A lot of liberal blogs, and a few conservative ones, are discussing this article from the New York Times, which points out that if you look at actual economic resources, instead of prices, increasing health care utilitization isn't going to be so easy, because there's not a lot of spare capacity in the system. Gee, where have I heard this before?
The core problem is that we don't actually have a ton more doctors and nurses. Libertarians (and I think some liberals) argue that the problem is the AMA cartel: they control the number of med school admissions slots. But when I look at the numbers, I don't see all that much room to believe that getting rid of the AMA would let a thousand flowers bloom. In 2008, 42,000 people applied to medical school, and 18,000 enrolled. Presumably some who were admitted decided not to go, and some who weren't shouldn't be doctors. There don't seem to be, say, 10 qualified people for every slot. And nursing schools aren't swamped by more qualified applicants they can handle, yet there's a nursing shortage.
Another problem is that a teaching hospital is a hard thing to construct--given how much training doctors need, we won't do that overnight. Teaching hospitals are very expensive, and receive heavy government subsidies. Obviously, we could increase the number of doctors by some amount, but it wouldn't take care of the supply problem.
It's more reasonable to note that reimbursement structures are creating an undersupply of primary care physicians, compared to the number of specialists. We reimburse for procedures, not wellness, so surgeons are well paid and GPs aren't. This has led to the bizarre fact that Medicare chronically underreimburses (and thus insures an undersupply of) geriatricians, which should be the one doctor a program like Medicare produces a lot of.
Most commentators who note this seem to think they have discovered a miraculous new fact. Unfortunately, this has been true for decades, and generations of wonks and policymakers have also lamented it in their time. It's a lot harder to change than it sounds.
First of all, thanks to previous generations of these reimbursement policies, the AMA is dominated by specialists. It's a democratic organization, and there are more specialists than GPs, so guess who wins? They will launch an all-out war against any politician who changes the reimbursement policy, and the politician will lose, because they can't fight ads featuring sad, sick, telegenic grannies.
Second of all, it's actually really, really hard to pay GPs well, at least in the context of cutting overall costs. Note that private insurers, who are presumably not attempting to ingratiate themselves with the AMA, also reimburse procedures, not wellness. That's because procedures can be monitored, and wellness can't. Oh, you can implement some insane, byzantine system to take into account prior conditions, but this will not improve your administration costs. What you will see--what you do see, among specialists who are monitored for their success rates on procedures--is what liberals complain about with insurance companies: physicians will compete to get rid of their sicker patients. Pay for office visits, and you will get a lot of unnecessary office visits. As David Cutler once told me, it's no coincidence that health care and education are the two fields where outcomes are hardest to monitor, and where costs are growing uncontrollably.
Nor can you simply slash specialty reimbursements as a way of herding people into general practice, because med school applications are already declining; they're down 3.5% since 2001. Doctors are not, by and large, altruists who dream of living on a GS-13 wage. Nor can I blame them.
Copyright © 2009 by The Atlantic Monthly Group. All rights reserved.
This may be right, but note that applicants may self-select. If admission requirements are unreasonably high, then many otherwise qualified people will choose not to apply. In addition, the hazing that interns go through in the name of "training" after medical school may dissuade a lot of qualified applicants from applying.
Megan, this may be offtopic, but perhaps not: medical school just isn't as attractive for intelligent people like law or business is at this point.
Most people like to make money and not be attacked mercilessly in court. However, the current system, dominated by plaintiff's lawyers who feed off malpractice and fight no-fault/workman's comp esque insurance with a passion, make this impossible.
With about half a doctor's pay going to malpractice premiums (at least a GP) and time wasted in court fighting everything, the medical profession isn't very attractive, especially when their other college friends are making just as much or more but spend far less money on insurance and less time in court on their own behalf.
42,000 applications? Contrast that with 2004 in law schools, which saw 100,600 applicants. That's more than double the number of people vying to be the plaintiff's lawyer attacking the doctor rather than the doctor himself.
This is the sad truth. I'm not sure how typical this is, but I was considering medical school and was scared off by the idea of spending another 4 years in school + 4-8 years making peanuts as an intern/resident only to have gov't take over and tell me I couldn't make more than 100k per year. I figured that if we moved towards more regulation and government involvement, lawyers would be the only ones that could avoid getting screwed without directly participating in government corruption, and if we moved toward something closer to a free market, there'd be opportunities for me to get out of law if I wanted to. Looks like I will be practicing law for the foreseeable future.
I'm sure there's something to be said for discouraging people like me from going into medicine if the money is that important, but there's also something to be said for having enough doctors.
True dat, Johnson. ;)
Megan revives the old myth that doctors are more altruistic than others. I don't buy it; many are God-complex, self-aggrandizing womanizers and careerists too prickly to make compromises in the business world and too ego-driven to hide in research-intesnive fields (a la chemistry or physics). Beign a Doctor is a social privilege and it used to be economically rewarding; today, it isn't.
Fact is, we need good doctors, and I've heard many people (not experts, just common folk) claim that the lower pay and aggravation somehow ensure we only get good doctors (!), because they really want to help people. Good, I say, let's lower teaching salaries to get better teachers. That's when they yell at me.
I can honestly say Johnson's case isn't typical; I've known more than one lawyer who thought of medicine but were discourageded. One, a clerk for an appellate court currently, told me that her own parents, both doctors, discouraged her from the profession due to the headaches they face.
I'll second that; both my parents (both doctors) discouraged me from going to med school, not that it was ever a serious consideration.
It's an easy comparison:
Top student goes to law school, accrues $150K debt ($50K/yr for 3 years), gets job with $160K/yr salary right out of school and can pay it off fairly well.
Top student goes to med school, accrues $200K debt ($50K/yr for 4 years), then goes through another few years of residency at near minimum-wage, then depending on specialty if lucky can make what a lawyer in BigLaw makes. Oh, and instead of charging customers according to what the market will bear, they're stuck dealing with the arcane complications set by insurance companies and government. Don't forget malpractice insurance!
The only reason to go to medical school now is if you really, really want to be a doctor. That's a good way to get a shortage of doctors.
You'd have to be a masochist to be a doctor under the current system in the US. You spend your youth working virtually around the clock for very low wages. You'll be middle-aged before you even get out of debt, and by the time you have both money and time you'll be too old to enjoy it. If you decide you just can't handle it and bail out how will you ever pay your student loans?
You're expected to put in big hours up front in business and law, too, but they pay you more than fifteen bucks an hour while you do it.
You may have to be a masochist to become a doctor in the US, but remember, this is the country doctors are flocking *to*. Imagine how much fun it is in countries where the government has even more control over the industry.
Sure. After they become full-fledged doctors they come to the US.
Reply to tsotha below: they still have to complete another residency in the US in order to practice here.
Well - there are also those who can't do math. I did damn well at law school, yet would probably have been hopeless at med school. Most doctors I know could probably at least pass law school if the tried.
The iqs cluster together, and with motivation, you could pass.
No one can fail out of law school these days. If medical school is incredibly tough, law school is incredibly easy---except if you want top 10%, of course. The hardest part about law school is getting in.
P.s. Megan, please link to NY Times article (please don't make me search their website, its the Jayson Blair Times!)
One solution to the GP shortage is to replace them with nurse practitioners. While not MD's they are qualified to do most of the things that GP's do. They can analyze symptoms, prescribe medication, and refer one to a specialist.
No ideas on how one would monitor wellness effectively.
"Another problem is that a teaching hospital is a hard thing to construct--given how much training doctors need, we won't do that overnight."
Similarly, I think the thinking above reflects the flawed idea that it is necessary for doctors to do the amount of training that they do. I've always felt that the training regimen is designed to keep them enslaved to the medical establishment. Additionally, I'm skeptical that MDs produce better health results than nurse practictioners would product with greater treatment authority.
Health care costs are going up for the same reason education costs are going up. It's not because results are hard to measure. It's because the people making the decisions aren't paying the bills.
That may be part of it, but I'll still say that results are damn difficult to measure. If they were so easy to measure then 1) there would be good ideas out there on how to measure results, and 2) hopistals and schools would start measuring results in order to gain a competitive advantage.
link:
http://www.nytimes.com/2009/04/27/health/policy/27care.html?_r=1&hp
Ken's got the right idea. The "urgent care" type doctor's offices that utilize nurse practitioners are becoming quite popular where I live both for cost and availability (convenient location, extended hours and no appointment necessary).
Makes sense to me. I wonder how much time doctors spend on sniffles and sore throats. Hell, I could treat that.
It is still important to have physicians involved in care. Mid-level providers (PAs, NPs) are trained to recognize common presentations of disease - but there will always be 'zebras' - or uncommon diseases presenting in common ways. Is that recurrent sore throat simply viral? GERD? or maybe something worse like lymphoma or an immunodeficiency? MDs are over-trained for a reason.
No argument there. But MDs usually pick up the exotic stuff after they've tried treating the most obvious thing and it doesn't get rid of you. What I'm proposing is a layer of PAs or RNs for that first visit, where doctors normally give you antibiotics. Stump the PA and its off to the doctor. This is really not much different than stumping your doctor and getting a referral to a specialist.
I had a friend go back to her doctor for a cough and fever. After being sent home with antibiotics for "bronchitis" twice she ended up in the hospital to treat her TB. Primary care physicians just can't reasonably cover all the zebras for every cough or sore throat - it's impossible.
Isn't this more or less how dentistry works...?
Education is far easier to determine outcomes than medical wellness, and conveniently offers cohorts in a size adequate to be measured against themselves.
There is definite hope that K-12 (ok, maybe first grade through 12) can be a merit-based system based upon a set of outcomes, which appropriate hirings and firings.
Medicine, on the other hand, has sooo many more variables involved in determining wellness, determining who the cohort is to be analyzed, and trying to eliminate environmental factors. I still think it can be done, just not as easy.
If I'm doing the math right, let's assume 15,000 of those doctors pass and become MDs or DOs (I'm assuming "med school" includes osteopathy and precludes dentistry and chiropractic). Of those, 10,000 become GP. Big assumptions here.
Does that mean that for every generation, we have 200,000 GPs? Or about 1 GP per 150 people?
It seems to me you would only need about 1 GP per 900-1000 people, on the whole. If you had 30 minutes per visit (including dictation, administration, etc.), you could examine 8 patients (4 hours a day) for 120 days a year and easily exceed your quotient.
I'm making up metrics here, but even if we had 5,000 new GPs a year I think we'd still have over capacity.
Is my math wrong?
Yes, your math is wrong. The big problem is the proportion you have becoming GPs. You put it at 2/3 of doctors, or 10k out of 15k. In reality, it's more like 20-25%. Thus the shortage.
Ok, so I'll revise my math to be more conservative and say ~20% of the total admittances become GPs.
If there are 72,000 GPs per generation (3,600 new per year), that would put the GP to general population ratio (assuming 300 million gen pop) at 1 out of every 4166 people.
Assuming 240 working days a year, that's 17.4 people per day to evaluate. I'll make the assumption that it evens out with people who need multiple visits vs. people who don't visit at all.
http://www.annfammed.org/cgi/content/abstract/3/6/494
There's a study that shows in an 8 hour day, the average GP was able to examine 20.1 patients.
None of the practices utilized electronic records, so I'll assume those practices averaged out to be towards the inefficient side of the GP curve.
It seems to me like we are either balanced out, have a slight capacity and definitely an ability to grow more efficient, or the average person is utilizing more than one GP visit per year.
Speaking as someone who barely ever sees a doctor (aside from dentist and optometrist), and my wife who sees about 4 specialists a year, perhaps we need to teach more self-healthcare to reduce the burden if it's people going to a GP more than once a year on average?
I haven't checked through all the math, but you need to provide additional time for the paperwork. Every practicing pediatrician I know sets aside at LEAST one day/week to do nothing but finish notes, check labs, call back patients, contact referring physicians, etc. It's easy to see/examine/decide/treat 1 patient every half hour or so, but you have to factor in the time for all the other work (labs, notes, calls, etc).
As an aside, it amuses me to see that people assume electronic medical records are going to increase efficiency. Ha! Scribbling a little note on a paper document takes much less time than laboriously typing in the detailed notes the EMR requires. Of course, the EMR has other benefits (easier access later down the line, legibility), but increased efficiency isn't guaranteed.
Megan,
You said:
"Libertarians (and I think some liberals) argue that the problem is the AMA cartel: they control the number of med school admissions slots."
While it's useful and true to say that the problem is the cartel, it isn't fair to the libertarian position to claim that med school admissions is the(a?) big deal in the cartelization of medicine. The actual (anti-AMA) position I think undercuts your argument.
The real cartelization is not Med school admissions, it's licensing. Bail on licensing, and you have any number of people who are willing to perform some medical procedures for substantially less that what doctors are being paid. Bail on licensing for even some legally-mandated doctor activities...and you get a whole different picture than what you're outlining.
Now...I'll grant up front this has even less of a likelihood of getting passed than a change in reimbursement policies. But...I'd rather be fair to the AMA-cartel-sucks position than outline a solution. :)
The AMA-cartel does have something to do with it. Notice that there are many non-ABA accredited Law Schools. The graduates of these law schools can sit for the Bar and become attorneys in their states--although this does vary from state to state and does anchor a person to the state where they completed Law School.
The only alternative an aspiring physician has to an AMA-certified/accredited Medical School is the Carribean ones.
(I think Milton Friedman touched on this in a book about how it is reasonable that part-time legislators wouldn't want the options limited for them to pursue an evening law degree--and so this is one reason for the difference between the two professions. Another obvious one is the great expense of medical technology vs. just casebooks, paper and chalk for law school/ lawyers.)
The solution to the rise in costs in both education and healthcare is quite simple and would already have been implemented if there weren't evil, greedy people working to stop it on both issues.
You simply create a bureaucracy to oversee the whole shebang. Doctors might not be altruists willing to work for a GS-13 wage but bureaucrats sure are!
They can gather information about what the real educational and health needs of the American population are and then allocate resources in cost-effect ways to meet those needs.
Everybody wins!
Except the evil and greedy folk who refuse these common-sense solutions in the name of their poisonous "freedom" ideology... but they deserve to lose, right?
Dry as toast. Delicious.
Blighter,
In what fairy tale universe do you live? Is everyone is greedy and evil except bureaucrats, or just those that work for, gasp, profit? How naive. Gov't workers act on self interest like everyone else you silly brainwashed man.
I think the real answer though is that if we want to lower the cost of medical care, we're going to have to re-think who is providing medical care and how. Part of the problem creating the expense is that the amount of available medical knowledge has boomed in the past decades (meaning there is more training and learning necessary and that you still need the best and brightest) but unlike other specialties the medical community hasn't found a way to have that doctor help more people more efficiently. (It still takes a one-on-one meeting with said doctor).
Ultimately, we're going to need to find away to have less skilled people providing medical care to keep it affordable. The person I ask about my allergies doesn't need to know how give birth to a baby, but the way we do training and residency is that we train every doctor to know lots about everything and then specialize to know even more about that.
Moreover, think how much of doctors time must go into checking about someone's sniffles and sending them off with antibiotics (that they probably don't need). One doesn't need five to 10 years of post college training to handle a lot of that.
Sure, we need some doctors to have really good understanding of a broad variety illnesses, but these should not be the first person you talk to. People trained in everything are expensive, particularly when once they diagnose you, they have to send you to the specialist who was also trained in everything, but also training in his/her specialty.
I'm sure there would be worry that someone with itchy eyes might go to the allergist, who wouldn't realize something important because they never had that surgery rotation, but I'll bet that could be trained for and (more importantly) when things didn't work they'd consult with the generalist to see where else they should look.
We already have a great alternative to lowering costs, Physician Assistants. My ex-wife is a PA. She was a medical undergrad and then got her masters in PA. PA training is very focused at diagnostics. Starting with a comprehensive patient interview and then identifying the problem and referring a solution. She worked for a GP and I'd wager her diagnostic skills against his any day. So two years and about $50k in expense for a low-cost GP.
Now here is the sad part. The AMA has vigorously fought against advancing the PA role. It varies state by state but there are many hospitals that won't employ PAs. In some states PAs can subscribe but in many they can't. There is also very little money in the field. My wife was making about $50k and could have gotten to about $75k (where the surgeon made $750k) as a surgical assistant. She ended up getting into Pharmaceutical Sales and more than doubled her income. If we just paid PAs even thirty percent of doctor pay we would have tens of thousands new providers every year.
Medical training needs to be re-invented. I say this as a graduate and a practicing MD. A few points that I'd like to add:
It hardly needs saying that your first 10 patients of the day may have the sniffles, but the eleventh may try to drop dead right in front of you, and we have to know what to do. A good Physician's Assistant or Nurse Practitioner is like gold. In fact, they are better than gold. They know their limits, they know what they don't know. They can treat what they know, and they also know when to get help. Not all of them know that, unfortunately. Yes, you can say the same about doctors.
Medical training needs to be re-invented. The question, "How should we train doctors?" has been asked for many years, and it's still evolving. The most instructive part of internship was when I was forced to save someone's life when I had had no, repeat, no sleep. Yes, I was a zombie and yes, I saved the person's life. And you know what? I couldn't forget how to do that if I tried. If you drop dead in front of me, I can do a lot to bring you back, even on no sleep. (A good analogy for non-docs: if your baby was dying at night, would you say, "sorry, I feel like an exhausted zombie and I'm going to sleep now"? No you would not. You would find it in yourself to stay awake, and the doctor does, too. That is the why being on call is so terrible, and so essential, imho.)
The EMR that does not make our lives hell, has not been invented yet. They are cranky, slow, inefficient systems, crashing at the wrong time, serving up useless and poorly accessible info. How to separate the "signal" from the "noise," and get meaningful info, is almost impossible with some systems. Plus, the info that is supposed to be there, may be wrong. Or incomplete. Or mistaken. And who has time to read them?
Slowly, slowly, my colleagues and I are winding down our practices. Seeing fewer patients, taking more time off. And that's good! That also means fewer doctors.
"Gee, where have I heard this before?"
Call me a troll, but are you even going to pretend not to think that you know everything now? Given how majorly wrong you've been about a number of things (the war, Bush, not being in a recession, etc.), patting yourself on the back in such a ham handed and arrogant way for maybe getting one thing right seems kind of, well, not very self-aware.
Troll.
sycophant
Begone troll. Begone.
One solution to the GP shortage is to replace them with barefoot doctors.
I don't think the shoe budget is a significant part of the cost.
Hah! Have you checked out the price on a pair of Berlutis lately?
"I don't see all that much room to believe that getting rid of the AMA would let a thousand flowers bloom."
What an ominous and oddly appropriate phrase! 'Let a thousand flowers bloom' was a campaign by the Chinese Communist Party to encourage people to speak out. Once enough people voiced their true feelings about the government, they were rounded up and 're-educated'. That was how Deng Xiaoping first made his mark, by leading the crackdown on those independent thinkers that had been stupid enough to trust Mao.
So I take it that you're envisioning a scenario where the AMA lets many more people become doctors with the idea that they'll have a good life and will recover both their direct and their opportunity costs of medical school. Then the government will crack down and force them all to work for peanuts. Is that about it?
Yes, I'm wondering if that's what Megan was implying as well, or if she just tossed in the phrase carelessly because it sounded cool.
Megan,
"But when I look at the numbers, I don't see all that much room to believe that getting rid of the AMA would let a thousand flowers bloom. In 2008, 42,000 people applied to medical school, and 18,000 enrolled. Presumably some who were admitted decided not to go, and some who weren't shouldn't be doctors. There don't seem to be, say, 10 qualified people for every slot."
Aren't the number of applicants endogenous to the probability of getting accepted? Preparing for medical school application is not costless. You have to take appropriate undergraduate courses, prepare for the MCAT exam, forgo preparing for another graduate career, etc.
If the AMA made it so that only women over 6 feet tall named Megan Mcardle could apply to medical school, and every year two out of three Megan Mcardles that applied got accepted, then by your logic the lowering of the crazy requirements wouldn't matter because "There don't seem to be, say, 10 qualified people for every slot."
This is only relevant if the standards for becoming a doctor are too high. I'm not sure if that's true or not, as I know that that the one medical school in my state manages to generate some doctors that I wouldn't rely on, while at the same time failing out a number of students, which makes me think the applicant pool is not simply limited by the odds of being accepted.
However, the school has an aggressive affirmative action policy and an admissions committee subject to political sway, so this may be responsible for unqualified applicants being admitted even though the pool of qualified applicants is relatively robust, and also account for the school lowering its standards enough to produce incompetent MD's
There were incompetent MDs before there was affirmative action. I see that as much more likely to be a reflection on the use of grades and standardized testing to choose applicants.
I write software for a living. For me troubleshooting a software problem is relatively straightforward - the mental process is the same problem-tree solution your mechanic uses to fix your car, and it's the one your doctor uses treat your sore throat. What I've found over the years is some people who are otherwise very intelligent just don't "get" it. And surprisingly they can't seem to learn it either. I dunno, maybe it's one of those things your brain can't adapt to after a certain age, like learning a second language. A doctor with this deficiency will always be second rate, no matter how good his grades were or how much experience he gets.
The part of your analysis I would disagree with concerns the nursing shortage. While this is just antecdotal, at the University of Mississippi there are many more qualified nursing majors than there are slots available in the nursing school. Many of them are forced to transfer to another school after their sophomore year in order to continue their nursing major or change majors in order to stay at Ole Miss. The same applies to both the University of Memphis and in the University of Tennessee system. Granted, this is local, but I wonder if it is not this way in other areas of the country as well.
There was a time, not that long ago, when nurses did not attend college. They went to 3 year Nursing Schools - run by hospitals. Their training was all nursing, and a lot of it was like "on the Job" - as doctors are taught. At the end of the 3 year course the girl got her RN. The cost was quite low.
I'm well aware of the above because I have 2 sisters who dit that - at St. Vincents Hospital School of Nursing. Both ended up being post op nurses.
Somewhere along the line some bureaucrat idiots decided that a BS in Nursing was necessary. Further, union types (at least in NY) argued that the girls were "working for free" during their training, so clinical training was reduced. Both of my sisters "retired" to raise families. One decided to go back after her youngest went to college. She took a refresher course, but was required to get a BS to maintain her RN. What did she have to take? She had to take stuff like History and English Lit.
Now, you might be saying: "Why does a nurse need History or English Lit?". Well, ask the bureaucrats.
Now girls are expected to spend exorbitant sums of money on tuition, take courses that have NO bearing whatsoever on nursing, get little clinical training, and then have to work shifts, weekends, holidays, etc.
Ole Miss provides a BSN, not an associate's degree RN. Much better opportunities for advancement if you have a BSN. (Not to mention than an ADN won't get into nurse practitioner school or nurse anesthetist school.)
One thing we can do is look at the curriculum of med school to see how it could be speeded up, and then we should do the same to pre-med. If we could save a year in each step, it would be meaningful. Also, one factor driving specialization is the need to pay back money borrowed for the education. We could arrange debt reductions for generalists. Public universities particularly should offer this option.
If I may make an analogy:
If I have a minor car problem (i.e. a rattle that occurs every once in awhile and is a minor irritant), I don't take it to the dealership unless I know it can be fixed.
Similarly, I think we need to teach the american public to conduct a healthcare needs assessment prior to taking up a healthcare professional's time.
I see a HUGGGEEEE amount of people who take their 8+ year old sons and daughters to a daughter for a 2-3 day old cold and a fever of 100.5. Simple rashes that haven't gone away after a few days. Etc.
What people don't understand is that vague symptoms that are not presenting any sort of urgent problem can rarely be dealt with....that a fever can actually be a good thing, as long as it's controlled....and that often times the prescription for an antibiotic is being given to fight a virus.
I think this is an area of low hanging fruit that needs to be addressed as well; it's just politically unfeasible to tell a broad part of the population to not seek medical care for what THEY feel is a deserving cause.
I am too lazy to look it up, but I seem to recall that some material percentage of our nation's health care expenditures go to pay for treating the terminally ill at the end of their lives (i.e., last month or so).
By contrast, what portion of healthcare spending is taken up by 8 year olds visiting a pediatrician for 10 minutes after 3 days with a fever? I am doubtful that number is significant, frankly.
I realize that your real point is (1) people run to the doctor for things that don't need a doctor, and (2) this comprises a significant enough portion of overall health care costs to warrant attention. That may be so, but I think you should support (2) especially with a fact, not just state it as an innumerate "I see a huge amount...".
If people with the sniffles comprise a big portion of the spending, and that spending is public spending, then yes, we need to address it.
"Estimates show that about 27% of Medicare's annual $327 billion budget goes to care for patients in their final year of life."
http://www.usatoday.com/money/industries/health/2006-10-18-end-of-life-costs_x.htm
Of course, that is Medicare which will more often cover people who are towards the end of their life.
http://www.annfammed.org/cgi/content/full/7/2/112
Here's a study on the outcomes of "watch and wait" mentality rather than test ordering.
I don't have metrics on how many people visit their doctor for reasons that could be skipped. I imagine that sort of data would be hard to amass short of an NHANES study.
My point was that simple education early on can reduce the burden on our health care system placed by unnecessary testing, personnel time, etc.
Health Insurance is, in many ways, similar to social security. The well pay into it which offsets the cost of the sick. I personally (through my own contribution and employer) pay about $11000 a year for my health insurance. I don't visit the doctor at all, which helps drive down the costs for others. I probably have a 15-17 year window of time in which I can offer this service to society (18-35 roughly, as a healthy male).
The more we can reduce the burden on the healthcare system, the more we can increase the number of people paying into health insurance without taking out unnecessarily, the better chance we will have of reducing the overall cost, increasing capacity, and decreasing premiums.
Just my .02
Spartee,
I am too lazy to look it up, but I seem to recall that some material percentage of our nation's health care expenditures go to pay for treating the terminally ill at the end of their lives (i.e., last month or so).
Yes, it's a "material" percentage, and depending on how you define it, it's a very large one. Generally if you want to bump the percentage impressively up, you make it "the last six months" rather than "the last month," and "of life" rather than "terminally ill." That way, any money spent on treating anyone critically ill automatically goes into the wastebucket if the treatment fails, but is counted as money well spent if it doesn't.
And you are able to portray the money spent as wasted on obviously hopeless cases, whereas obviously if you don't want to waste money trying to help people who are at serious risk of death, the most expedient thing to do is confine treatment to people who aren't seriously sick. Presto: Your rate of "money spent in the last six [few/whatever] months of life" goes down precipitously! Everyone wins! Except possibly the people you didn't treat, some of whom would probably have survived if you had, but whatever. The stats are nice.
I'm not talking about triage here. I do think that there are cases where care is almost certain to do no good and is tried anyway, just because no possible hope should be untried. But, really, shouldn't we expect that the more severe the danger to the patient, the more medical attention s/he will get? that the greater the danger, the greater the chance of failure? that the greater the danger, the more likely that something new and relatively untried (and probably concomitantly expensive) will be attempted? If I found that a negligible fraction of a society's medical expenses went to people shortly before they died, I think I'd assume that the only "medical service" afforded the seriously ill was an overdose of barbiturates.
TreeJoe, I hear you, but I quibble a bit:
1) you may not take it into a dealer, but plenty of people take their car in at the first sign of noise. Especially older folks and women (for the most part, that is true) who aren't knowledgeable about cars but are terrified of mechanics ripping them off. I know people who will only buy new cars just for the rationale that the maintenance is free and they're worry warts.
2) Since most families today are small, mothers aren't as experienced with children getting diseases and what to do. A mother in my town who had 5 boys was known to make her youngest walk off fevers under 101 until he "proved" he was sick; invariably, her kids were fine. Lack of large families=lack of experience in the profession. And she had been a worry wort with her first 2.
3) Kids are a special case; I think panicking over them is justified, considering that if your kid dies, its not only heartbreaking to the nth degree, you're known as the lady or guy who refused to take your kid to the hospital on a fever and you get to be arrested for neglect.
Lurker -
1. Yes, and education does wonders for these people and their bank accounts.
2. Again, my point behind education
3. Hospitals and some doctor's offices are hotbeds of sickness within a concentrated place. Taking a child with a cold that will resolve itself in 48 hours into such an environment can be neglectful as well :) Seriously though: A fever is one of the bodies ways to fight off an infection. By reducing a fever, you typically prolong an infection. But people do it anyway. Similarly, taking a child to the doctor and getting an anti-bacterial medication for a viral infection won't help, and may hurt. But most doctor's feel they are expected to provide something. Education on these simple matters can help improve the quality of life/healthcare these people experience.
Yes, but TreeJoe, in our world of specialization, and people having different talents, there will always be a subset who will overpay for the right not to learn things for themselves and let others take care of basic, not-real problems for them rather than become educated and do it themselves.
Outside of car maintenance, we call those people liberals. ;)
Depends on the noise. Cars may develop irritating creaks and rattles with age, but unlike people, they generally don't develop problematic symptoms that usually clear up in 2-5 days, but have a very slight chance of being the first sign of something awful. If a strange and unexplained noise crops up, it usually gets progressively more expensive for each day it is left unattended. At the same time, the owner goes to the mechanic knowing that a stack of money must be made ready in exchange for the favor.
The current structure of the healthcare market doesn't teach people to look at their health problems in this fashion, so those who are insured with minimal copayments have every incentive to visit the doctor early and often.
The answer is obvious.
In addition to appointing Dr. Kuttner to the administration, we need Dr. House and Dr. Cuddy as medical Tsar's. While Dr. House is somewhat unorthodox, his unbelievable analytical skills will definitely find a way to reduce overall healthcare costs. Dr. Cuddy is needed to keep up the sexual tension, as well as keep Dr. House in-line.
You know, you make an amusing point, but one that has some serious implications, I think. You don't have to have a Ph.D in semiotics to realize that movies and TV are in part reflections of the culture, and in part culture drivers. Shows like House and others present a semi-idealized world where--despite their personal idiosyncracies and occasional blunders--every doctor (even House!) REALLY REALLY cares about getting people well and will spare no expense or effort--will leave no diagnostic or protocol unturned--to do so.
Even if their patients are obviously indigent and have no means of paying!
So this is what people imagine "free" medical care would be like: the Hollywood vision, where everything is high-tech, clean, free, and there's never any paperwork to fill out.
It's no wonder the idea is so popular!
Well, the Hollywood idea is wrong, obviously -- it's not that doctors don't care what happens to their patients, but that they are, of necessity, capable of dropping all that stuff at the office door and going home and thinking about other things. They don't actually, by and large, go home and brood over their patients -- and a good thing, too, be cause they's soon be sicker than the patients are if they tried it. I would rather an efficient and alert technician, who knows what to look for and what to fix, than a caring but careworn person waring him/herself ragged over all the ills of the world, or even of his/her caseload.
Once when I was very ill, I apologized to one of my caregivers for setting such cares on her. She said, in so many words, "Nonsense! This is my job, and when I walk out of here I lay it aside." That was a tremendous relief at the time.
I both love and hate House.
I love it because he is politically incorrect, whiny, self-serving, petty, impulsive, funny, criminal, drug addicted, short, and yes brilliant. He is a great antidote to the normal "poor put upon" angel doctor seen in most shows (notably, "Scrubs" has both JD as the angel doctor and Dr. Cox and Turk as the jerk doctors).
I hate him because although I can suspend my disbelief on the Potw syndromes, I hate the wacky personnel moves that happen---firing the black doctor for personal relationships, no one worrying when House's moves lead to lawsuits, firing his entire staff on a whim, running Cuddy into the ground, people shooting themselves, etc. I can live with case of the week syndrome, but when you don't know which interns will survive or even show up from week to week, its distracting. Plus many times the intern actions are overtly preachy to contradict House's amoralism.
exactly. Give me House over Dr. Cameron and Dr. Cox over J.D. any day.
I would argue the problem is not the licensing requirements for MDs but the requirement that they perform low level, as well as high level medical services. Studies have repeatedly shown that for many basic health services RNs perform just as well, yet the law requires you pay for the services of the MD for them.
I think this is a really good point. I'm thirty years old and I've been to the doctor dozens of times in my life, but only once was it for something that by any stretch of the imagination could have POSSIBLY required eight years of medical school to treat (it was a ruptured ovarian cyst- the diagnosis was the hard part; the treatment was: "Go home and it should be healed up by tomorrow".) The rest of the time it was routine physicals/ coughs and colds/ food poisoning that pretty much anybody with a clipboard, an IV, and a bottle of penicillin could have managed.
Wouldn't we have less need for primary care physicians (and other health care professionals) if the 12-20+ million illegal aliens here went home?
As for increasing the number of GPs, this doesn't seem to be rocket science. If the cost of medical school is an issue, offer scholarships to applicants who agree to work for, say, $75k per year for three or four years after finishing their residencies. The difference between what they would have earned and $75k ought to easily compensate the government for the cost of their med school tuition.
Another idea would be to stop requiring foreign physicians from countries with medical schools of comparable quality to ours to re-do their residencies in order to practice here. By all means, make them pass licensing exams, require them to be fluent in English, etc., but the requirement to re-do residencies just seems like an anti-competitive restriction by the AMA guild.
Stop it with the blatant racism.
Stop it with the baseless accusations of racism.
What post/comment were you responding to here? Where exactly is the "blatant racism"?
Apparently anything which implies that illegal immigration is illegal. Also, using the term "illegal immigration" - it should be "differently admitted residents".
Arrowsmith=thug.
Yes, illegal aliens are the problem with health care in this country! Ever wondered how practically all other first world nations manage to get better and cheaper results from their medical systems? Think no more. They must have expelled all illegal aliens!
USA Today:
"Illegal immigrants can get emergency care through Medicaid, the federal-state program for the poor and people with disabilities. But they can't get non-emergency care unless they pay. They are ineligible for most other public benefits."
"Because most illegal immigrants are relatively young and healthy, they generally don't need as much health care treatment as U.S. citizens, studies show."
The article also states that illegal aliens are responsible for 2% of the total health care costs in the country. Which is kinda funny, illegal aliens now constituting 4%-7% of the population, 40% of them paying for health insurance, and that's in spite of working from less money and less benefits than the average American.
DaveinHackensack, beware of teh internets, for they are the enemy of those who practice the fine art of scapegoating.
Naturally, the prospect of axb = c, where "a" equals money to physician for patient contact, b = people seen (said to go up shortly), and "c" equals a dollar number the government (society) would like to see go down doesn't make them excited. The final problem with being a physician is that it is like being a 19th century cobbler. You can treat people really well but there really is no good way that you can translate your skill into mass production.
Essentially, to have more people seen, you have to have people with less training see them. A friend of mine went to a nationally known dermatologist's office over her psoriasis. She had light box treatment and was told by a nurse at his clinic that she had herpes and was given acyclovir, an appropriate medication for that. Actually, it appears that she had a staph infection picked up in the light box. The buzz in the dermatologist's office was that the light box brought out herpes. Years later she had a CVA (CERBROVASCULAR ACCIDENT, stroke) that almost killed her, did disable her permanently, was, in the illness, treated for a staph blood infection. Such chronic infections increase the risk of CVA. "I never saw the doctor," she said over the issue of the herpes diagnosis. She actually was treated by the nurse who had whatever training she had. So the doctor may be brilliant but how and what do the physician extenders know; they will be the 'doctors.' As they say, "Your results may vary."
"Actually, it appears that she had a staph infection picked up in the light box."
Are you saying that your friend caught a disease from the diagnostic equipment in this physician's office, or that she was misdiagnosed by a nurse using that equipment?
The light box is a treatment, not a diagnostic modality but otherwise both are correct.
Whose responsibility is it to keep the light box clean?
The light box is to give you the equivalent of sunlight in the desert which is known to promote healing of psoriasis. Your skin thus has to be exposed. The office would have a protocol for cleaning it. Staph however can be very good at adhering to surfaces. For surgical instruments, for instance, you don't just wash them off and then clean with isopropyl alcohol. 'Sterilization' might involve being put in argon gas or high temperature neither of which might be practicable for a light box.
Argon? I find that unlikely, as argon's inert and doesn't really do much of anything. I'd be happy to be corrected.
Answering Klug, argon gas can be electrified into a plasma which kills microbes (google "argon sterilization" if you don't believe me). Kinda cool, IMO.
Very cool. I stand more educated -- thanks!
Isn't a big solution to have government funding for medical schools so that a newly minted doctor doesn't arrive at residency with 200K in debt?
There is no reason why somebody should need to get a regular undergraduate degree in some random subject prior to attending medical school. Decontrol licensing and you'd see trade schools that teach doctoring fresh out of high school or community college. Starting med school four years earlier would mean doctors have far less college debt and would be able to start paying it off sooner.
(Removing licensing restrictions would also mean that if US-based medical training was unusually inefficient or expensive, doctors could get their training in Canada or Mexico or wherever for less than half the price and then come back here to work.)
You still need a significant level of undergraduate science courses in biology, organic and inorganic chemistry, physics, math, and another advanced science to pass the MCAT and be prepared to work at the medical-school level. Even non-technical courses help provide the composition and research skills needed to produce well-written scientific papers. There's also a very good argument to be made for requiring foreign language proficiency (specifically in Spanish), as most premed degrees do.
I'd even increase the admissions requirements, if I were in charge, to include undergrad statistics, discrete math, and a class in introductory logic and rhetoric -- med school isn't as solid in those areas as it could be, and they are directly relevant to doctors' research and critical thinking skills.
You could possibly cut a year's worth of electives out of the undergrad curriculum, maybe even two (there are a few six-year programs which lead directly to MD). Beyond that, though, you really can't cut requirements without directly impacting students' capabilities and preparedness for medical school. Premed students generally aren't wasting a lot of time in "random subjects" like art history or anthropology -- they usually major in hard sciences, and the bulk of their coursework is oriented toward fulfilling the specific med school admissions, not just in getting a generic BA.
In any case, the majority of doctors' student debt is from medical school itself, and cutting out a year or two of undergrad work really isn't going to make that big an impact on their overall burden.
Nonsense. About 50% of the courses required to get a B.S. in physics/chem/bio are in random subjects. Even at an engineering school (which has a disproportionately low amount of it), I spent about 25-35% of my time in fluff.
Physics, Chem (including orgo), math, bio, and biochem are all freshman and sophomore classes. And that's all a medical student needs.
You still need a significant level of undergraduate science courses in biology, organic and inorganic chemistry, physics, math, and another advanced science to pass the MCAT
But do you need all that course work to do medicine? Some sorts of it, I'm sure, but I'd happily get stitches from someone who's been doing it for years without a degree over someone who knows Organic Chemistry, but hasn't done many stitches.
Aarow,
How would that make any difference to the price the public has to pay? If Drs get their education for free then taxes will have to rise slightly to pay for it. Yes, the fees they will charge should be lower, but for the taxpayer it's a moot point. It's just moving the money from one pocket to another.
Healthcare is too important to leave to the whims of the private sector. Nationalize it now. Health care is a god given human right, no debate.
If health care is my right, no debate, then it's your obligation to give it to me, right? So start applying for med schools. When you finish your training I'll expect you to treat me at no charge, of course. It is my right, after all, no debate.
Is this satire? The "whims of the private sector"? Food is obviously more important than health care. Why don't we nationalize all food producers/distributors immediately too? How thick can one be?
Anyway, Hackensack makes the more important point: As soon as something becomes a "right", someone becomes obligated to provide it.
No debate...and no sarcasm! (Ruler on knuckles)
If it's a God given human right, how did it exist before government existed to provide it?
Heh, that would mean that Christian Scientists are at the cutting edge of medicine, right?
The 42,000 number is who applies to medical school. This is not the only source of doctors. It's important to note that due to the fact that med school here generally costs a ton, in other countries it is free or subsidized. So, many doctors go to med school in their home country and then attempt to come to America afterwards, which means they must apply to the Residency Match Program, which is essentially a big computer program run by the med schools and residency programs, which matches up applicants to residencies, based on submitted lists from each side. If you are matched, you are legally obligated to attend. I believe the program was sued under antitrust laws, (i.e. employers forming a cartel to assign labor) but the suit failed.
12,000 foreign medical school grads (i.e. already doctors) applied to American residency programs. They are highly disadvantaged to US grads, with only 55% getting matched, as opposed to 94% of Americans. So right off the bat, we could get approximately a third (of your 18,000 number) more doctors each year. So US docs/medical students aren't the whole picture. Note that getting rid of the AMA would also open up this path, as they help administrate the match program.
http://www.internationaldoc.com/
http://en.wikipedia.org/wiki/NRMP
http://kuznets.fas.harvard.edu/~aroth/jama.html (kinda old)
A lot - a LOT - of foreign medical grads have extremely weak language skills in English. Many of them are... not nearly as academically strong as American grads. There are a few who slide quite easily into American residencies, but most don't have the stronger quality of training found in the US/Canada/Europe.
A couple of comments, and bear in mind this is coming from someone who is currently a 1st year medical student after applying and eventually getting accepted on the 3rd try, which is about average.
First, regarding the level of education needed to be a GP, specialist, and the use of Nurse Practitioners/Physician Assistants:
I would argue first that the GP needs the most education, especially as compared to specialists, and in fact Medical School seems geared toward this idea. A GP in general needs to be able to recognize the often subtler presenting symptoms of what could be either minor disorder that could then be quickly treated or a major disorder that would then be referred to the appropriate specialist. The better the ability of the GP to make the correct diagnosis, the lest time wasted, the less money wasted etc. With a reliable GP, specialists would need to know less, because they could focus on their particular specialty (cardiology) rather than worrying the GP made an incorrect referral (patient needed an endocriniologist, etc.) As far as NP's/AP's are concerned, they would be very useful in the initial screening of a GP office, but don't forget that they require an MD for oversight, and there's definitely a balance that needs to be found between efficiency and allowing the MD to oversee enough to keep major disorders beyond the NP/AP's education to slip through the cracks (these would be every disorder seen on House).
As far as medical school applications/acceptances and their correlation to the number of Doctors, the main variable, as I believe was alluded to above, is more the number of residencies available. Recently, medical schools have been increasing the number of admittances, but as far as I have been able to find, the number of residencies, and thus the number of licensed MD's produced per year, has remained mostly static 15 or 20 years (couldn't find the relevant statistics here). This also relates to the percentage of foreign MD's entering the country, which has decreased because there have been an increase in the number of American medical school graduates, correlating to a higher percentage of Americans in American residencies.
My thoughts on increasing GP's and decreasing health care costs overall somewhat interrelate. To increase GP's, increase their pay. I find it hard to justify decreasing the pay of specialists, because what many of them do (Cardiac specialists and valvular replacement, neurosurgeons, etc) requires a degree of talent that should be rewarded. However, I believe more proficient and efficient GP's would be able to prevent some of the necessity for specialists, which would also reduce the cost for some of their fees (ie diagnosing diabetes earlier reduces exponential costs later, etc.) Therefore, increase the amount paid to GP's, based on number of people seen (which is I believe how Medicare does it now), unless a better estimate of patient outcome paired with compensation can be found. This is tough to do, especially in this economy, but I believe it would lead to an overall reduction in health care.
I think the biggest way to reduce health care costs, especially taken in tangent with my preceding arguments, would be to detach health care from job compensation. This would result in higher wages/salaries, obviously. It would also allow health care companies to be more specific in the premiums, etc charged to their consumers. Just as a person with 6 traffic citations, 2 accidents, and a DUI pays a more in car insurance than an accident, DUI, and ticket free driver, so should a smoking or non-excercising consumer pay more for health insurance. Freeing health insurance companies from job related health insurance would allow these sort of individual changes, which are hampered in the current system. Other reductions in policy costs could be given for yearly physicals/prostate exams/breat exams, etc, in order to give incentives to the public to maintain good health. These would empower the physician, as well as help keep the public at least somewhat educated.
Obviously this is a general outlook, and not specific, and the biggest problem would be the initial investment, but it's the only way out I can see. Well, that and capping lawsuits to reduce malpractice, but like I said, I'm in med school, so I may be a little biased on that point
Forgot to add that, as far as number of Doctors, a good way to increase number of GP's would be to increase the number of GP residencies more than increasing the number of specialties
FYi, in some states (including my own), nurse practitioners can practice independently without physician oversight. They hang out their own shingle. The good ones know that they are nurses and that they are not doctors. They know what things they don't know, and refer appropriately. The not-so-good ones can do some unfortunate things. We doctors can end up fixing their mistakes quite a bit. And yes, we are also fixing other mistakes, when we can.
The problem with the idea that doctors are overqualified to do routine diagnosis/treatment is that major illnesses sometimes present with the same symptoms as less serious conditions, or can potentially be caught when a patient presents for an unrelated minor problem.
Only once have I taken a child in in for something that I felt wasn't necessarily serious -- my daughter had a bad diaper rash, and I thought she might have a UTI as well. The doctor did a CBC to check for bacterial infection, and thirty minutes later we were in the car on the way to the children's cancer hospital. She didn't have a UTI, just diaper rash, but she also had potentially life-threatening low platelet levels, which required immediate hospitalization and (very expensive) IV drug therapy.
Anyone with an ounce of medical training could have looked at her CBC results and known that there was something very, very wrong that warranted immediate attention from a specialist. However, would a NP (or a GP under pressure to avoid performing "unnecessary" tests) have even done the CBC to begin with? Or would they have seen the obvious explanation of diaper rash and decided to treat that first instead of working her up for UTI, thereby missing the unrelated platelet disorder?
I know other people, in real life and on the internet, whose children's cancers and serious diseases have been diagnosed like that, when mom brings the kid in for minor illness and the doctor spots something really concerning. That's what you're seeing the doctor for -- not to be told you have bronchitis, but to be told that it is *just* bronchitis rather than lung cancer. A less experienced practitioner is most likely going to do just fine at diagnosing the normal course of illnesses, but how well do they do at spotting the odd zebra in a large herd of horses?
They don't spot the zebra at all, they merely need to be uncertain about the diagnosis.
In your case, the NP would do the CBC to check for bacterial infection just like the doctor did. He/she would then observe platelet levels which are wildly off and call in the doctor. The story would continue as you described it from that point on.
I think that the Obama administration recognizes this problem, which is why they're making electronic medical records (EMR) such a big part of the push for health care reform. Humans are notably bad Bayesians, and doctors are the only people we presume to have remembered everything they learned in school.
Improved medical testing increases the number and accuracy of datapoints we collect but does nothing to improve a physician's ability to compare them against a representative sample of other people. When results from datamining EMRs start to come back, we'll see a tremendous increase in the effectiveness of frontline medical care as computers assume more of the diagnostic burden. That will free up doctors to do things they're much better than computers at doing (like surgery).
Which seems from the statistics to be what they want to do anyway.
If you allow your medical information to be accessible to federal data mining you're batshit insane. The federal government has been shown to be incompetent at protecting public data -- every time they claim "this time it'll be different", sure, right up until someone is selling your medical records to ad companies. No thanks, I'll go cash.
Of course this only applies if you have embarrassing medical details.
Frankly, the only records I want secret are my financial records, and I really only want to hide them from the taxman. But that's against the law (damn it!).
Any other personal information is already available for free on my blog.
I agree with BladeDoc. You'd have to be insane to want the government with your data. Just ask Joe the Plumber what can happen when bureaucrats run amok. Next thing you know your STD test results are on page 1, above the fold.
Also, the more sinister part of the system is when the government starts coercing doctors to "cut their losses" on Grandpa's case when the computer says their treatment isn't cost effective.
"Daschle says health-care reform “will not be pain free.” Seniors should be more accepting of the conditions that come with age instead of treating them. That means the elderly will bear the brunt."
from "Ruin Your Health With the Obama Stimulus Plan"
http://www.bloomberg.com/apps/news?pid=20601039&refer=columnist_mccaughey&sid=aLzfDxfbwhzs
How cute; BruceC still reads *paper* newspapers.
(/snark)
BladeDoc
BruceC
Yes, we should worry more about what Big Brother could do with the knowledge that we had the measles than with allowing doctors to have access to medical records that could potentially save a patient's life.
You guys realize that you inadvertently revealed you suffer from an unusually severe case of paranoia. Don't worry, I'll never tell the Gnomes of Zurich.
I am a first year resident (e.g. VERY new intern) currently engaged in the process of medical education, so I thought I would add a couple of quick thoughts.
Couple of factual points that could add something to the discussion: the limiting variable in a "teaching hospital" is not the actual physical facility. Rather, it is finding senior physicians willing to mentor (e.g. evaluate) trainees during the clinical rotations, typically in the third and fourth year of training. Currently, in both the academic and especially the private world, faculty preceptorship is done out of something akin to charity. One could imagine that with alteration of the incentives (e.g. payment) you might see a lot more senior physicians willing to mentor students and thus be more able to quickly ramp up the supply of new physicians. This, of course, assumes a concomitant increase in the number of residency spots credentialed by the ACGME (alluded to by the first year med student commentor above). These should probably all be primary care spots, but in the current system, the primary care spots don't fill anyway. Maybe a more libertarian solution would be to open up limitless number of specialty spots. Theoretically, the price of a colonoscopy would fall dramatically. Would make for crappy medical care, so I wouldn't seriously suggest it.
As far as the lack of "qualified" applicants, the assumption that the current screening guidelines select for those who would be "good" doctors is suspect. Current admissions standards are heavily weighted towards those who can perform well on multiple choice tests (e.g. the MCAT), with a heavy weighting toward brute memorization. Personally, I am not complaining as these requirements have been good to me, but these qualities are only tangentially related to being a "good" physician, under any acceptable definition of this term.
Also, I think rather than a 42k applicants/18k accepted students, a more instructive number might be the number of students who start undergraduate as pre-med and decide on another career path. In my experience, this was a much heavier weed-out factor and even LESS applicable to the day-to-day practice of medicine (e.g. more heavy basic science). For example, if you don't get an "A" in physics/organic chemistry, it is tough to get into med school. I can now tell you that I have never even used the smallest piece of these subjects in a clinical scenario. Essentially, the problem is that in addition to all of the disincentives on the back-end, the pipeline to medical school is also broken. Never see anyone write/talk about this, though.
I would say that the bachelor's degree is one of the biggest ways to discourage more people from entering med school. William is right that the Physics and O-Chem will not be used in any serious fashion (although some O-Chem may be needed to help prepare for Biochem). Everything that you need to know for med school can be learned in one year, so why require the four year degree when the opportunity cost of that degree is so high? Hell, students should be able to apply for med school directly after high school if they are smart enough. Contrary to William, I think tests are a good requirement as they could serve as an acceptable substitute for required classes. Students would be more willing to handle being 23 with 200,000 in debt than being 27.
Outlaw third-party payment systems. Including government ones. People don't go into medicine because they like the job of insurance/Medicare/Medicaid paperwork filer. Payment at time service is rendered, by the patient, will assist in the recruitment and retention of doctors.
Oh, it'll also help control costs by eliminating the disconnect between consumption and payment for medical care.
Libertarians (and I think some liberals) argue that the problem is the AMA cartel: they control the number of med school admissions slots.
And the evidence for this is what, exactly?
Also the canard about medical schools being AMA certified: False.
Medical Schools are certified by the AAMC: http://www.aamc.org/about/history/start.htm NOT by the AMA.
As for membership in the AMA, do you have any idea what percentage of physicians are members?
The answer will surprise you: somewhere between 15-19% of practicing physicians (excluding those in training, medical school, residency, fellowship.)
The notion that the AMA somehow dictates to medical schools their admission numbers, curricula, is simply fantasy.
Can Ms. McArdle or any of her readers provide any evidence for this, let alone proof of such assertions?
Lastly, as to the AMA being dominated by specialists is also bunkum.
And for all of your non-physician readers who think that admissions-boards are choosing the wrong applicants and not enough applicants...Good luck with that.
Approximately 2% of medical students identify themselves as wanting to go into primary care.
Good luck with that too.
And by the way, when people start complaining about not being able to see a doctor for their blood pressure, or a neurologist for their stroke, I can only say you get what you pay for, and you got what you asked for.
Lastly, certain fields like neurosurgery and general surgery will be nationally underserved as more women than men are entering medicine and there are not enough women interested in these fields.
Like I said, America will get what she asked for: European Socialized Medicine. The American Health Service is only months away from being initiated (in its nascent forms).
Enjoy or hate what you got now while you still can.
What's coming is going to be a whole lot worse.
I don't know numbers, but my experience talking to female friends who are physicians leads me to believe that a lot of the reason there are fewer women than men interested in surgery is that many surgical residency programs, for whatever reason, are headed by male physicians who are openly hostile to women. I don't pretend to understand the dynamics or origins of this attitude, but I have heard from more than one woman that it exists, particularly with regards to orthopedic surgery programs. A female friend who just entered an orthopedic surgery residency is optimistic that this will change over time as the dinosaurs die off.
NeuroDoc,
While I certainly don't want nonphysicians deciding what we do or how we do it, you know that the system is broken and we as physicians have done a poor job in monitoring ourselves and controlling costs. We have been just as irresponsible as the bankers in letting the system get out of control.
I don't know the solution, and I'm fairly certain no one knows a politically acceptable solution. What's coming is going to be a whole lot worse I agree which will look like European Socialized Medicine, but America didn't ask for this. We lost control, we let drug companies buy us out, we let our love of technology increase costs to the point where it consumes too much of GNP without significant benefits. We did it to America.
Confused,
How exactly did physicians "sell out" to Pharma?
How exactly?
Do you mean by precribing the greatest revolution in human health care in any generation?
Statins alone have probably sustained and lengthened more lives than any other class of medication.
Do you recall when ascending cholangitis was lethal. Today, there are safe and incredibly effective antibiotics coupled with laprascopic surgery, and voila, people walk out of the hospital.
Valve replacement, joint replacement, medicated stents, improved and safer anti-hypertensives, cholinesterase inhibitors, stereotactic neurosurgery, coiling of aneurysms and AVM's, oh yeah, and all that useless 64-slice CT angiography, MRIs, bone scans, yup, all of these tests are wasteful, no one wants them, no is benefited by them, and it is the fault of physicians for implementing and sustaining their use.
With all due respect, what is the color of the sky where you practice?
And none of this even begins to explore the crippling cost of running a practice: it takes scores of person-hours just to get pre-approval for above mentioned tests, on both ends I should add, the doctors' offices and the insurance companies. HOURS of phone calls to get one test approved.
I haven't even touched on the notion of defensive practice.
Yup, it's the doctors who created the escalation of costs, not the trial lawyers, state and federal regulatory commissions, insurance companies, the patients themselves and their expectations.
It's all the fault of the doctor, who is working hard to establish a diagnosis, find the time to explain it, discuss indications, risks, benefits, and alternatives of therapies to the patient, initiate and monitor therapy, and most importantly, to deliver all these services every time the patient demands its, as fast as it is demanded, each and every time, to do it without mistake or misstep, and with the threat of litigation looming with each and every encounter.
Have you ever been called to labor and delivery to attend to a teenager with no prenatal care, on methamphetamine, in hypertensive crisis, in status epilepticus, 30 weeks gestational age, no known past medical history, with her baby in distress, emergency delivery, APGAR 1 and 3, comatose mother, intubated 3 pound premie, with an angry family demanding that everything be done, oh, and here's the best part, the patient has NO INSURANCE, and you and the hospital is doing this for free.
Ever do that?
Try doing that, and worse, for 16 years.
Wait, just wait, it won't be long before there will be no neurologists in our community hospitals. It is already happening.
And so it goes with general surgery, neurosurgery, trauma surgery, orthopedic surgery, etc.
And, it is the fault of the physicians for not keeping costs down.
Wow. Just wow.
Good Times, Good Times.
I for one will enjoy the Wilderness.
Amusingly, I HAVE been called to labor and delivery to attend to a teenager with no prenatal care on [cocaine] in hypertensive crisis in eclampsia at that gestational age with her baby in distress with myself and the hospital doing this for free. If you're a NeuroDoc, I can guarantee you that I've done this many more times than you have. And incidentally, the hospital will often get reimbursed some by the state as taking care of neonate usually earns quite a bit of money. (None of which gets bottom lined to the Ob department, but that's a different irritation).
Yes, there have been great advances in medical technology in the past 20 years, I cannot dispute that, but yes defensive medicine as you didn't get into, all that wonderful technology that gets overutilized (as you can guess my field, I could go on about how overutilized ultrasounds are), and all those procedures that are done excessively either because it's the newest thing, ignorance or that there are some financial benefits. As an aside, I left general Ob/Gyn because everyone was doing laser treatment of veins in my community. I've always believed the respect of physicians is limited by doing such crap which of course we then decry that "our reimbursements are done and that's why I'm doing it." Yeah OK. I was forced to pick up the laser instruments.
Oh, and new drugs? How much Vioxx and Bextra was prescribed to non-chronic users of NSAIDS because it was the newest thing and you didn't want to disappoint that pretty little drug rep (the general you)?
As physicians, it was our responsibility to control our own costs. Forget the patients and the trial lawyers. Yes they pushed us to do so, but who's responsibility was it? They needed to get what they could get. It was OUR responsibility to keep costs down. Otherwise, whose job was it?
For more clues about my background,
The sky is blue with pretty sunsets where I live, and actually no, I don't remember when ascending cholangitis was lethal.
Perhaps it is time for you to retire. It seems like you're a good doc, but medicine certainly doesn't seem like it satisfies you. I hope I don't get to where you are some day, although I won't say that I won't.
Successfully completing high school would be a poor predictor of success in med school--the complexity and volume of information acquired in med school is massive. In my opinion, an undergraduate education provides a base of science (and other) knowledge essential to the successful study, and eventual practice, of medicine. Diagnosis demands broad medical knowledge 5-10% (my estimate only) of the time--much too high a percentage to be trusted to narrowly-trained diagnosticians.
Given the staggering amount of mortality and morbidity associated with driving, it would make sense, for individuals and society, for drivers to operate only the safest automobiles--let's say it's a Mercedes. If we purchased autos the same way we purchase health care, we'd all pay in roughly equal amounts of money and choose which car we wanted. In that event, wouldn't we all want the Mercedes? But in the real world, even though our health and life itself is at risk, we don't all choose a Mercedes. We make individual decisions that take numerous other variables into account as well--initial cost, maintenance cost, fuel cost, comfort, amenities, etc. Despite the relatively high risk of injury or death, we all keep driving, often in relatively unsafe vehicles.
Health care costs would be reduced most effectively, and most fairly, if we as a society could somehow incentivize the consumer to shop for their healthcare, much as they are incentivized in car purchases. In addition, a legal system set up to parasitize medicine (and other industry) adds hugely to costs.
I agree that merely completing high school would be a poor predictor of med school success in itself, but there are some who would be able to handle it. I favor a super-rigorous test that demonstrates that the student knows what is necessary. Certainly now, it is not much more than basic biology. Most students would probably take a year to learn the necessary material (and trust me, a year is plenty), whether through a class or through self-study (I admit that Charles Murray has influenced my thinking). However, 4 years between high school and med school is absurd.
"And trust me, a year is plenty" Just curious--have you been through it?
Even if you are correct and we were able to turn out MD's three years earlier, what does this have to do with health care costs and "shortages" of doctors? Do you think more people would go into medicine if only they didn't have to go to school (undergraduate) those extra three years? (i.e., typical 4 years of indergrad minus your one year of pre-med studies)
For myself, getting to make money three years early would have made a huge difference. We're asking people to go to school 8 years, pile on debt, and not make any real money until they finish their residency, all while facing the constant threat that the gov't will end up taking over and cutting their expected salary in half. That's a lot.
If there had been the option to go to med school after a year of undergrad studying basic biology, micro, biochem, etc., I would probably be a doctor right now. When I finished undergrad, I just couldn't stomach the though of waiting until I was 30 to be able to start climbing out of debt.
That's 8 years under pretty idealized conditions. Such as going to a private college that makes a point of getting kids out in 4 or not having to spend a non-trivial amount of time during the school year working. In my undergrad days (Chem major) I didn't know any science or engineering majors who did their degree in 45 months.
I think 6 year BS/MD programs, with appropriate and non-ruinous washout points, make a lot of sense. I think five years might be a bit abrupt...I don't see how you can get around biochem and I don't see how you can meaningfully study that without a solid base in o-chem.
I've been a doctor for 35 years--20+ as a family physician (GP) and 10+ in occupational medicine (worker's compensation clinic). I finished my training at age 29, going well into debt in medical school and earning basically minimum wage as a resident starting at age 26. After expenses, before taxes, I now make about $90/hr., a little more than in my family physician days but substantially less than most specialists. I've practiced with some fine mid-level people (nurse practitioners, physician assistants) who are perfectly adequate for the average person's problem. (In my region they make about $50/hr. including benefits.) The high cost of medical care seems to me to be primarily technology-driven and patient-expectation-driven. Most people expect an accurate diagnosis (e.g., an MRI), enough information to understand their condition (e.g., provider time to answer their questions), some kindness and encouragement in their care, and a specialist referral when needed (e.g., to be treated by the most qualified person). These are reasonable desires for patients, but they do not come cheaply. There are very few patients (or parents of children-patients, or children of aging parent-patients) who want to cut corners on their OWN care. So for the commenters here making suggestions, I'd suggest you consider what is the least qualified provider YOU would see, most brief office visit (in minutes) YOU would accept, or longest wait for a test or to see a specialist, or maximum number of days YOU or A LOVED ONE would endure moderate to severe pain before seeing a surgeon. I've met my share of folks who would limit others' care without mercy, yet demand "only the best" for one of their own.
NeuroDoc--I meant to make the same point you did about the AMA and med school admissions.
Also, most people have little idea how hard physicians work. Imagine how efficient docs will be when they are unionized, 8-5 employees of government!
Very good point. At this early stage, I am looking into ER medicine because I don't have to take my work home with me/be on call. The notion that physicians work standard 8-5 days is laughable in nearly every field.
Damn, neurodoc beat me to it.
The AMA has absolutely nothing to do with setting enrollment numbers for medical schools, as that’s done by the AAMC (Association of American Medical Colleges). Further, the big choke point is at entry into residency - and that’s set by the Federal Government, because residency funding is carried out by CMS. The AAMC has for years called for increasing the number of medical school and GME (Graduate Medical Education) slots. In fact, back in the 60s, both the AAMC and the AMA had committed to the
1982, the number of medical schools had grown to 127, from 89 in 1972, and the number of
had doubled. This plateaued, because everyone expected managed care to cut down on the number of physicians needed.
In any case, the AMA now represents less than 20% of physicians - I don’t belong, and I’ve never missed it.
Increasing med school enrollment as a solution is quick, attractive, makes a good sound bite - and is completely wrong!
There are any number of reasons for physician shortages:
1. Early retirement
2. MDs can’t make enough to pay staff, rent, overhead, etc. and still take home enough to make the whole thing worth it - I can remember as a resident (years ago) hearing from one of my mentors that the taxi driver bringing his patient to his office would make more than he did!
3. A much higher percentage of women as physicians, who work fewer hours than men at all comparable stages of practice, with the possible exception of late in their careers (this is from AAMC demographic data)
4. Changing demographics - the population gets older, and utilization of all medical services increases
5. No matter how hard payers bang on MDs to become more “productive,” there’s a limit on how many patients you can see, how many procedures can be done; and switching to EMRs compounds the problem, because most EMRs are horrible and timeconsuming, rather than time-saving
6. It’s just not particularly fulfilling anymore, and the attractions of getting up in the middle of the night to fix some abusive drunk in the ER begin to wane.
What drives costs is patient need and/or demand, increased use of technology, and an aging population. As a specialist in hip and knee replacement, I haven't seen too many patients who volunteer to put up with pain and disability to "keep costs down."
I have three kids, and none of them will be physicians if I have anything to do with it….
As for #2, I don't know any taxi drivers who have a big house, a nice ride, a good looking wife, a hot girlfriend, and vacations in Hawaii and Europe. I know lots of doctors who do.
Granted, I know more doctors than drivers and I understand the difference between anecdote and datum. And I certainly wouldn't argue that doctors don't deserve all those things.
But even if the pay is not enough to be worth all the hassles (and who am I to argue with that?), I'm pretty much from Missouri on the idea that driving a cab is a more lucrative business than being an MD.*
*Not counting, of course, residents and owning large fleets of cabs.
I am a Registered Nurse of 18 years and after reading the comments here I absolutely have to correct information that is highly erroneous.
First the three year nursing program someone referenced their sisters graduated from were Diploma programs. They were run by individual hospitals in conjunction with the instructors, frequently Nuns. Next there are still thousands of diploma nursing still working in todays health care system. There is NO requirement for nurses to be a bachelor degree except in one of the Dakotas. Some diploma programs were still in place in the early 90's. I know of none today. They died not because of some government bureaucrat but because of the American Nurse Association and the National League of Nursing. If a diploma nurse had to go back to school it would only be because they quit renewing their license, and had been out of nursing for years. And if they did have to go back to school, as I said a bachelors is not necessary, community colleges across the country offer associate programs, in fact there are more associate nurses than bachelor nurses, despite the fact that the ANA has been attempting to make a bachelors the only way into nursing. Only 7% of RNs even belong to the ANA. There are also thousands of LPN/LVNs in this country. There isn't a nursing home in the country that could run without them.
The nursing shortage started at least 10 years ago, driven by cost containment HMOs, thousands of lay offs happened, skilled nursing duties that were fairly run of the mill were given to unlicensed staff. It increased patient to staff ratios so high competent care could not be given to so many sick people under your care. In CA the situation got so bad patients were calling 911 from their room to get someone in the room to help them. So not only were there layoffs, thousands of nurses threw up their hands and walked out, refusing to work in an environment that was not safe for patient or staff. Things have never been caught up since. The other issue is clinical nurse instructors have to have a masters degree, and with only 6-7% of nurses with a masters, there simply are not enough instructors to go around.
Next, to think medicine can't quantify outcomes is extremely erroneous. It's called evidence based practice, and through research and studies it is quite possible to determine what labs, drugs and treatments are MOST appropriate for best outcome. The biggest problem is not the knowledge base, but getting physicians to routinely follow the recommendations once diagnosis is made. If they don't the only real consequence is perhaps decreased reimbursement when an insurance company decides by not following recommendations it cost them too much, but any kind of discipline for poor patient outcome is virtually none existent except a patient or family member suing. If given a true recourse besides the legal system I firmly believe lawsuits would decrease. Not every patient every time will benefit by following fairly dogmatic guidelines of care, but most will and physicians also have to have the leeway to figure out a different course of treatment IF the common protocols fail. There is near zero chance you will ever be able to just checkout just how good he is, the AMA does not want that information out there easily or free. The AMA is more like a medieval guild than a modern day profession organization. The goal is their members, its not good patient outcome and the will protect people who should not be protected.
That said most physicians practice evidence care, and most are good physicians, but some are awful and they should not get protected. And when they scream at a nurse and act a fool their should be consequences that are not there. The inability to deal with disruptive physician is nearly impossible.
That said physicians work horrendous hours, and put up with their share of difficult patients. On calls are either up all night or are frequently awakened through the night. Even the ones I don't like deserves good compensation.
There was very little useful information in this article except to note what the problems are and to note the government isn't the best way to deal with it. Well. at least it had at least one redeeming feature.I think better or more appropriate way to write a health care article is more or at least better research on the subject so more relevant writing would get done.
I think this is a great comment, and I especially agree with your point about the lack of discipline for poor patient outcomes outside of lawsuits. As an attorney (who does not practice medical malpractice, but has seen a fair share of med mal cases) I have observed two things: first, a very sizeable percentage of med mal cases are brought against a fairly small percentage of doctors. Doctors in some specialties are more at risk, sure, but beyond that, it seems that a few incompetent doctors are driving up the cost of insurance for everybody. If there was a better way to weed these people out, or at least alert patients to the fact that their doctor is a bad apple, I think a lot of litigation could be avoided. Second, a lot of med mal patients do not set out looking for a huge settlement, they just want some kind of justice for what was done to them. Sometimes an apology would be fine, or some public recognition that the doctor screwed up. Instead, they get stonewalled by the hospital and its lawyers, and that kind of treatment absolutely infuriates people. THEN it becomes a grudge match, and they decide they want a huge settlement.
I am a CKD-5 patient, and I see the heath care system from the belly of the beast in dialysis treatment and transplant programs.
The biggest issue I see is that the bureaucracy of Medicare(which is politically driven ) is impervious to medical guidance.
Medicare pays for transplants, but only three years of anti rejection drugs. After that, many Meidcare patients lose their kidneys because they cannot afford the out of pocket costs. They go Back on dialysis, which is paid for by Medicare. The problem is that the medicine is $12-$15k/annum, and dialysis is $50k/year. That goes up in the last year of life.
"5. No matter how hard payers bang on MDs to become more “productive,” there’s a limit on how many patients you can see, how many procedures can be done; and switching to EMRs compounds the problem, because most EMRs are horrible and timeconsuming, rather than time-saving"
The bit about EMR is empirically false. The VA, for all of its faults, is a more efficient system to work in precisely because of the EMR. Resistance to EMR represents a generational split, where the older generation is simply wrong.
See: Bain, PA. WMJ. 2008 Dec;107(8):380-1.
You must have a great EMR. I would love to see it. Ours is terrible. Young and old, we all hate it.
The problem with medicine is its over-reliance on labor versus capital. Any such system eventually succumbs to Baumol's Cost Disease.
Before the Model T, cars were hand-built by machinists, and cost megabucks. Today manufacturing jobs are disappearing because all but the most skilled labor can be replaced by machines. As a result, manufactured goods are so cheap that we call it "affluenza."
Part of the problem is that people define "quality healthcare" not just by outcome but by process. A lot of what people get from doctors isn't physiological medicine but psychological wellness.
What we need is technology which doesn't just make your family doctor a little more efficient, but that makes him redundant.
This entire discussion ignores the huge presence of alternative medicine in this country.
Putting a price tag on it is difficult, but a recent National Business Journal study put it at $45 billion, with an additional $2 billion for supplements.
From what I see of uninsured/underinsured, they turn to alternative healers first, and find they're getting better outcomes than from the Medical Doctor for most run-of-the-mill stuff.
Many more people would apply to medical school if the chances of getting into medical school were better. Obviously you can't get 10 times as many doctors, but that's sort of an actually idiotic point. What if you could only get 50% more doctors? That would be a big deal. There is a bottle neck here and eliminating it would go a long way towards lowering the cost of medical care and the crazy hours that new doctors have to put in which may well increase the amount of doctors.
My two son's both decided to become doctors. I have always been in finance and told them that if they want to make money, medicine was not the best route...however, if they wanted to help people, then their desire was the right course. My oldest son is now 33 years old and still has 1 year left of a five year residency and another year after that for a fellowship. His debt is $250,000 and is currently paid around $45K as a resident. How many people are willing to spend fifteen years in higher ed/residency before they can really start their careers?
Hopefully after Obama gets through with "health care reform" and redistribution "fairness" tax policies, they will still have enough to pay off their quarter million dollar debt! After all something has to be left for the plaintiff lawyers.
"5. No matter how hard payers bang on MDs to become more “productive,” there’s a limit on how many patients you can see, how many procedures can be done; and switching to EMRs compounds the problem, because most EMRs are horrible and timeconsuming, rather than time-saving"
The bit about EMR is empirically false. The VA, for all of its faults, is a more efficient system to work in precisely because of the EMR. Resistance to EMR represents a generational split, where the older generation is simply wrong.
See: Bain, PA. WMJ. 2008 Dec;107(8):380-1.
OK, I did.
Bain refers to a single task: "This article describes how collaboration between a government agency and a medical group that uses the Epic EMR resulted in an electronic version of a commonly used form." Big deal.
Now let's look at some other studies.
Keshavjee et al (Proc AMIA Symp. 2001:309-13) showed that "Staff time spent on charting increased with time, in keeping with our anecdotal observations that nurses were given more responsibility for charting in many offices. Physician time to chart increased initially by 50%, but went down to original levels by 18 months."
Linder et al (Arch Intern Med. 2007 Jul 9;167(13):1400-5) showed that "for 14 of 17 quality indicators, there was no significant difference in performance between visits with vs without EHR use."
In the last 10 years, I've used Allscripts, Mindscape, EPIC, Centricity, ORCA, and a couple of homegrown systems. Most are, in fact, horrible, and designed by people who have no clue what physicians do. They do not save time in charting; they can, if well configured, help save time in data retrieval, assuming that they aren't down/rebooting/being updated/misfiled. Few of them talk to each other, so EMRs and imaging from one institution can't be loaded on another.
Sorry, but I stand by my statement. Also, I'm not old (yet)...
Who would be satisfied with a doctor who would be satisfied being a robotic GS-13?
"First, do no harm"; 50 years too late for that.
Top-down repair will not work.
Probably not at all, certainly not in time;
The repair machinery is also broken.
Bottom-up reinvention _might_ work, by pushing
Hi-Tech diagnosis and treatment to the limit,
and using Telepresence to multiply the medicos.
The Stopper here is the same one that got
The Barefoot Doctors, itinerant autodidacts
in the Land of a Thousand Flowers, De-rezzed;
The State does not tolerate competition.
The Saviors will be greedy entrepreneurs,
operating out of reach of State interference
(in the 2nd world), who get rich by making
Health Care universally affordable, and available.
I sense an Ayn Rand reference...
Megan,
I live in the 11th Congressional District of NC - currently represented by Heath Schuler, previously represented by Charlie Wilson, one of the Cardinals on the Appropriations Committee. No district in this country has been harder hit by job losses due to imports, needing restructuring/retaining, and our Congressmen have been aggressive in providing funding for this purpose. Yet for the last 5 years there has been a two and a half year waiting list for slots in the nursing program at my local community college. I know of dozens of [primarily] women that would love to have an opportunity to train for nursing, but are prevented by the guilds.
Confused,
Thank you for your reply.
And incidentally, the hospital will often get reimbursed some by the state as taking care of neonate usually earns quite a bit of money. (None of which gets bottom lined to the Ob department, but that's a different irritation).
Um, no. Often getting paid some does not pay the bills. So where and how does the free care get paid?
It is the systems costs of information technology, procedures, protocols, training, oversight, and regulation that makes hospital care so expensive. Surely as an experienced OB/GYN you must know this.
Or not. And if not, then you haven't been paying attention or you are in denial.
How is the free service provided by physicians and hospitals systems recouped? What kind of economical model can allow for it?
As to defensive medicine, what is your solution? What is your solution to the demand of patients, their families, and the legion of med-mal lawyers to your practicing perfect medicine, all the time, on-time and every time?
BTW, Vioxx and Bextra? That's how physicians failed to control costs? That's your example?
How is that exactly? Explain that to me.
Sorry, it is not the responsibility of physicians to maintain costs. It is our responsibility to provide the most accurate, effective, and compassionate treatment for our patients. Period.
Not perfect, cost-free, risk-free, painless, instantaneous, or patient-responsibility-free care.
As for the reference to ascending cholangitis, it was meant to be representative of the fact that a one-time lethal disease, in less than two generations is now a routinely treated disorder.
Thank you for making my point.
And yes, thank you, I am a very good doctor. I am blessed with an excellent job, chief of my department, wonderful staff, and patients who, more so than not, inspire me to do my best for them as they are interested in making the most of their lives despite incurable illnesses.
My plans do not include toiling under the direction of petty bureaucrats who know nothing about my patients and who care little for their well-being. Rather, they care only for their adherence to their arbitrary and often dangerous check-lists.
No, I will enjoy the beauty of the same sunsets, thank you, in the Wilderness, where those who think they can do a better job of it than I will be free to have their hand at it.
Lastly, I am sorry to hear that you sold-out. I hope that gets better for you.
Thanks for the enjoyable, if aggressive, discussion that you, Confused and others people are conducting.
Ok, but let me ask you 2 questions:
- don't you have to deal with some bureaucracy as things are, but with insurance company representatives instead of government bureaucrats?
- you seem to care a lot about your patients. So I assume you're bothered by the fact that uninsured and underinsured people don't have access to non-emergency medical care. What changes in the health care system would, in your opinion, fix this problem?
These questions are, by the way, also directed to every other expert in the thread.
1. "Often getting paid some." No it doesn't pay all the bills. But the point was it wasn't totally free care as you had stated. And you know where that money comes from, higher charges to the private healthplans.
2. There are a lot of costs. Systems cost are one. Costs which (as far as I know) have never been studied to see whether or not they are effective in providing care. Just some made up demand by bureaucrats (80hr resident workweek, really?) and this is my entire point, because physicians are "too busy" to take care of these things.
3. I don't know how to control costs either, but physicians spend a lot of time whining about attempts to control costs than actually taking aim at the problem. Imagine how expensive medicine would have really been if insurance companies didn't try and do that for us. Even if they are bureaucrats.
4. Bextra and Vioxx are just some examples of "brand name" drugs that make it to the market that were never proven to be better than the generics out there at diminishing morbidity or mortality. Bextra and Vioxx just happened to have WORSE outcomes than the generics. I think you knew that. How many times have you prescribed Zosyn or Unasyn instead of cheaper Amp and Gent IN ROUTINE CASES?
5. Our job was to be cost effective for society's sake. We didn't do it. Now it's the bureaucrat's turn. Reading the non medical opinions out there. I agree with you. God help us.
6. I didn't sell out, my colleagues did which is why I left general Ob/Gyn. I prescribe mainly generics and TRY to limit the use of the latest and greatest technology and tests. It's not easy and I know my partners do not.
7. I'm relatively young, so I will be toiling for some time. I missed out on the "golden age." I will be doing my best to be influencing those "petty bureaucrats" that are attempting to limit us physicians from bankrupting the system. So yes, I will be "trying [my] hand at it."
I do appreciate your viewpoint and having an excellent job with an wonderful staff makes it easier to appreciate life.
LOL, "golden age." I graduated in 1985. Back then, the old-timers were bemoaning the demise of the "golden age." I remember the huge divide between those who were still allowed to deduct med school loan interest on their taxes, and those of us who came later. We knew we had missed that boat. The "golden age" is always at least seven years before you yourself graduated. Honest.
Sorry, one last question.
Whose job is it/was it to control costs? I can see it wasn't yours and in your opinion, it wasn't the responsibility of the experts who actually work in the medical field (ie doctors).
So whose job was it?
Nimed,
I am not health care expert. I am an expert in the diagnosis and treatment of neurological illnesses.
Yes, there is already an oppressive bureaucracy under which patient care operates. My staff routinely spends hours every single day on the phone trying to obtain authorizations for medical testing, medications, and other treatments.
A single call to have one MRI authorized may take as long as 30 minutes or more. Imagine the multiplier of that in that an average neurologist in an average practice may see 15 to 20 patients each day (many neurologists seem more than this number each day.)
At this point, dealing with the insurance companies and their proxies is about as bad as I am willing to tolerate. Dealing with a federal bureaucracy can only be imagined as something far worse and intolerable.
Getting any answers or anything done with CMS is nearly impossible now, imagine if they were to run every patient's care.
As to access to non-emergency care, it is a problem no doubt.
As to fixing it? Greater minds than mine and many millions and billions of dollars have been spent already trying to solve it.
My answer to your question may sound like an evasion or a cop-out but it is not.
The answer lies in understanding the seemingly infinite complexity of what is called the health care system. The "system" itself is comprised of many more exceedingly complex subsystems, and so-forth as you move through yet additional and still complex subsystems until you reach the patient-physician encounter.
One cannot "fix" health care. It is like fixing the weather. The system and its subsystems are excessively complex to allow it. Change one aspect of it and you must be prepared for all of the changes, known and unknown throughout the entire system, i.e., the butterfly effect.
It is a systems problem that requires a systems solution.
In my practice now, and in all of its previous iterations, I have always seen any patient regardless of their ability to pay. For the first time, in my current practice, we now ask patients with no insurance to make some nominal payment for service. Our so-called public-aid patients (state insured) are seen at a loss. We do not discourage them from seeing us, rather, as a community (in this case neurologists) the different groups try to share equally in their care.
But this does not answer your question.
What is needed to provide universal health coverage is free medical and nursing education, forgiveness of existing student loans, tax incentives to medical groups for so-called "charity" service, tort reform and caps on pain and suffering, stronger penalties for frivolous lawsuits, higher thresholds for bringing a med-mal case, caps on lawyers fees, etc., closing the borders to illegal immigration (illegal immigration, BTW, is another source of overwhelming the system), higher premiums for smokers who refuse to quit, or any other evidence for poor compliance.
These are but a few changes that will keep costs down and promote better care. And NONE of the these have any chance whatsoever of ever being enacted.
Never. Never. Never.
Or a novel and I think better approach was offered by this book: In Our Hands : A Plan To Replace The Welfare State, by Charles Murray
In Sum, give every citizen a fixed dollar amount each year, eliminate all entitlement programs, a certain amount of the money given must be used to purchase health insurance, open the market of health care to competition thereby reducing costs of procedures, testing, and therapies.
Chance of implementation: Zero. Zilch. Zed.
The notion that Mr. Obama or anyone else can fix health care is a fantasy, and a sadly improbable and ultimately dystopian one at that.