Philadelphia Reflections

Some Strategies in Reserve

1. Temporarily forget about retirement funding, just finance healthcare. A smaller sum is easier to handle. I certainly hope this is merely a transition expedient.

2. Forget about death. Just keep re-investing the remaining money until its debts are paid off, and then have it terminate. The model is a trust fund.

3. Forget about childbirth. Start a trust fund in anticipation of having at least one child, and if you don't, provide for a legal contingency. The model is a "Bride's Hope Chest", which sometimes ends in funding spinsterhood.

4. Forget about living trusts. If you anticipate or even want to anticipate, having children, start financing for it by saving money, investing it, and transferring it to its purpose without taxation of the transfer. But since we recoil at government ownership of the means of production, the model is a trust fund, not Socialism. Lawyers are puzzled about trust funds without living owners, so there must be a legislative approval of whatever we do that hasn't been done, before.

5. At present, we do all of our post-graduate medical education as "residencies" in hospitals. The consequence is twin silos with impaired communication. And then, our graduates (except surgeons) spend the rest of their lives working out of their offices. The consequence is the greatest flaw in the system comes from "hand-overs" of the patients from hospital to office practitioners who can't know what happened in the hospitals. The reverse is also true, from office to hospital, although it makes some sense to do a complete work-up when the patient is sick enough to warrant admission -- as long as you also make it available to the referring physician. The reason behind this is the desire of hospitals to maintain a monopoly silo for the transfer of information, lest they lose control of the patient himself. In Switzerland, almost all medicine is practiced in 15-25 bed "clinics", but that goes too far in the opposite direction.

If doctors get good at typing, they are spending too much time at it.

One solution to this is to use retirement villages as half-way houses, with a resident in charge, under supervision, in an attached medical shopping center which also serves the retirement facility better. Naturally, the retirement villages resist that hospital control feature. A great deal could be done with telemedicine that is not being done, but the idea flounders because of equipment start-up costs. However, when you see thirty billion dollars spent to patch this over with "meaningful use" of electronic medical records, you have to wonder how sincere the objections are. Because we don't have retirement villages well integrated into such a system, the extensive use of demonstration projects is advised, before the whole system is converted. In fact, it may make more sense to start with small rural areas than with large urban ones. Let a hundred flowers bloom.

6. My suspicion is the electronic record would make more progress if it were limited to laboratory, etc. data, and deliberately excluded doctor communication in favor of tape-recorded communications or even video recordings. But not composition or typing. If doctors get good at typing, they are spending too much time at it.

In time, of course, this is a technical issue which will be solved. However, it exaggerates the time spent reading the stuff, so a major project of automatic periodic summarization is urgently needed. Presumably, that should grow out of an expanded search and retrieval system, which records whatever doctors have been interested in seeing, in similar cases, and at what stage. The basic fact is that if no doctor ever looks at it, it isn't worth including in the archive. Conversely, if doctors go after it like a dog after a bone, it should be highlighted.

Originally published: Wednesday, November 23, 2016; most-recently modified: Wednesday, June 05, 2019