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Medicine and Public Issues: Thomas Bodenheimer High and Rising Health Care Costs. Part 2: Technologic Innovation Ann Intern Med 2005; 142: 932-937 [Abstract] [Full text] [PDF]

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Response to William L. Berger's letter to the editor

Thomas Bodenheimer   (23 August 2005)

Technological Innovations and Benefit

Cynthia X. Pan   (20 June 2005)

For whos good?

Ashish Goel   (7 June 2005)

Response to William L. Berger's letter to the editor 23 August 2005
Thomas Bodenheimer, MD UCSF Send rapid response to journal: Re: Response to William L. Berger's letter to the editor TBodenheimer{at}fcm.ucsf.edu Thomas Bodenheimer	To the Editor Annals of Internal Medicine I like Dr. Berger's letter. Thank you, Dr. Berger, for writing it. Thomas Bodenheimer MD University of California at San Francisco Conflict of Interest: None declared
Technological Innovations and Benefit 20 June 2005
Cynthia X. Pan, MD Mount Sinai School of Medicine Send rapid response to journal: Re: Technological Innovations and Benefit cynthia.pan{at}mssm.edu Cynthia X. Pan	Dr. Bodenheimer's series on High and Rising Health Care Costs has been informative and digestible, addressing a critical issue in today's health care. From my clinical observations, I would agree that technological innovation contributes most significantly to rising costs, and we are only at the beginning. Because technology is there, physicians will use it. At the end of Perspective 4, Dr. Bodenheimer mentions the question of "benefit," which merits exploration. One, for many patients, benefit or the ultimate outcome may be difficult to predict before a technological intervention. For example, a patient with several comorbidities may undergo cardiac bypass and valve replacement with the hope of recovering uneventfully, but instead remains septic, ventilator dependent, receives a tracheotomy and feeding tube, and ultimately dies in the hospital. Second, how is benefit defined? Is the above outcome a benefit because the patient lived for another few months? There needs to be clarification between quantity of life and quality of life. Third, technological advances are being offered without upfront discussions with patients about the limitations of the interventions or what could be done with them once the patient reaches the end stages of a disease when such an intervention may become more of a burden than a benefit. An example is the implantable defibrillator that shocks the patient with endstage heart failure as the patient is dying, because it is difficult emotionally to turn the defibrillator off. Some physicians may even oppose turning off the defibrillator for ethical reasons. More medical education needs to emphasize communication skills and ethical principles that guide these discussions. There are also systems problems with rapidly developing technological innovations. As a result of technological interventions, there is a growing population of patients who are considered “chronically critically ill,” defined as those who have received elective tracheotomy, have other medical comorbidities, and may or may not be able to wean from mechanical ventilation. Because of the high level of skill required to care for these patients, there is a dearth of settings or facilities that are equipped to competently care for them. These patients typically have a long hospital stay and are difficult to discharge because it is hard to find facilities that can take care of ventilators, dialysis needs, and infectious disease isolation requirements all at once. As the technological imperative progresses, the medical community needs to also develop palliative care services across all settings to address patients’ goals of care, symptom assessment and management, negotiate a complex health care system, and help patients and families determine the burdens and benefits of interventions at each stage of their illness. Conflict of Interest: None declared
For whos good? 7 June 2005
Ashish Goel, MD Medicine AIIMS, New Delhi INDIA Send rapid response to journal: Re: For whos good? ashgoe{at}yahoo.com Ashish Goel	The article on rising costs of health care made excellent reading and Dr Thomas Bodenheimer, needs to be congratulated for the thought proving comments. Another interesting thought that often comes to mind is that whom does techology benefit? It might be acceptable for developed nations, but when you practice medicine in a developing nation where a huge majority of your patients cannot afford two square meals a day, such escalating costs of techonology are certainly not going to benefit the patient. The doctor never gets anything out of technology. It is like the artificial brain which dulls the clinical skills of a physician. It is probably helpful to fill the coffers of large corporate hospitals and the pharmaceutical firms. It is the doctor who is the loser in this technology rat race. One who loses more is the patient. One who loses most is the doctor-patient relationship. Conflict of Interest: None declared