Aaron E. Carroll

Almost anyone with a child in day care or preschool has received the call. They say your child has a minor ailment like pink eye and must go to the doctor. Otherwise, they say, the child won’t be able to return to school or day care. Sometimes, they even say your child can’t come back until they’re on antibiotics.

The best evidence, however, says there should be less treatment for pink eye and other minor illnesses, not more. Day care centers usually ignore this evidence — and parents often pay the price.

This pattern is extremely hard to reverse. There is an understandable urge to be protective when it comes to children (and also an incentive to protect yourself from future criticism should your decision not to act go poorly).

Being overprotective has costs, though. Visits to the doctor aren’t free nor are drugs. Parents have to skip work to take their children to the doctor. They already pay a lot for day care, and this is a forced expense that often lacks value.

About 30% to 40% of working mothers pay for child care outside the home. In a recent Upshot article, Claire Cain Miller pointed out that child care can cost a typical family a third of its income. And the current administration keeps adding work requirements to many safety net programs.

Moreover, a visit to the physician is not harm-free. Children are exposed to other potentially ill children in a waiting room. Day care centers seem concerned that children could spread disease to other children in their facilities but not nearly as concerned that they could spread illnesses to other children in a clinic.

They Don’t Have Medical Training

Day care centers sometimes act as medical experts. In 2010, researchers examined the medical policies of day care centers in Pennsylvania. Almost all (97%) of them had written policies for when ill children should stay home. In almost all cases, those making decisions about who was too ill to attend were directors or teachers — neither of whom had medical training.

More than 90% had policies requiring antibiotics for pink eye with a white or yellow discharge. More than half had policies requiring antibiotics for diarrhea. Neither requirement makes sense.

Pink eye, also known as conjunctivitis, can be highly contagious, which helps explain why day care centers have such strict policies regarding it.

But a lot of pink eye is caused by viruses, which are unaffected by antibiotics.

Even when pink eye is caused by a bacterial infection, antibiotics have a limited effect. They slightly increase the chance that a child will feel better within two to five days. But there’s no promise of a cure the “next day,” as most day care centers seem to believe, and no lessening of infectiousness.

This is not just an American problem. A study of child care centers in Ontario found workers often recommended that parents visit the doctor for a runny nose or cough; they also said antibiotics would be useful for colds (they are not). More than two-thirds had allowed children to return if they were on antibiotics. Studies in England have also found that about half of policies required antibiotics for pink eye and that such policies influence clinicians’ decisions about whether to prescribe them.

The American Academy of Pediatrics, along with some other major health organizations, has published recommendations on when children should be kept from child care centers. Two main criteria should drive considerations, according to the recommendations. If children are so sick that they cannot participate in activities, they should stay home. If they need more attention than the staff can provide, they should stay home, too.

Otherwise, it should depend not on whether they are sick but on how sick. Clearly a very ill child should stay home, but each child experiences illness differently. Fever requires staying away only if it causes changes in activity participation or if it’s accompanied by other symptoms like a sore throat or rash. Vomiting requires staying away if it occurs more than once.

Optimal Strategies

Multiple studies have shown that the optimal strategy for managing pink eye is to delay antibiotics — to see if it resolves on its own. There’s certainly no reason to require antibiotics or to delay a child’s return until they’re on them.

Many schools will probably be too worried about children who spread infections to follow these guidelines. But children are often infectious before they show any symptoms, and we’re never going to be able to prevent all transmission of illness.

Our best bet is still focusing on hygiene, like proper hand washing, covering your mouth when you cough or sneeze, and not sharing food and drink with others.

Instead of relying on antibiotics and after-the-fact measures to prevent the spread of disease at day care, a center’s staffers could focus on disease prevention. A randomized controlled trial published last year in Pediatrics examined a hand hygiene program at child care centers in Spain that focused on more diligent hand washing or sanitizing. The program resulted in a reduction in respiratory infections and antibiotic prescriptions, as well as fewer days missed. Another study from a decade earlier found a similar result.

Unnecessary treatment isn’t just a problem with pink eye. It happens for sore throats. It happens for rashes. Taken together, it essentially amounts to a tax on being a parent, with costs both obvious and hidden: medical fees, missed work, lost time.

The idea is to protect children, but current practices don’t seem to be serving anyone well.

This article originally appeared in

Day Care Directors Are Playing Doctor, and Parents Suffer

(The Upshot: The New Health Care)

In a paper published early this year in Nature Human Behavior, scientists asked 500 Americans what they thought about foods that contained genetically modified organisms.

The vast majority, more than 90%, opposed their use. This belief is in conflict with the consensus of scientists. Almost 90% of them believe GMOs are safe — and can be of great benefit.

The second finding of the study was more eye-opening. Those who were most opposed to genetically modified foods believed they were the most knowledgeable about this issue, yet scored the lowest on actual tests of scientific knowledge.

In other words, those with the least understanding of science had the most science-opposed views but thought they knew the most. Lest anyone think this is only an American phenomenon, the study was also conducted in France and Germany, with similar results.

If you don’t like this example — the point made here is unlikely to change people’s minds and will probably enrage some readers — that’s OK because there are more where that came from.

A small percentage of the public believes that vaccines are truly dangerous. People who hold this view — which is incorrect — also believe that they know more than experts about this topic.

Many Americans take supplements, but the reasons are varied and are not linked to any hard evidence. Most of them say they are unaffected by claims from experts contradicting the claims of manufacturers. Only a quarter said they would stop using supplements if experts said they were ineffective. They must think they know better.

Part of this cognitive bias is related to the Dunning-Kruger effect, named for the two psychologists who wrote a seminal paper in 1999 entitled “Unskilled and Unaware of It.”

David Dunning and Justin Kruger discussed the many reasons people who are the most incompetent (their word) seem to believe they know much more than they do. A lack of knowledge leaves some without the contextual information necessary to recognize mistakes, they wrote, and their “incompetence robs them of the ability to realize it.”

This helps explain in part why efforts to educate the public often fail. In 2003, researchers examined how communication strategies on GMOs — intended to help the public see that their beliefs did not align with experts — wound up backfiring. All the efforts, in the end, made consumers less likely to choose GMO foods.

Brendan Nyhan, a Dartmouth professor and contributor to The Upshot, has been a co-author on a number of papers with similar findings. In a 2013 study in Medical Care, he helped show that attempting to provide corrective information to voters about death panels wound up increasing their belief in them among politically knowledgeable supporters of Sarah Palin.

In a 2014 study in Pediatrics, he helped show that a variety of interventions intended to convince parents that vaccines didn’t cause autism led to even fewer concerned parents saying they would vaccinate their children. A 2015 study published in Vaccine showed that giving corrective information about the flu vaccine led patients most concerned about side effects to be less likely to get the vaccine.

A great deal of science communication still relies on the “knowledge deficit model,” an idea that the lack of support for good policies, and good science, merely reflects a lack of scientific information.

But experts have been giving information about things like the overuse of low-value care for years, to little effect. A recent study looked at how doctors behaved when they were also patients. They were just as likely to engage in the use of low-value medical care, and just as unlikely to stick to their chronic disease medication regimens, as the general public.

In 2016, a number of researchers argued in an essay that those in the sciences needed to realize that the public may not process information in the same way they do. Scientists need to be formally trained in communication skills, they said, and they also need to realize that the knowledge deficit model makes for easy policy but not necessarily good results.

It seems important to engage the public more, and earn their trust through continued, more personal interaction, using many different platforms and technologies. Dropping knowledge from on high — which is still the modus operandi for most scientists — doesn’t work.

When areas of science are contentious, it’s clear that “data” aren’t enough. Bombarding people with more information about studies isn’t helping. How the information contained in them is disseminated and discussed may be much more important.

This article originally appeared in <a href="https://www.nytimes.com/2019/07/22/upshot/health-facts-importance-persuasion.html" id="a8dafbc2-2c2d-3a1c-a907-fb39f39a9987">The New York Times</a>.

Health Facts Aren't Enough. Should Persuasion Become a Priority?

The American medical malpractice system is doing almost nothing to improve the quality of health care, research suggests. What may be more concerning is that there is very little discussion, much less action, about changing this.

Despite worries among doctors that they are at financial risk from large payouts to plaintiffs, it turns out that a small percentage are responsible for a huge number of claims. A new study, confirming earlier research, found that about 2% of doctors accounted for about 39% of all claims in the United States.

The study contained other valuable information about a system that not only compensates patients who have been harmed, but is also supposed to identify physicians who may be performing poorly and need correction.

First, the good news: These doctors quit at higher rates than other physicians. And they also tend not to pick up and move somewhere else to start fresh (which many thought they’d do given that licenses and malpractice are regulated at the state level).

But the overwhelming majority of doctors who had five or more paid claims kept on going. And they also moved to solo practice and small groups more often, where there’s even less oversight, so those problematic doctors may produce even worse outcomes.

We have long known that some doctors are likelier than others to be sued. Those who practice in certain higher-risk specialties — like surgery, obstetrics and gynecology, and emergency medicine — are more likely to be sued than those in lower-risk specialties like family medicine, pediatrics and psychiatry. Men are more likely to be sued than women. Lawsuits seem to peak when doctors are around 40.

A few years ago, a study in the New England Journal of Medicine sought to examine this group of physicians specifically and see what happens to them after lawsuits.

The study’s authors used the National Practitioner Data Bank, which houses information on actions taken against physicians by hospitals or licensing boards as well as any payments made on their behalf because of malpractice claims. Although researchers cannot obtain information about individual physicians through the database, anonymous identifiers allow them to see if more than one claim is attributed to the same physician.

Over a 10-year period, only 6% of physicians overall had a paid claim. This means that the vast majority have no paid claims at all. Only 0.2% of physicians account for 12% of all paid claims.

Logic would assume that these physicians with a large number of claims over a set period would be those who may need intervention. Certainly, we might expect changes in where and with whom they work.

Many of these same researchers went back to the practitioner databank to see if this was the case and have recently published their findings. This time, they looked at records from 2003 through 2015. As before, they found that a small number of physicians accounted for most claims.

In this analysis, the researchers linked this group of doctors to another database, the Medicare Data on Provider Practice and Specialty, which contains information on practice location and type. This allowed them to look at whether physicians moved or changed jobs after claims.

Those who accumulated more claims were more likely to stop practicing medicine. Even though they were more likely to retire, more than 90% of doctors who had at least five claims were still in practice.

Physicians with more claims were also not any more likely than those with fewer or no complaints to move to another state and continue practicing. This is actually one of the reasons the practitioner databank was created — to prevent doctors from running away from their history by moving between states. In that respect, it appears to be working.

What’s worrisome, though, is that physicians with more claims shifted their type of practice. Those with five or more claims had more than twice the odds of moving into solo practice.

This makes sense, in some ways. Doctors with many claims may find it harder to find employment in large groups or in big clinics. Anyone can, however, set up his or her own practice. The general public is much less likely than a potential employer to seek out information about prior lawsuits.

This may be the most disturbing finding. Michelle Mello, an author of these papers and a professor of law and of health research and policy at Stanford University, said: “Malpractice frequent flyers could benefit from intervention from peers, hospitals and insurers to help them improve their practice or recognize limitations that should lead to changes in what they do clinically. When they instead just hang out a shingle, that opportunity is likely to be lost.”

Research has shown that the malpractice system, in terms of being a deterrent, has limited effects on the quality of care. A National Bureau of Economic Research working paper from 2014 found that the system — which largely holds physicians to “standards of care” — doesn’t seem to lead to higher quality according to widely accepted metrics.

In theory, licensing boards could flag and address physicians who have had a worrisome number of claims against them.

“In practice, they may lack some of the necessary information to see the patterns, especially if prior cases occurred in another jurisdiction,” said David Studdert, another author of these studies and a professor of law and medicine at Stanford. “Also, like courts, boards tend to focus on wrongdoing in particular instances, rather than looking at the bigger picture. There are sound legal reasons for doing that, but it doesn’t jibe well with how we think about quality of care outside the law.”

Many in the medical profession spend time worrying about how unfair the malpractice system is to physicians and how it’s overused to punish innocent doctors. They say the system is failing to help us reduce spending. This may be true. But it seems more attention needs to be paid on how it might improve the quality of care as well.

This article originally appeared in <a id="449e1722-dd83-38c2-a83d-f48c0ca5af84" href="https://www.nytimes.com/2019/05/27/upshot/malpractice-health-care-missed-opportunity.html">The New York Times</a>.

A missed opportunity for the malpractice system to improve health care

(The Upshot) ; (The New Health Care)

This law goes even further, though: Although the intent of the law is to block abortion, it has opened a vigorous debate about whether women who miscarry could be questioned or even prosecuted.

The new law, which goes into effect Jan. 1, gives a 6-week-old fetus the legal status of a human being. One definition of second-degree murder in Georgia includes cruelty to children during which “he or she causes the death of another human being irrespective of malice.” This raises the question of whether a woman who miscarries because of what is perceived to be her conduct could be held liable for that conduct.

“This suggests that women who ‘cause the death’ of a fetus, with or without malice, could be charged with second-degree murder,” said Eric Segall, a law professor at Georgia State University, and a supporter of abortion rights. He said the law would most likely be struck down in the lower courts.

Even if the Supreme Court reverses course on abortion, law enforcement authorities with scarce resources may not investigate women this way. “One would hope,” he said, “that there would be a political cost if they did.” But, he noted, given the ambiguities in the new law and its complex interactions with other Georgia statutes, prosecutors would have a lot of discretion, and it would be “completely up to” them.

Other Georgia criminal statutes may still protect women from prosecution for ending their pregnancies or for miscarrying. Even if that winds up being true, the new law says doctors who perform abortions will be prosecuted, and that could still have an effect on women who miscarry.

Staci Fox, president of Planned Parenthood Southeast, told The Washington Post she didn’t think that the Georgia law could be used to successfully prosecute women, but that a woman who miscarried “could be pulled into an investigation looking at whether someone performed an illegal abortion on her.”

It would be helpful, of course, if legislators and judges and prosecutors understood the basics of miscarriage. Early pregnancy loss is not uncommon. It occurs in about 10% of recognized pregnancies. Four out of 5 cases occur in the first trimester. Many women miscarry before they know they are pregnant.

About half of miscarriages are because of abnormalities in the fetal chromosomes. These defects are usually incompatible with life, and spontaneous abortions occur. The chance of an early pregnancy loss rises with age. While it is less common in younger women, about 80% of pregnancies in 45-year-old women can end this way.

Without randomized controlled trials, which really are not possible here, we cannot know for sure what is causing many miscarriages not involving chromosomal abnormalities. We have a great deal of information about what is associated with them, but that is not the same.

A woman who has health problems in general is more likely to suffer early pregnancy loss than one who does not. Women with high blood pressure, diabetes and thyroid disease are at higher risk. So are those who have hormone problems, immune disorders or infections.

Circumstances at work can be associated with miscarriages. A 2013 systematic review found that working nights was a risk factor, as were things like working in a three-shift schedule, working 40 to 52 hours per week and standing for six to eight hours per day.

Smoking has been associated with an increased risk of miscarriage, according to a meta-analysis that included 98 studies. Obesity has also been linked to recurrent miscarriage.

To be clear, there is no evidence that any of the factors mentioned causes a miscarriage. All of these data arise from observational studies that investigate associations, not causes. It is easy to make an erroneous leap from one to the other. Smoking, obesity and night-shift work are each associated with being poorer and having fewer resources for health. That probably would not stop some people from quickly blaming women for their choices rather than considering their socioeconomic status.

Ask almost any medical professional what caused a miscarriage, especially one early in pregnancy, and — other than chromosomal abnormalities — they will say that “we do not know.” If medical professionals cannot make that determination, it’s hard to understand how someone in law enforcement might.

A bigger concern is that a fear of becoming part of an investigation may cause women to avoid medical care. Women who are bleeding or are heading toward septic shock may not come to the emergency room or doctor’s office. They could die. This would only increase America’s maternal mortality rate, which is already much higher than that of most other advanced nations.

John Becker, a state representative in Ohio, recently sponsored a bill that would also change how pregnant women with unsustainable pregnancies are treated. He suggested that ectopic pregnancies, which are not viable, should in part be handled by “removing the embryo from the fallopian tube and then reinserting it in the uterus so that’s defined as not an abortion.”

This procedure is not possible. It is not clear that those who are writing many of these bills understand how pregnancy works.

We do know some things about how miscarriage works: It is a common, natural and unavoidable health outcome for many heartbroken people. Inserting politicians and the criminal justice system into the grieving process seems as if it could only cause further pain.

This article originally appeared in <a id="b51d02d8-788a-4aa7-b723-e8cd567c9ee2" href="https://www.nytimes.com/2019/05/14/upshot/miscarriages-politics-georgia-law.html">The New York Times</a>.

Why politics should be kept out of miscarriages

(Upshot: The New Health Care): Georgia’s much-discussed new law on abortion is one of the most restrictive in the nation. Abortion will be banned as early as six weeks into pregnancy — before many women even know they are pregnant.

Legislators and gun safety advocates often focus on how guns are purchased. But many lives could be saved, especially among children, if they looked more at how they are stored.

In the past decade, guns killed more than 14,000 American children. A startling number of those deaths — more than a third — were classified as suicides, and around 6% as accidents. Many more children were injured.

Nearly everyone agrees that children should not be able to buy guns, and no state lets them do so on their own. When children die by suicide using guns, it’s a result of being able to get hold of a gun that someone else already obtained — often legally.

How guns are stored matters. A study published Monday morning in JAMA Pediatrics has found that even a modest increase in the number of owners who lock up their guns would pay off in an outsize drop in gun deaths.

Dr. Michael Monuteaux, an assistant professor of pediatrics at Harvard Medical School and an author of the study, said: “We need to communicate to parents that storing guns in a way that makes them inaccessible to children can reduce the number of children who die year after year, especially from suicide.”

In 2010, researchers examined who owned the firearms used in youth suicides. In cases where this could be determined, three-quarters of the time the owner was a parent, and for a further 7% it was some other relative.

In a 2005 study published in JAMA, researchers found that keeping guns locked and unloaded, and keeping ammunition locked and separate from guns, were significantly associated with lower levels of suicides and accidents among adolescents in gun-owning households. This held true for both handguns and long guns.

But such safety practices aren’t common. If a recently passed New York bill is signed into law, it will make the state one of just a handful with comprehensive gun storage laws intended to protect children.

Last year, a study based on a national survey in 2015 found that about 1 in 3 of all households in the United States owned at least one gun. Of those households with both guns and children at home, more than 20% reported storing them both loaded and unlocked — the least-safe way. An additional 50% stored them either loaded or unlocked.

This meant that about 7% of all children in the United States lived in a house in which at least one gun was stored in an unsafe manner. This was about twice the number reported in the previous national survey, published in 2002. Other research suggests that many people in gun-owning households, typically not the primary owner of the gun, think they are safely stored when they are not.

Critics also say safe storage laws are hard to enforce because of privacy concerns. As a model from Monday’s study in JAMA Pediatrics shows, though, even a modest intervention that motivates households to safely store guns could reduce youth firearm deaths by 6% to 32%.

Suicides are less rare than self-defense shootings and, along with accidents, they are more likely in children who have parents who abuse alcohol. Studies have also found that children living with an adult who misuses alcohol were more likely to live in a house with a gun stored unsafely, and that heavy alcohol use was most common in those who store guns loaded and unlocked.

“We know from prior studies that children who live with alcohol-misusing adults are at a greater risk of suicide attempt, bullying victimization and perpetration, and unintentional injuries,” said Dr. Ali Rowhani-Rahbar, an associate professor of epidemiology at the University of Washington’s School of Public Health.

— Possible safety measures

Last year, in the journal Injury Prevention, Rowhani-Rahbar and other researchers reported on the results of two community-based firearm safety events in Washington state. They found that presenting people with information and offering to sell them trigger guards or lockboxes resulted in an increase of about 14% of households that stored all guns locked and 9% more that stored them unloaded.

In 2017, the Government Accountability Office reviewed 16 public or nonprofit programs that aimed to improve the storage of guns. It also reviewed studies of these programs. It found that distributing locks led to more safely stored guns. Few of these evaluations were rigorous, however. (Gun research, as with most things related to guns, is a politically divisive issue, and for many years research funding has been very low relative to other major causes of death.)

Policy can make a difference, too. In 2004, a study examined how laws that focused on the sale of guns affected the suicide rates of children, compared with laws mandating safe storage of firearms. They found that between 1976 and 2001, minimum-age purchase laws and possession-age laws had no effect on adolescent suicide rates. Laws preventing children’s access to guns, on the other hand, were associated with significant reductions of suicides by guns, even when reductions were not seen in suicides by other methods.

About two-thirds of gun deaths in the United States are suicides, and given political stalemates over gun rights, it seems an area in which policymakers could be more productive. Safer storage of guns, especially in households with children, might make more of a difference than many legislative and advocacy efforts that get more attention.

This article originally appeared in <a id="8de92ce4-b5cc-389d-a863-fbdc789fe2c9" href="https://www.nytimes.com/2019/05/13/upshot/gun-safety-children-storage.html">The New York Times</a>.

The potentially lifesaving difference in how a gun is stored

(The New Health Care) ; (The Upshot)

SINGAPORE — Singapore’s health care system is sometimes held up as an example of excellence and as a possible model for what could come next in the United States.

When we published the results of an Upshot tournament on which country had the world’s best health system, Singapore was eliminated in the first round, largely because most of the experts had a hard time believing much of what the nation seems to achieve.

It does achieve a lot.Americans have spent the last decade arguing loudly about whether and how to provide insurance to a relatively small percentage of people who don’t have it. Singapore is way past that. It’s perfecting how to deliver care to people, focusing on quality, efficiency and cost.

Americans may be able to learn a thing or two from Singaporeans, as I discovered in a recent visit to study the health system,although there are also reasons that comparisons between the nations aren’t apt.

A population that is healthier

Singapore is an island city-state of around 5.8 million. At 279 square miles, it’s smaller than Indianapolis, the city where I live, and is without rural or remote areas. Everyone lives close to doctors and hospitals.

Another big difference between Singapore and the United States lies in social determinants of health. Citizens there have much less poverty than one might see in other developed countries.

The tax system is progressive. The bottom 20 percent of Singaporeans in income pay less than 10 percent of all taxes and receive more than a quarter of all benefits. The richest 20 percent pay more than half of all taxes and receive only 12 percent of the benefits.

Everyone lives in comparable school systems and the government heavily subsidizes housing. Rates of smoking, alcoholism and drug abuse are relatively low. So are rates of obesity.

All of this predisposes the country to better health and accompanying lower health spending. Achieving comparable goals in the United States would probably require large investments in social programs and there doesn’t appear to be much of an appetite for that.

There’s also a big caveat to Singapore’s success. It has a significant and officially recognized guest worker program of noncitizens. About 1.4 million foreigners work in Singapore, most in low-skilled, low-paying jobs. Such jobs come with some protections and are often better than what might be available in workers’ home countries, but these workers are also vulnerable to abuse.

Guest workers are not eligible for the same benefits (including access to the public health system beyond emergency services) that citizens or permanent residents are, and they aren’t counted in any metrics of success or health. Clearly this saves money and also clouds the ability to use data to evaluate outcomes.

Things to like, for the left and right

The government’s health care philosophy is laid out clearly in five objectives.

In the United States, conservatives may be pleased that one objective stresses personal responsibility and cautions against reliance on either welfare or medical insurance. Another notes the importance of the private market and competition to improve services and increase efficiency.

Liberal-leaning Americans might be impressed that one objective is universal basic care and that another goal is cost containment by the government, especially when the market fails to keep costs low enough.

Singapore appreciates the relative strengths and limits of the public and private sectors in health. Often in the United States, we think that one or the other can do it all. That’s not necessarily the case.

Dr. Jeremy Lim, a partner in Oliver Wyman’s Asia health care consulting practice based in Singapore and the author of one of the seminal books on its health care system, said, “Singaporeans recognize that resources are finite and that not every medicine or device can be funded out of the public purse.”

He added that a high trust in the government “enables acceptance that the government has worked the sums and determined that some medicines and devices are not cost-effective and hence not available to citizens at subsidized prices.”

In the end, the government holds the cards. It decides where and when the private sector can operate. In the United States, the opposite often seems true. The private sector is the default system and the public sector comes into play only when the private sector doesn’t want to.

In Singapore, the government strictly regulates what technology is available in the country and where. It makes decisions as to what drugs and devices are covered in public facilities. It sets the prices and determines what subsidies are available.

“There is careful scrutiny of the ‘latest and greatest’ technologies and a healthy skepticism of manufacturer claims,” Lim said. “It may be at the forefront of medical science in many areas, but the diffusion of the advancements to the entire population may take a while.”

Government control also applies to public health initiatives. Officials began to worry about diabetes, so they acted. School lunches have been improved. Regulations have been passed to make meals on government properties and at government events healthier.

In the United States, the American Academy of Pediatrics and the American Heart Association recently called on policymakers to impose taxes and advertising limits on the soda industry. But that’s merely guidance. There’s no power behind it.

In Singapore, campaigns have encouraged drinking water, and healthier food choice labels have been mandated. The country, with control over its food importation, even got beverage manufacturers to agree to reduce sugar content in drinks to a maximum of 12 percent by 2020.

Should beverage companies fail to comply, officials might not just tax the drinks — they could ban them.

What’s really special is the delivery

Singapore gets a lot of attention because of the way it pays for its health care system. What’s less noticed is its delivery system.

Primary care, which is mostly at low cost, is provided mostly by the private sector. About 80 percent of Singaporeans get such care from about 1,700 general practitioners. The rest use a system of 18 polyclinics run by the government.

As care becomes more complicated — and therefore more expensive — more people turn to the polyclinics. About 45 percent of those who have chronic conditions use polyclinics, for example.

The polyclinics are a marvel of efficiency. They have been designed to process as many patients as quickly as possible. The government encourages citizens to use their online app to schedule appointments, see wait times and pay their bills.

Even so, a major complaint is the wait time. Doctors carry a heavy workload, seeing upward of 60 patients a day. There’s also a lack of continuity. Patients at polyclinics don’t get to choose their physicians. They see whoever is working that day.

Care is cheap, however. A visit for a citizen costs 8 Singapore dollars for the clinic fees, a little under $6 U.S. Seeing a private physician can cost three times as much (still cheap in American terms).

For hospitalizations, the public vs. private share is flipped. Only about 20 percent of people choose a private hospital for care. The other 80 percent choose to use public hospitals, which are — again — heavily subsidized. People can choose levels of service there (from A to C, as described in an earlier Upshot article), and most choose a “B” level.

About half of all care provided in private hospitals is to noncitizens of Singapore. Even for citizens who choose private hospitals, as care gets more expensive, they move to the public system when they can.

So Singapore isn’t really a more “private” system. It’s just privately funded. In effect, it’s the opposite of what we have in the United States. We have a largely publicly financed private delivery system. Singapore has a largely privately financed public delivery system.

There’s also more granular control of the delivery system. In 1997, there were about 60,000 ambulance calls, but about half of those were not for actual emergencies. What did Singapore do? Itdeclared that while ambulance services for emergencies would remain free, those who called for nonemergencies would be charged the equivalent of $185.

Of course, this might cause the public to be afraid to call for real emergencies. But the policy was introduced with intensive public education and messaging. And Singaporeans have identifier numbers that are consistent across health centers and types of care.

“The electronic health records are all connected and data are shared between them,” said Dr. Marcus Ong, the emergency medical services director. “When patients are attended to for an emergency, records can be quickly accessed, and many nonemergencies can be then cleared with accurate information.

“By 2010, there were more than 120,000 calls for emergency services, and very few were for nonemergencies.”

The good times may not last

Singapore made big early health leaps, relatively inexpensively, in infant mortality and increased life expectancy. It did so in part through “better vaccinations, better sanitation, good public schools, public campaigns against tobacco” and good prenatal care, said Dr. Wong Tien Hua, the immediate past president of the Singapore Medical Association.

But in recent years, as in the United States, costs have started to rise much more quickly with greater use of modern technological medicine. The population is also aging rapidly. It’s unlikely that the country’s spending on health care will approach that of the United States (18 percent of gross domestic product), but the days of spending significantly less than the global average of 10 percent are probably numbered.

Medical officials are also worried that the problems of the rest of the world are catching up to them.They’re worried that diabetes is on the rise. They’re worried that fee-for-service payments are unsustainable. They’re worried hospitals are learning how to game the system to make more money.

But they’re also aware of the possible endgame. One told me, “Nobody wants to go down the United States route.”

Perhaps most important, the health care system in Singapore seems more geared toward raising up all its citizens than on achieving excellence in a few high-profile areas.

Without major commitments to spending, we in the United States aren’t likely to see major changes to social determinants of health or housing. We also aren’t going to shrink the size of our system or get everyone to move to big cities.

It turns out that Singapore’s system really is quite remarkable. It also turns out that it’s most likely not reproducible. That may be our loss.

This article originally appeared in <a href="https://www.nytimes.com/2019/04/22/upshot/singapore-health-system-lessons.html" id="5c1f5873-7042-3033-ae1c-7f321d20d2b4">The New York Times</a>.

What Can the U.S. Health System Learn From Singapore?

Then I counsel them if they answer in the affirmative. I want young people to be safe.

But doctors lack the evidence base — we don’t have enough studies — to know how much of a difference this makes.

Here’s why we may want an answer. Excessive drinking is responsible for 88,000 deaths per year in the United States, about 1 in 10 deaths among working-age adults. The cost in 2010 was almost $250 billion.

And drinking is a serious problem among adolescents. More than 9 percent of 12- to 17-year-olds drink alcohol, and almost 5 percent engaged in binge drinking in the last month.

We know how to screen people for alcohol misuse. It’s not hard. The Alcohol Use Disorders Identification Test-Consumption asks three simple questions: how often people drink, how much, and how often they drink heavily.

The Single Alcohol Screening Question asks simply, “How many times in the past year have you had 5 (men)/4 (women) or more drinks in a day?”

The latter is positive (when the answer is more than once) in about 80 percent of people who have unhealthy use of alcohol (as defined by the National Institute on Alcohol Abuse and Alcoholism) and negative in about 80 percent of people who do not. That is pretty good for a quick one-question screen.

There are also specific screening tools that have been validated for pregnant women, adolescents and older people.

Asking a question in a visit costs very little, other than time. It also has few harms. So why not recommend it for everyone?

Screening is useful when a condition is prevalent, when we can screen in a cost-effective manner, when early diagnosis makes a difference, and when we know that acting on that screen will make a difference.

Susan Curry, immediate past chairwoman of the U.S. Preventive Services Task Force, told me: “There have simply not been enough studies that assess the effects of screening and behavioral counseling in adolescents to address this issue. In addition, many of the existing studies have been conducted in school settings, and it is unclear if the results would translate to primary care.”

Theeffectsof behavioral counseling on adults are proven enough to show a moderate benefit. The same holds true for pregnant women, although the evidence is a bit less strong. But when it comes to adolescents, the evidence is almost nonexistent.

In a large systematic review, there were two studies (out of 68 total) that addressed how counseling interventions might affect adolescent alcohol use. One was a randomized controlled trial of 119 urban adolescents screened in a medical clinic, published in 2015, that used peer networks and motivational interviewing. Overall, it failed to achieve statistical significance with respect to reducing alcohol use.

The other was a 2017 randomized controlled trial in Switzerland schools (not clinics) of a web-and-text-based peer-network messaging system to reduce single-occasion binge drinking. It decreased the chance of that happening by 5.9 percent in the intervention group. But it had no effect on how much youths drank overall or the estimated peak blood alcohol concentration during binge drinking.

That’s all we’ve got. And before 2015, there was nothing.

“We are calling for additional research in all areas related to screening adolescents for alcohol use and providing counseling interventions to those who need them,” Curry said. “It is also important to explore whether such interventions could reduce other risky behaviors. In the meantime, we encourage primary care clinicians to use their clinical judgment when deciding whether to screen their adolescent patients for alcohol use.”

There’s disagreement on the definition of unhealthy alcohol use for adults.

For men, risky drinking is more than four drinks on any day or more than 14 drinks in any week, according to the national institute. And for women, it’s more than three drinks on any day or more than seven drinks in any week. (The institute defines a drink as 12 ounces of beer, 5 ounces of wine or 1.5 ounces of spirits.)

The American Society of Addiction Medicine, on the other hand, defines “at-risk use” as “use that increases the risk for health consequences.”

Young people tend to consume more alcoholic beverages when they’re drinking than adults do. Most of their drinking is binge drinking. Excessive drinking among adolescents — what we’re talking about screening for here — accounts for more than 4,300 deaths each year.

The economic costs of excessive drinking in just this population were $24 billion in 2010. Of those who drive, about 8 percent report having driven after drinking alcohol; 20 percent report having been in a car with someone who had been drinking. About 20 percent of teenage drivers who have died in crashes had been drinking.

Physicians who assure confidentiality and earn the trust of their patients can screen for alcohol use in adolescents pretty well. It’s not that we can’t uncover the problem. I’m often humbled by what my young patients will tell me in private. The issue is that we don’t have the knowledge for what to do with a “yes.” We don’t know that what we’re doing actually helps.

Although it endorsed screening of adults and pregnant women in a recent statement, the U.S. Preventive Services Task Force did not recommend universal screening for alcohol use among adolescents in primary care settings. That speaks more to a failure of our knowledge base — we need more studies — than to the failure of the recommending body to recognize the importance of the problem.

This article originally appeared in <a id="4cb6435d-c360-4ccc-9f9b-65f636a672a8" href="https://www.nytimes.com/2019/04/08/upshot/teenagers-risky-drinking-doctors-counseling.html">The New York Times</a>.

Does counseling help adolescents who drink alcohol? No one knows

(The Upshot) ; (The New Health Care): I’m a pediatrician, and when I see adolescents in my clinic, I ask them if they are drinking alcohol (among other risky activities).

I’m a pediatrician, and when I see adolescents in my clinic, I ask them if they are drinking alcohol (among other risky activities). Then I counsel them if they answer in the affirmative. I want young people to be safe.

Here’s why we may want an answer. Excessive drinking is responsible for 88,000 deaths per year in the United States, about one in 10 deaths among working-age adults. The cost in 2010 was almost $250 billion.

And drinking is a serious problem among adolescents. More than 9 percent of those 12 to 17 years drink alcohol, and almost 5 percent engaged in binge drinking in the last month.

The latter is positive (when the answer is more than once) in about 80 percent of people who have unhealthy use of alcohol (as defined by the National Institute on Alcohol Abuse and Alcoholism) and negative in about 80 percent of people who do not. That’s pretty good for a quick one-question screen.

This article originally appeared in <a href="https://www.nytimes.com/2019/04/08/upshot/teenagers-risky-drinking-doctors-counseling.html" id="107d2140-b293-3418-aa75-98e3ebafbc5e">The New York Times</a>.

Can Doctors Talk Teenagers Out of Risky Drinking?

Last year, one of my best friends learned he had cancer.

In many respects he was lucky. He had great insurance. He had enough money. Partly because one of his friends (me) is well connected in the health care system, he got excellent care.

So this is not a story about how the system failed, or how people need insurance or access. He had those. He got the care. This is the U.S. health care system at its peak performance.

But I was utterly floored by how hard it all was.

Americans spend so much time debating so many aspects of health care, including insurance and access. Almost none of that covers the actual impossibility and hardship faced by the many millions of friends and family members who are caregivers. It is hugely disrupting and expensive. There is no system for it. It’s a gaping hole.

My friend, Jim Fleischer, missed a few days of work as the diagnosis was made, then missed many more after surgery. His wife, Ali, had to take time off. His mother-in-law had to come and help take care of him and the children when Ali had to go back to work (she is a teacher).

Every appointment required Jim and Ali to take off work. They live in Indiana, and at one point they had to pay for flights and a hotel room and everything else associated with a trip to New York — none of it covered by insurance — because no one would do the second opinion remotely. (He had a kidney removed in an initial operation, then doctors found he had a rare cancer, a neuro-ectodermal tumor, instead of the expected renal cell carcinoma).

Chemotherapy is rough. After each cycle, Jim would pretty much sleep or rest for a week, unable to work. Someone had to take the time to be with him. Sometimes it was Ali, sometimes it was my wife, or me, or other friends.

Aaron E. Carroll

Articles written by the author

Day Care Directors Are Playing Doctor, and Parents Suffer

Health Facts Aren't Enough. Should Persuasion Become a Priority?

A missed opportunity for the malpractice system to improve health care

Why politics should be kept out of miscarriages

The potentially lifesaving difference in how a gun is stored

What Can the U.S. Health System Learn From Singapore?

Does counseling help adolescents who drink alcohol? No one knows

Can Doctors Talk Teenagers Out of Risky Drinking?

My friend's cancer taught me about a hole in our health system

A diabetes home test can be a waste of time and money

A Diabetes Home Test Can Be a Waste of Time and Money

Doctors and Racial Bias: Still a Long Way to Go

The unsung role of the pharmacist in patient health

The Reasonable Way to View Marijuana's Risks

Congratulations on the Promotion. But Did Science Get a Demotion?

Scant Evidence Behind the Advice About Salt