white. If a junior with limited experience writes that a particular clinical sign is positive in the notes, you may well want to repeat that examination to re-assure yourself before you allow it to guide your treatment.

None of this is excusing unpreparedness or poor practice, but hopefully shines a little light on some reasons why it seems like there is so much needless repetition.

Unfortunately, I expect this may create a lawyer averse culture where process is as repeatable as possible, because in the event of a suit, systematic process is a solid defense.

Think of it like talking to a project's stakeholders yourself rather than relying on requirements gathered by somebody else.

No. Doctors can have mostly normal 8-hour workdays, 5 times per week. Nurses administer drugs and monitor the patients. If a problem arise, they can call the doctor in charge of the patient or bring the doctor doing the night —or weekend— shift.

>> Friend's mother was recently in hospital, multiple doctors thru a single day, each one had to completely relearn what was going on.

> What's the alternative? 24 hour shifts for the doctor and the new doctor each day needs to relearn everything?

This is from your response:

> Is there really a need for 24 hour doctor visits most of the time?

The exact situation described is hospitalization. Pointing out that most treatment may not be on a 24h basis is not relevant here.

As has been pointed out in many submissions on HN about USA's medical practices, the main reason you get many visits is to inflate your bill. I think someone even wrote that he was charged $600 per 1-minute visit during his stay in the hospital.

Most residencies are paid for by Medicare. Big hospital systems just can't seem to find the funds to train doctors on their own.

This sounds like first world problems. You have a doctor you trust to go off script? You trust that when your kids' teachers treat them differently they aren't just stereotyping and limiting them? Lucky you. While you work to unshackle your providers from the mediocrity of "best practices" (and I say that as someone for whom "best practices" is a bane in my own work) keep in mind there are a lot of people for whom competent cookie-cutter care is a wish, not a disappointment. In technology we can let a thousand flowers bloom and we all get to choose and enjoy the most beautiful ones, but in education and health care there's no natural elimination of the worst and amplification of the best. Everyone just lives (or dies) with whoever they randomly end up with, so worst-case performance matters just as much as best-case, and average-case matters a whole lot more.

Of course, by now there is no turning back, and the government has decided that actually training doctors must be prevented at all costs.

VERY short term vision, constantly sacrificing the future for a quick buck, leads over the span of decades, to spiraling costs and worse outcomes. Who knew ? Well, everybody knew.

If you live in a town where smart and educated people like to live, you get the cream of the crop of doctors. It's very different from living in a backwater where ambitious young people aspire not to live. And most of the world lives in backwaters, with unexceptional doctors who make simple but deadly mistakes when they go off script.

The care I received at that hospital was a night and day difference compared to what I received in the suburbs.

My favorite experience was the time I was very sick, went to a doctor in the suburbs and was told I was absolutely fine, despite the coughing, difficulty breathing, looking like I was dying, chest pain and X-ray results. I was sent on my way without even a script for antibiotics.

The next day, I went to see my PCP who demanded the names of the doctors responsible for letting a patient with severe pneumonia leave their care without proper treatment. Said if I waited another day, I'd have to be hospitalized.

I payed just $3k, but that was ridiculous to be surprised by and I'm still confused what the treatment plan is because front desk didn't schedule me until July. The doctor is great but support staff has become so beuracratic...

You really don't have much contact with teachers if you believe this.

The education system runs in spite of its systemic horribleness precisely because there are enough teachers who do care and fight/ignore the system when necessary.

If you want to actually fix the educational system, we have models for doing so in several different countries. However, they all tend to share the same characteristics.

You have to raise standards for both admission and completion; you test to those standards; you raise salaries to match those standards; and you give respect, autonomy and authority to the people now adhering to those standards.

HOWEVER, that is going to cost money. Quite a lot of money. And, really, nobody is actually interested in doing that in the US. They're really only interested looking like they are concerned rather than actually fixing the problem.

This seems to imply that the US doesn’t spend enough money on education, even though it is (one of?) the highest spender(s) on education in the world (just from a quick Google search). I believe the real change needed is better management of how the existing money is spent.

The US isn't that out of line with spending:

US is $15,171 per student while Switzerland is $14,922 per student. US is 7.3% of GDP while Denmark is 8% of GDP.

Source: https://www.cbsnews.com/news/us-education-spending-tops-glob...

There is not some magic bank of "misused" money waiting to be tapped.

The US also has a lot of students who fall into the education assistance category (free breakfasts, lunches) who would fall into a "social safety net" in countries like Sweden and Norway. A lot of the poorest students eat up the largest chunks of funding.

Finally, the Gates Foundation, whom I don't necessarily like, has shown time and again two fundamental things about education attainment:

1) any SUSTAINED focused resource improves educational outcomes

2) resource allocation is strongly sub-linear--it takes FAR more than 10% more resource to cause 10% improvement in outcome from our current system

As anecdata about this misallocation in US education funding: I come from another part of the world (a first world country), and something that I have not, for the life of me, been able to reconcile with the funding arguments is the stupendous sports facilities that most schools have. High schools in the US have sports stadiums bigger than many cities where I come from. If there were a real funding problem in an education system, sports should be the first thing to downsize in order to protect the core mission. But the priorities are just not aligned right for education.

Also, schools in US are not funded equally and sports have special status in society. You have art teachers paying supplies out of pocket in one district and expensive stadium in another district. You have well funded schools and badly funded schools.

Fun example of inefficiency, - 2 units at university using same enterprise software package - I propose consolidating to one license, 1 server, both departments split cost. - Both department heads agree, both IT depts agree, campus IT agrees - cancelled last minute - that was 7 years ago, by now both departments combined (not each) would have saved $250k

I’d like to learn more about these 2 points, particularly the first (how it’s measured, etc). Is there any specific work of the Gates foundation you could point to?

https://docs.gatesfoundation.org/documents/Lessons%20from%20...

Page 16-17 talks about known effective programs and their costs. Note that the more expensive programs (almost all exceeding $15K per student--sometimes dramatically) are almost always more effective. Under $10K is almost uniformly not helpful and the further you get from 10K the less helpful they get. You can have effective programs for $10K, but it's really hard. Money really does make things easier.

From Page 21: "At the highest level, this “doing many things well” requirement results in a high degree of difficulty and is a key reason why high-quality early learning that sticks is so infrequently seen."

From Page 22: "ESSENTIAL ELEMENTS OF HIGH-QUALITY PRE-K THAT STICKS"

"3. Teachers delivering high-quality instruction is a key differentiator between early learning that sticks and early learning that, more than likely, will not stick. ...

4. All exemplar programs have two adults in the classroom—one lead teacher and one paraprofessional/aide— at all times. ...

5. All exemplar programs have maximum class size of 22 children or fewer and adult-to-child ratios ranging from 2:15 to 2:22. Adult-to-child ratios at the lower end of the range are particularly advantageous for classrooms where a significant number of English language learners (ELLs) are present and/or where a significant number of children with special needs are present.

6. Lead teachers with a B.A. plus suitable early learning credential, paid at same level as K-3 teachers. ...

7. Dosage. Three of the four exemplars offer pre-K that runs 6-6.5 hours/day, for 180-205 days/year. The other (Maryland) offers full-day (6.5 hours/day, 180 days/year) and part-day (3 hours/day, 180 days/year) options. It is clear from the exemplars and consistent with research findings that within high-quality pre-K programs the dosage required is related to the size of the achievement gap that must be closed for each low-income child. For low-income children who enter pre-K already on a trajectory to be kindergarten-ready, a high-quality part- day option may be sufficient. For most low-income children, at least one year in full-day, high-quality pre-K is needed to be kindergarten-ready. For low-income children for whom English is not spoken at home, children with special needs, and children who are significantly below age-level competency in one or more domains, it is likely that two years of high- quality, full-day pre-K is ideal and, in fact, may be necessary for most of these children to be kindergarten- ready on time. "

It goes on to other things as well.

And these exemplars are at the $10K-$12K per student mark, roughly. And even successful ones still can't get funding--"New Jersey was poised to expand the Abbott Pre-K Program in 2013, but budget pressures have delayed that expansion.".

And the Gates foundation is VERY gently suggesting that all the mediocre, non-useful programs should be shut down in preference to spending ALL that money on the most underperforming students. While this is likely the best use of resource, it is going to be a politically unviable one.

The upshot is that teaching properly is expensive, and money really DOES have an impact. And the effectiveness "breakpoint" is somewhere around $12K with some adjustmemts for cost of living. And your primary expense is the teacher vs class size--see page 17. The cost per student with a teacher at BA I qualification ranges from $10K with a 15 student class size to $8K with a 20 student class size. Of course, teaching effectiveness is inversely related to class size--pick your optimization point.

I don't always like the Gates foundation because I think they sometimes helicopter in, muck things up, leave, and then other people have to clean up the mess. However, they have been quite forthright with publishing their information and do acknowledge when they have NOT succeeded even when it goes against their agenda. That I applaud.

In the US at least, you can't read too much into the averages, because there are so many additional factors that vary by state and between cities. Some states spend far more per pupil than others, although different states can have very different cost-of-living, so comparing absolute numbers in that case doesn't make much sense.

Even within a state, different areas have very different cost of living, and very different hyper-local conditions like concentrations wealth or poverty, that have a big affect on how far each dollar spent goes.

[1] http://www.oecd.org/education/EAG2014-Indicator%20B1%20(eng)...

Maybe I've had bad luck in doctors. It's not like I get a choice in them, the way the US system works. Three times in my life I have had severe chronic problems that were ultimately solved by my own inexpert research and experimentation or by the inexpert observations of a casual observer. These days I only bother to go to a doctor after I have a good suspicion of what's wrong already, like if I broke a bone or something.

Technological innovations that reduce costs will be the most lasting ways to reform these sectors.

Regular people can change the countries they are living in if they don't like the tradeoffs their government is doing, you know... Or vote to change them, but don't be surprised when improving lives comes at the cost of losing "top dog" status.

(Note: I'm not an American, but I see the tradefoffs the U.S. made, and I understand they make sense to some.)

We should realize that it isn't a fundamental property of government, just the one we have and we have mechanisms for making changes that we haven't yet tried.

5% of patients are half of all costs in the US healthcare system; 1% of patients are 22% of the cost. People over the age of 65 are a greater share of cost in the US system than in universal healthcare systems, because the US doesn't have a big lever for rationing care.

The healthiest half, is 3% of the cost in the system.

A market healthcare system, which is widely considered immoral, will drop many of the most expensive and poorest patients from the system. That's how you can dramatically lower costs in the US system, if you want to go the market route. A market system would particularly focus on the 50% that are only 3% of cost, with costs being far higher for everyone else (resulting in lack of access to expensive treatment for many, and many millions of people would get denied healthcare coverage due to pre-existing conditions).

A universal healthcare system smashes costs by rationing care, and tightly controlling everything from drug prices to healthcare worker salaries.

The US today has neither of those approaches widely implemented. We have a lot of government and private healthcare without enough of the tight cost checks. The obvious outcome, is a perpetual cost spiral until it can't spiral anymore (which is about where we're at now).

Is that including the entire population or just those on Medicare?

> government's mostly laissez-faire approach to handling both

actually those are among the most heavily regulated and subsidized industries in the us.

Spending goes up because a majority of politically engaged people have good access to care that they don't directly see the cost of.

Yep, and they all have administrators that make a ton of money.

I worked for a Blue Cross Blue Shield franchise a decade ago. It is/was a "non-profit", the CEO made 2.1 million dollars per year.

Non-profit != Money well spent

But hundreds of millions in executive salaries at companies that pay billions in insurance claims isn't the thing driving health care costs. It barely registers.

http://www.commonwealthfund.org/publications/in-the-literatu...

Overall the administrative overhead is 8% for healthcare in the US, more than double global average (3%)

http://money.cnn.com/2017/01/11/news/economy/healthcare-admi...

That 25% share, is about double what it is in Canada (although a few are equally high, the Netherlands is at 20%).

The famous chart showing the US growth in admin vs physicians since 1970: https://i.imgur.com/lnIcjo2.jpg

If a dollar amount chart showed the same effect it would do a better job of making the point that chart is intended to make. But I think it is pretty likely that the 1970 administrative baseline is tiny (because in 1970 there were lots of small hospitals run by 1 doctor).

But you could sidestep all of that by comparing to other countries, non of which ever had a significant number of “small hospitals run by 1 doctor”; their expenditure as a percentage is mostly consistent through the years and about half as high as the US, with similar trends in education.

The higher administrative costs at US hospitals account for something like 3% or 4% of total US healthcare spending. A huge win if you take it all back and not any sort of solution to the cost problem.