“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.”
Come Down To My Basement…I’ve Got Candy Down There…
Organized medicine is certainly facing a little bit of a faith crisis. From those they’re supposed to represent come cries that the AMA, specialty and state societies do not do enough for [put individual specialty here]. From the interested public and other interest groups comes cries that the AMA, specialty and state societies move to benefit the physician over the patient.
Throw amongst those pragmatic concerns the intellectual and long held criticism that organized medicine suppresses the supply of physicians and the scope of non-physician practice and is thus inherently anti-free market.
I’ve ignored this topic for long enough considering my considerable involvement in leadership roles within organized medicine and my libertarian leanings.
The clamoring from far right wing free market speakers like the late Noble Laureate above (who I respect considerably, despite the little joke above) and crazy think tanks like the Ludwig von Mises Institute is that the AMA is essentially a guild whose will the government has succumbed to. In a publication titled “100 Years of Medical Robbery” the think tank has this to say about the history of the American Medical Association and its goals:
In the days of its founding AMA was much more open–at its conferences and in its publications–about its real goal: building a government-enforced monopoly for the purpose of dramatically increasing physician incomes. It eventually succeeded, becoming the most formidable labor union on the face of the earth.
To accomplish the twin goals of artificially elevated incomes and worship by patients, AMA formulated a two-pronged strategy for the labor market for physicians. First, use the coercive power of the state to limit the practices of physician competitors such as homeopaths, pharmacists, midwives, nurses, and later, chiropractors. Second, significantly restrict entrance to the profession by restricting the number of approved medical schools in operation and thus the number of students admitted to those approved schools yearly.
The emphasis is my own.
I’ll offer a candid response to this. Through it’s history the AMA appears to have focused largely on improving physician income. Perhaps not as single minded or nefariously as the Ludwig von Mises Institute would have you believe but it remains. And the AMA has had considerable success doing such. The allowance of self goverance that medicine enjoys and the sway it holds over the scope of practice for other providers is incredible. I think there are some real issues of ‘patient safety’ buried in those issues, as the AMA would argue, but it is hard to argue that physician income did not, does not play a role in the AMA’s focus in securing physicians influence over who practices “medicine.”
Organized medicine was responsible for the Flexner Report and continues to hold the greatest sway over the number of physicians this country will (or will not) have by controlling the LCME and ACGME. To argue some conspiracy to suppress the number of medical students (and thus number of future physicians) through these entities is baseless, but it does display how much control organized medicine has wrested for physicians. As does the limiting of the scope of practice of all other medical practitioners. Indeed, that aspect of the AMA’s success (getting state governments to agree to follow their rules on who should be allowed to perform certain procedures or write perscriptions) may be the most marvelous.
It is clear that the ‘thinkers’ and ‘economists’ who criticize the AMA are far removed from the practice of medicine. Some of their rails simply show a lack of understanding of how medicine works. For instance, the article above tries to criticize the AMA’s restriction on who can practice medicine in the name of ‘patient safety’ and ‘quality,’ by saying,
A final challenge to the Lexus standard is the number of accidental deaths occurring in U.S. hospitals every year. Harvard University’s Lucian Leape estimated that there are approximately 120,000 accidental deaths and 1,000,000 injuries in U.S. hospitals every year. To understand what staggering figures these are, imagine a Boeing 777-200 with its maximum of 328 passengers crashing every day for an entire year with no survivors. This would add up to 119,720 deaths, still not as many as are killed through medical error in hospitals every year. UCLA Professor of Medicine Robert Brook, M.D., told the Associated Press, “The bottom line is we have a system that is terribly out of control. It’s really a joke to worry about the occasional plane that goes down when we have thousands of people who are killed in hospitals every year.”
In anycase, the point is there are questionable assertions like this throughout the works of the libertarian thinkers who criticize organized medicine. Despite that, there is some validity to their points. As another Ludwig von Mises paper, “Bring Back The Guild System?” says,
Government regulations on the chiropractic profession, lay midwifery, and on the freedom of nurse practitioners to offer services within their competence, all of which make perfect sense from the point of view of the medical guild that lobbied for them, make no sense at all from the point of view of consumer wishes (as repeatedly expressed in polling data) or from economic considerations. In many cases, such people can provide health services far more cheaply than can licensed physicians (or, in the case of chiropractors, can provide services that licensed physicians do not provide at all), but consumers are prevented from making their own decisions regarding their medical care. Given the logic of the guild structure, no one has the right to be surprised to find that the AMA has put so much effort into undermining its professional opposition.
There is nothing wholly unique about physicians’ efforts towards this. Other professions do the same and also limit their membership through limiting education spots but medicine is certainly one of the most successful at it.
I will accept the blows Milton Friedman lands against the American Medical Association but let me make an argument on why the AMA’s actions are reasonable despite violating the libertarian ideal.
Let us call what the AMA and the rest of organized medicine does a necessary evil. It might not have been through all of its existence granted but today it is. It is because physicians are not playing on a level, free market playing field.
I am a Christian. Jesus Christ is my personal savior. I can reconcile my faith with a host of scientific facts including evolution. But as we’ve seen, there are plenty of believers who apparently cannot.
It is distressing because it is difficult to view such individuals as anything but morons. The following is a video posted to GodTube, which is currently being (rightly) mocked on Reddit. You can use the terminology of evolution correctly all you want and create reasonably good looking CG models but it doesn’t make your points any more valid.
Watch For Lightning When Making This Type of Mockery
Some people will tell you 2+2 = 5 and no amount of effort will convince them that their little closed definition is wrong. ‘Creationists’ have no place arguing the science of evolution. They’ve created their own rules, their own definitions which make debate or discussion impossible.
In the end you just gotta let some of them be. Sometimes it ain’t even worth taking a horse to water if you know it won’t drink.
That is the question the thoughtful should be asking; not whether guaranteed access for all can work. Let us be honest, if you goal is improving utilitarian public health measures - life expectancy, infant mortality, time to treatment for diseases, access to care - then a single payer system could work in the United States, provided enough funding. Complaints and nay say against such a system by providers is nonsense and nothing but protection of self interest. There are tradeoffs with such a system, but there are trade offs with any health care system. Look at our current one. If you want to improve what the public would consider ‘health’ then a well funded single payer system would be far superior to our current system, no matter America’s ‘uniqueness’.
But should we do that? The real debate is should the government fund access for those who cannot afford it themselves. Who has such a right?
The Miller Center of Public Affairs tried to do that recently with a panel debate. On the transcript at times the talking heads fall short in defining the debate and staying on course, but it still something worthwhile to look at.
Simplified
In a perfect medical school the basic science education would be cut down. What I mean is that the focus on minute ‘physiologic’ biological processes would be limited. The basic sciences, especially in the first year, have become too complex and unnecessary. Too often what students are introduced to is influenced by the research of the faculty of the school. At the perfect medical school such would be limited with strict curriculum oversight. Further cutting of the basic science years would be limited by the National Board of Medical Examiners and their continued insistence that memorizing a host of biochemical pathways is somehow imperative for a single test day, somehow is imperative to becoming a physician. If that obstacle was removed the perfect medical school would significantly cut down on the traditional ‘first year’ material.
Early Clinical Exposure
The perfect medical school would also compress the basic science years. Already there are schools which do the first “two years” in eighteen months. An applause to such schools. The perfect medical school would do the same. The key is to get the medical student out of the classroom as soon as possible.
As I’ll discuss in the clinical sciences post, clinical exposure would be early in the first year and often. The 18 months at the beginning of the perfect medical school could hardly be called ‘basic science,’ despite the title of this post.
Integrated Curriculum
The perfect medical school would have a truly integrated curriculum. There would be no distinction between ‘first’ and ’second’ year. You would progress through the 18 months of basic science in modules focusing on various topics (i.e. cellular metabolism, cardiovascular system, GI system, etc.) in which you would cover the physiology, anatomy, pathology, related pharmacology, etc. The basics, which are hard to integrate, would be covered in the first two months in the classroom and then it would be off.
Despite the abandonment of the anatomy lab by some schools, gross anatomy and human dissection would remain a strong component of the perfect medical school.
Technology
The perfect medical school would be the most integrated school in the country, technology wise. The obvious things, done in most schools nowadays, would include virtual microscopy (no student should ever have to fix a path or histo slide), online lectures, online grades, online syllabi, computerized test taking.
Summary
Remove frivolous basic science minutia
Condense the basic science education to 18 months of less
Early clinical exposure
Strongly integrated curriculum with no distinction between ‘first’ and ’second’ year
The move towards cost transparency is generally something I support. But there is an argument I will buy that such should be prospective. That’s the line I’m buying with the current lawsuit over Medicare provider data that some consumer groups are waging.
In an unusual statement, the Health and Human Services Department endorsed the objectives of the consumer group that is suing, but said it wanted a higher court to clarify the lower-court rulings.
“We’re caught between court decisions,” said Christina Pearson, a spokeswoman for the department. “There’s conflicting information from different courts, so we’re pushing to get clarity.”
But the government’s legal brief in the case calls for the appeals court to reverse Sullivan’s ruling, leaving the restrictions on the release of data in place.
“I know the government was under a lot of pressure from the AMA in particular, arguing that the government should appeal,” Krughoff said. “Whether that’s the reason the government appealed, I don’t know.”
I’m torn, certainly. It is much easier to speak of the private insured having a ‘right’ to such data than Medicare patients considering what the two groups shoulder in terms of personal costs and responsibility for their health care access.
It is reasonable to imagine that a physician, somewhere out there, participates in Medicare under the understanding that his reimbursement data is shielded from public eyes based on previous court rulings, and would not participate otherwise. Under such a circumstance I think the opening of the Medicare database needs to be solely prospective and not retrospective. That means the data won’t be useful for years and years, I understand that but it is probably the right way to do it.
Several in the medical blogosphere (here and here) have picked up on a front page WSJ story concerning specialist income and shortages.
Probably an overblown story.
But a look at specialist income got me thinking. Is it just me or is diagnostic radiology the specialty most likely to be disappointed over the next couple of decades? When I was writing my previous posts on physician income I started really thinking that radiology may be in for a significant slow down in earnings growth. There are two factors which I think will contribute to disappointing growth in radiologist income:
1) Their rise in income over the past two decades has been precipitous and outpaced the growth in median income of just about every other specialty. And not all of that has been driven by the rise of interventional procedures. Radiology thus, as a specialty, has some of the most to “give back,” if and when physician income growth slows as cost sharing measures.
2) The rise of outsourcing is probably a little overstated but it seems real enough. With rising healthcare costs concerns over international radiologist work (liability issues, etc) may not be enough to prevent the outsourcing trend from speeding up a bit and driving down reimbursement.
This isn’t to make a claim as to the value of radiology or to say that diagnostic radiologists are currently over reimbursed (I don’t think they are). I’m just trying to imagine the future. Radiologists will never be ‘hurting,’ but in my career I think they’ll be doing more work for less dough.
I’m No Radiologist But Something Ain’t Right Here
I have a lot of respect for the ACR and RadPAC’s efforts but diagnostic radiology may not be in a completely defendable position with some of it’s unique aspects as a specialty.
I did my undergrad work in USC's School of Cinema-Television Cinematic Arts. I have a Bachelors of Fine Arts in Writing for Screen & Television. I loved it, but a future of waiting tables and taking meetings with B-List producers was not for me.
This blog is ostensibly to discuss healthcare policy and maybe educate a few of my fellow medical students. But it will stray into current events, politics, and other science topics when they draw my interest
Other odd notes about me:
I've skied half the resorts on this list (Squaw Valley/Lake Tahoe, Snowbird/Park City, Whistler, Taos, Vail)
I "played" lacrosse in high school and through a club level team in college
Nothing on this website is to be taken as medical advice. I am not a physician. Please consult a physician concerning any health related questions.
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Endorsements
"Please be more precise in your practice of medicine than you are in your blogging!"
- Mark Lanier
