The Dark Side of Doctoring(ericlevi.com) |
The Dark Side of Doctoring(ericlevi.com) |
To apply AI at the start of the process makes a lot of sense -- reduce/eliminate errors at the start and allow doctors and their time to be better used.
[1] http://www.nydailynews.com/news/world/ibm-watson-proper-diag...
[2] http://www.businessinsider.com/ibms-watson-may-soon-be-the-b...
indispensible. irreplacable. the rest of the industry should therefore be focussed on getting as much value out of these doctors. which means they should be focussing on taking any paperwork out of docs hands.
I have seen comments talking about "physician cartels" purposely encouraging a labor shortage to drive up physician pay. There is no physician cartel. Only about 15% of physicians even belong to the AMA, and only a subset of those have any political involvement at all. It just doesn't exist.
One of the things that I think contributes to the general dissatisfaction of physicians in 2017 is the increasingly negative public opinion of the medical profession and the imputation that there is some sort of evil conspiracy at work. A lot of the negative opinion is misdirected. It should be aimed at the for-profit health care system itself. Most physicians I know have very little control over the things people complain about, including cost.
I always see people ragging on EMRs. They're inefficient, have poor UX, require way too much documentation, etc. These are all fair criticisms, but I don't think people spend enough time asking why. Why are all the major EMR systems shitty in exactly the same way?
I think there's 2 main parts to the answer. The first is the sales process. The people selling EMRs to hospitals aren't selling their product to clinicians, they're selling their brand to the hospital administration. It's like the saying "nobody ever got fired for choosing Oracle", but far worse. The end result is years-long implementation processes, broken promises, and terrible tools that are optimized to allow the hospital to fire a few members of the low-level administrative staff (billing, coding, etc) instead of providing better care to the community they serve.
The second part of this problem is overregulation. The justification is that EMRs should be able to meet a certain level of functionality. Based on personal experience working with these regulations, I'm convinced that the real reason these certifications exist is to prevent new players from entering the market. They are very much in the spirit of "well all these legacy systems do [something], so _obviously_ everybody else should too" without ever leaving room to come up with a better solution. They shackle you to terrible design choices and assume that all hospitals, from a 10-bed critical access hospital to a 500-bed academic medical center, should all be run the same way. And worst of all, they make it impossible to design a system based on what the HOSPITAL needs, because half of the system is devoted to what the GOVERNMENT needs. Kind of like how people complain about interoperability between electronic medical systems. So the government introduces legislation to mandate interoperability, by requiring implementation of poorly-defined "standards" (designed by committees comprised mostly of, you guessed it, representatives from legacy vendors). From personal experience, I can say that every. single. one. of the interfaces required for federal certification is completely unable to be reused by actual hospitals. But that's the entire purpose, that's exactly why lobbyists paid so much money to get the regulations passed in the first place! If potential new competition has to sink thousands of man-hours every year into building useless functionality, that's thousands of man-hours that didn't go into making their product competitive and disrupting the marketshare of legacy systems. Meanwhile, legacy systems are maintaining their market share, not by improving their product and helping healthcare providers do a better job. Instead they're actively creating situations where smaller hospitals are forced to choose between buying onto the licenses of larger hospitals or shutting their doors.
Obviously this is all just my personal opinion.
The AMA caters to a base that is not happy with the influx of IMGs and DOs. The AMA inflates their numbers by auto-enrolling every allopathic medical student. The AMA is equally unhappy that the government using large scale funding levers at the residency level to overwhelm their efforts to tighten supply. By using money and their exclusive access to legislate, the government creates such a Venturi effect that they suck up all the available MDs, and all the available graduates from two other pipelines: the DO programs and the IMGs.
In 2017, the dissatisfaction of the 85% of physicians who don't belong to the AMA is ultimately driven by too much work.
Source: am physician. Have worked primary care, seeing 40+ patients a day, now completing a specialist residency. My work as an underpaid primary care doc was enough to keep 3-5 people fully employed (reception, x-ray certified assistant (sometimes 2), office manager, owner) from 8 am to 10 pm 7 days a week, while sending overflow to others.
Every one of the 85% of physicians who aren't in the AMA declined to renew their membership at some point. Many align with other orgs: almost invariably their specialty's organization, which aligns with the AMA but they are more professionally beholden to (for CME, board certification, etc). Many try to offset the ill effects of the AMA by aligning with other orgs like PSR or MSF or their local public clinics.
But the AMA has a bunch of offices in DC, and has had people in those offices, paying mortgages in McLean or Chantilly, or Silver Spring, <insert DC suburb here> for a century. Those people are motivated to continue their mission of lobbying in support of the legal grip of allopathic medicine, long past their original call to arms (licensure laws to cleanse the field of snake oil salesmen).
When I made the decision to become a physician twenty years ago, I thought medicine was my calling. I believed that the personal sacrifices one makes to be a physician--and there are many--would be rewarded with professional pride, the respect of my community, the gratitude of my patients, and a secure and well-paid living. I have gotten a little wiser, I think. I make a good living, my work is interesting, and I still think medicine is a great career. But times have changed, and I no longer consider medicine a calling for which one should be willing to sacrifice one's personal well-being. I find myself defending my profession on the internet a little more than I'd anticipated :)
Those who control the business of medicine take economic advantage of the patient-first mindset of our medical tradition, and it cheapens what we do, both literally and figuratively. It is for that reason that, despite its many flaws, I do think organized medicine does have redeeming qualities. It gives physicians at least some voice in politics, where they would otherwise have none at all. Maybe one day health care reform will right the ship.
Well, what other way are you going to put it?!
I'm all for organized medicine. But I favor PSR and MSF. They represent the ideals of the modern liberal social order. The AMA needs to be starved off the face of the earth.
The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents.
As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commodities in this complex industry. It’s no longer about the patient. It’s about the business of hospitals."
If doctors were viewed in their industry the way software engineers are viewed in ours -- as specialized skilled labor with extreme leverage and limited time -- then we would have well-supported, well-rested, and well-compensated doctors.
But as it stands, we have overworked and overtired doctors buried under a mountain of clerical work, who need to slot their patient in to 15-minute "encounters" in clinic to keep the profit machine running. Meanwhile, administrators, health insurance executives, and medical equipment CEOs work 9-to-5 and earn millions. It really boggles the mind and infuriates me, as a technologist.
p.s. Don't listen to any of the comment threads here that say long hours are required to reduce patient handoffs. Yes, it's true, patient handoffs cause some danger. But tired doctors make mistakes. Period. And, as this post indicates, a perpetually tired doctor burns out and either quits the profession or (worse) commits suicide, which is the worst possible outcome for the system.
While Medicare covers almost all of it, it became so nauseating to read the outrageous EOB totals that I tried to put a end to it - I requested that unless the on call nurse (after hours) or physician (during business hours) deems the fall to be a life threatening emergency, they are to be kept in the facility.
They found a workaround for that real quick - it's nearly always deemed life threatening because they are 1) unable to determine internal bleeding 2) unable to determine if a bone was fractured/broken.
The obvious solution to this is to have an xray machine on site, because since everyone in the chain gets paid huge $, and it removes the liability from the nursing home to ship them off to the hospital, the merry-go-round of insanity continues. We have two family members in an assisted care facility for almost eight years now, and between the two of them, they've tapped Medicare for just under $700K. Together, the sum of both their incomes throughout their entire working lives never totaled that amount. This is why I call it a ponzi scheme.
Elderly Americans experience about 29 million falls per year, which costs Medicare $31 billion. At about $1,000 per fall that seems quite reasonable. 27,000 older Americans die from falls each year. In an institutional setting like a nursing home, the rate of death per fall is even higher.
$700,000 for two people in assisted living for eight years is about $43,000 per year. That's not unreasonable for the cost of assisted care plus medical expenses.
https://www.medicare.gov/about-us/how-medicare-is-funded/med...
Oh, but it gets worse. It's bad enough that the government is being bilked for hundreds of thousands of dollars on behalf of those without the ability to pay, but even for those with significant assets, there are "perfectly legal" tax dodges that can be set up for $XX,XXX so that Medicaid pays the $XXX,XXX bills while the family inherits the $X,XXX,XXX estate. And if you pay the lawyers a little more, they can probably even figure out how to avoid paying capital gains on the distributed assets if they are below $10 million.
I don't see much hope for the insurance reform in the US until we can get end-of-life costs under control. I don't if "Ponzi" is quite the right term, but it's definitely a system rife with fraud.
More generally, "House of God" is a stunning inside look on how the US medical system actual works: http://slatestarcodex.com/2016/11/10/book-review-house-of-go...
There's a strong medical education research unit in the UK (Edinburgh?); I remember one of their reports on a series of med student interviews making the observation that it was unnerving how the top performing medical students weren't the most compassionate, they were the most ruthless.
I'm taking my boards soon and I have to say, the ability to commit to the task, regardless of the emotions of your self, patients, peers, support staff, and family can definitely be an asset at times. Do I hope to take a kinder view when I start working in a few months? I'm not sure kinder would be the word. Supportive of a somewhat different set of ambitions, perhaps.
Unfortunately, that ability to deny the emotions of both self and other in pursuit of good clinical care is difficult to separate from 1) the punishment of self-loathing, and 2) the behavior of someone who has been rewarded too long for blind obedience.
I'm also working at a healthcare tech startup aimed at reduced the administrative burden to doctors, administrators and insurers of managing their patients at home, which is where the worst outcomes often happen.
Each segment we work with feels this burden, it is not isolated to the physicians.
Healthcare is one of those fields where there's no guarantee on the quality of the service. There's no pay for performance. Actually, doctors who perform too well would reduce healthcare spending.
There are plenty of reasons to keep developers happy because it directly affects the end product and profit.
Docs and hospitals have been dealing with 'P4P' for decades and the ACA ramped it up significantly for the CMS.
The worst part is that many doctors often defend and work to perpetuate the system, rather than organizing to make it sane. It is truly boggling.
It's worth reading more about the history of medicine to truly understand what's going on here -- the culture of abusive overwork in American medicine goes at the very least back to Osler and the invention of the modern residency program, and has as much to do with cocaine than any corporate malfeasance. Certainly hospitals and the medical industry profit from this culture, but they hardly created it.
Also, on what basis do you say that longer hours with fewer tradeoffs don't improve patient outcomes? You frame it as though it's obvious but is there any evidence to back that up? My wife and most other doctors I know all claim they'd rather have longer hours with fewer handoffs.
Doesn't it sound like medicine is like a web service infrastructure where everything is on fire, and there's just no time to really fix the root causes?
FWIW, my mother is an MD, a Family Practitioner. She eventually became head of FP for a small commercial hospital chain in the US. Two years ago, after perhaps 18 years of professional practice, she moved to New Zealand and is a FP in a small town. She takes 3 days off a week, has reasonable hours, does less paperwork, does more with her own hands which she would refer to specialists in the US. She absolutely loves it.
I do think the increasing corporatization of medicine in the USA has accelerated the loss of autonomy and satisfaction, which makes the abuse and overwork far more difficult to take.
If you're exhausted or in physical pain or have a cold, you not only power through it but you suck it up and refrain from complaining, even if you're assisting a surgery. You may be officially encouraged to know and respect your limits, but if you actually do this you quickly go from being a "brother in arms" to weak and unsuited for the profession.
A software engineer is hired for their skills (at least ostensibly). No one is required by law to hire someone with a specific degree and specific post-degree training and specific exams.
Contrast this with healthcare. To do certain sorts of procedures, you have to hire a physician. Not because it's demonstrably necessary to have someone with an MD and a residency in such-and-such area do this, but because it's required by law.
As someone else pointed out, this is just the tip of the iceberg. That residency? Residents have no bargaining leverage over their conditions by fiat of residency rules--they cannot leave an abusive residency, for example, to change conditions. Financing the residency itself? Businesses won't cover the expenses because it's not actually worth the costs, so the government foots the bill. And once you leave residency? Well, subspecialty organizations are deciding that it's good to carve out even more regulatory capture with subspecialty credentialing.
People do not grasp how much of this insanity is codified by law and rule, and when they are informed of it, they shrug it off in the name of "safety." It's like terrorism or crime: no one wants to be branded as soft on terrorism or crime, so the government becomes more and more invasive and draconian, and the costs of maintaining the military-police-industrial complex increase and increase. Similarly, no one wants to be soft on safety, so the government becomes more and more invasive and draconian, and the costs of maintaining the medical organization-physician-insurance-industrial complex increase and increase.
There's something disingenuous for physicians to complain about being overworked, and then fight against the things that would alleviate their burden the most: letting perfectly competent professionals with different backgrounds do what they do just as well. But that would mean admitting that you don't need an MD at the apex of healthcare.
To some extent, financial market pressures are doing what I'm saying anyway, as hospitals are realizing that MDs are too expensive as they are. So maybe this is just the first sign of things to come. But the downside of the current system is that administrators aren't allowed to go elsewhere for alternatives, so they just crank up the hours expected of MDs. The upshot is they get devalued without even being given the benefit of being let off the hook.
I guess to address your comment directly: if healthcare were actually a transparent free market, my guess is physician salaries would go down, but their workload would also decrease also. What you'd see instead is much more diversity in who you see for any given service.
The biggest sin of the government in the healthcare debate is willfully ignoring the costs of healthcare, by failing to increase competition, choice, and transparency in pricing. We talk about who pays, but not why we're being charged what we are, and whether or not it's worth it.
Also, exorbinant salaries and good hours are not to be found in the hospital system. Yes, specialist doctors get paid "well", but not exorbinantly, when adjusted for required training, education, experience, and opportunity cost. In private practice, the hours are better, yes -- but only in certain subspecialties. But this is like saying major airline commercial pilots should just fly private charters for a better lifestyle, or that software engineers should just work at hedge funds as quants for better compensation.
It's the hospital system, not private practice, that shows us a healthcare system where doctors are being put to their unique purpose of advanced clinical treatment. And that's where the market is failing.
Healthcare requires the hospital system to provide the most advanced and emergent forms of care, and that is where doctors are overworked and undervalued.
As for the free market, I wish you were right that it could fix the US healthcare system. But patient health is, unfortunately, not valued correctly by the market. The market rewards chronic treatment, whereas society prefers one-time cures. The market tries to monetize patient-doctor interactions, whereas society would prefer fewer doctor visits with fewer hospitalizations. The market treats doctors as a cost center whose hours needs to be billed out at a profit, and society would prefer doctors as a value center who are given the professional leeway to use clinical judgment in assigning time to cases and patients.
I love market systems, but only when they work.
The other thing is that with the current system (i.e. medical doctor prescribes), there's liability coverage through the doc's liability insurance, which unless psychologists are interested in taking on huge liability insurance premiums...
> People do not grasp how much of this insanity is codified by law and rule, and when they are informed of it, they shrug it off in the name of "safety."
Not to make minimize the problem, but this feels a bit like privacy in IT (or lack thereof) due to government overreach.
People care much less about something when they are not directly impacted (or think they're not impacted).
However it also pays incredibly well. Even moreso for specialities and surgeons, who can make over 200k a year even in low cost of living areas. Despite the difficulties of being a doctor it's harder to get into medical school than ever. The difficulties are not deterring med students.
I don't feel bad for people that go into this profession then complain about how hard it is. It's extremely well known within the medical field that being a doctor is grueling. That's why it pays so well. And it's not like this is a new development. It's been like this for decades.
Complaining about it is akin to working on an oil rig and complaining about poor work conditions. It's pretty damn obvious that you're going to have poor work conditions from the start.
Nobody is forcing you to be a doctor, your school credentials plus MD is probably enough to swing a decent job in almost any field. Doctors are some of the most employable people out there.
I just find it rediculous that were having a "poor doctors" discussion when it's the second highest paying profession in the richest country in the world. Get over it.
Contrast that with what exactly is provided by healthcare insurance executives, bankers, lawyers, lobbyists, and certain departments in government.
To be blunt: once you note the fact that other countries in the world can provide healthcare at fractions of the cost, it's obvious those insurance execs, politicians, and lobbyists are eating value, not creating it. The contrast is that Doctors actually produce something of value.
And even if I were to agree with your premises, do we really want a system that selects for the kind of doctors who are willing to put themselves and their loved ones through years of hell in exchange for an eventual high and stable paycheck? What kind of people are these? Are they the kind of people you'll trust to treat your scared child gently and empathetically?
It isn't clear how much the grueling training actually factors in to limiting the supply.
I will say thought, that this is a really typical path in the US, at least:
* 4 years undergraduate ($200K debt, high competition/workload)
* 4 years medical school ($250K debt, high stress/workload, 50% odds of not being accepted)
* ~3 years residency (pay only $50K/yr, famously high stress/workload, possibility of being separated from loved ones or making hard choices in residency match)
So assuming starting undergrad at age 17, you have had a tough 11 years and are at least $300K in debt by the time you are 28 and getting your certification. This is ignoring specialties with fellowships. I don't have the time, but I'm sure it's possible to estimate the quality of the time sacrificed to education and lost compensation during that time and then amortize that over a typical career.
And the field is different... after all of that training they get to spend an inordinate amount of time doing paperwork/fighting with insurers, which (seems to be) leading to more group practices with workloads like those described in the article.
The hourly rate for some doctors (mostly non-procedural) are much much lower than people realise and is only made up for my doing ridiculous hours. This is just not right.
This delusion that all doctors do well financially draws more poor students into the long training commitment only to find out at the end that with all the debt and sacrificed family hours and stress (having been through this) they are going nowhere financially.
Looking after patients can be a great and fulfilling career but this depends so much on the particular speciality you choose and the work life balance that it provides.
Next time you see your ED physician or family practitioner feel sorry for them. The shit and conditions they deal with and poor renumeration is something you simply don't understand.
I wonder how many doctors would be up for "sharing work (and compensation)" - in other words, would a doctor be OK with dropping his comp to $150K (from $200K) so the savings can be used to add a third more doctors to the staff? The "relief" in working conditions may well be worth it, for the doctor's sanity of course, but also for the patients (and all of the benefits down the line from having fewer mistakes, etc).
It's obviously not the only dimension that can be played with to help, but it's one that could be fairly straightforward to implement, as long as there is enough supply of applicants to increase the workforce.
My wife is a pediatric emergency medicine physician and I get paid more than her because I'm in tech. Also, I started my career and began earning an income right after college, whereas she went to medical school and a fellowship before she could begin earning income.
I always joke with her that, in terms of income efficiency, my field is way more profitable than hers. And a lot less stressful too.
Is this the case? Or do they not adhere to the working time directive?
I think a UK doctor's hours are probably easier than a US doctor's but we all break the EWTD (except for some specialties like psychiatry). For example I am rostered to work an average 48 hours a week, although there are some weeks I work more, and I will often stay behind to get things done. My total hours per week is probably around 50 - and I'm in a job that isn't considered busy!
I'm willing to bet that something to relieve the massive amount of "other" stuff needed besides the Doctor would go a LOOOOOONG way...
That doesn't even tackle stuff like inability to see how much something actually costs - and shop around for stuff other than the ER.
15 minutes per patient isn't the answer...
Yeah?
I just recently had a friend completely burn out of medicine, sell his house, and start traveling the world. He was brilliant, a good doctor, a good person. It's a shame he's been driven out, and so many others.
I also recently had the experience of seeing a young doctor bright-eyed and busy-tailed treat me once, and then six months later see him again. The toll that those six months took on him was visible. He was just about haggard with the work. It's easy to imagine he won't last long.
I feel there's an interesting parallel with teaching. Teaching and medicine both have licensure requirements, both have a strong appeal to people who care and want to make a difference in the lives of children/patients. And in both cases the profession is gradually being taken over by administrators and subject to increasingly onerous regulations.
I also recently had a friend burn out of teaching. She's set to work in a completely unrelated industry now. She put up with crap for a long time due to her care for the children, but at last she couldn't take it.
My libertarian side says these are two improperly functioning markets, with massive human casualties. It's a shame.
Last week was the Royal Australasian College of Surgeons Annual scientific Congress in adelaide so physician wellbeing is well and truly on the radar, in particular following 3 suicides in the last 6-9 months of junior trainees, one of whom was a friend of mine from medical school.
There is now an enquiry into Doctor suicides and wellbeing being performed at the state level in NSW and we (doctors) expect this scope to be broadened to nationwide
The RACS, RACP etc are sclerotic organisations run by old white men in bow ties (I've met several of them) with no real incentive to improve conditions for trainees. The only way I have seen actual change happen is when junior staff band together and effectively go on strike.
Having said that within both organisations there are people who strongly and fiercely advocate for innovation and change, but you are right, they are severely sclerotic (even to the point of RACS making an absolute motza out of their trainees, they've got over $60m in the bank and our exams cost $4,000)
[1] http://www.usatoday.com/news/health/2005-03-02-doctor-shorta...
Missouri just passed the first bill of its kind to try and combat mental health issues in med school.
http://krcgtv.com/news/local/medical-student-suicide-prompts...
> The bill, also known as the Show-Me Compassionate Medical Education Act would establish a committee to study mental illness, suicide and depression in the state's six medical schools. The bill would also prohibit any medical school from restricting a study on the mental health of its students.
The absolute disturbing part is right here:
> While lawmakers debated the legislation, Frederick said the deans from each of the state's medical schools sent him a joint letter expressing opposition to his proposed law.
In other recent news, Saint Louis University fired their med school dean that was the absolute champion of promoting the mental health of SLU's students.
http://news.stlpublicradio.org/post/slus-medical-school-remo...
Furthermore, as part of the licensing process, you are asked whether you were diagnosed with a mental illness in the past. There will likely be an investigation if you say yes and it could impact your career.
This stigmatizes mental illness within the profession and keeps people from seeking help when they need it.
Simplistic supply and demand analysis of this issue is annoying and ignores basic economic theory.
You don't want to increase doctor supply, you want to increase the capacity of the healthcare system to deliver good care (obviously?). Doctor supply is one part of that, but if you pump medical students in at one end and do nothing else, you will fail - this is what the Australian gov has done, and you can see the result here, where trainee conditions are poor (so much competition that you don't complain about conditions, power is concentrated in hospitals and senior drs in charge of training programs and hiring who align the system in their favour), and incumbent physicians like the one that committed suicide work like demons and burn out.
The financial corollary is fiscal stimulus without any production capacity - GDP doesn't go up, inflation does.
As always, it doesn't have to be this way, but nobody is in charge who cares enough to fix it, and all the stakeholders look after their own interests.
She said she likes it because she can define her own templates and "dot phrases" that make it easy to set up her own workflow. Also that it's nice that everything is all in one app - in other systems you'd have to be jumping between apps to look at lab results and patient messages for example.
Karl Marx
I can't even recall how many young software companies I have sent my resume to that turned out to be in the business of building software for insurers and hospital systems that end up telling physicians how to do their jobs. Of course, the metrics all back this up as a solid plan that increases productivity and reduces expensive errors and negative outcomes due to inattention, but I know it just has to suck for the docs to have to experience exactly the same thing that has already happened to most other jobs.
I am sort of a medical system drop out. I took my toys and went the fuck home. (No, I was not a doctor. I was a patient who could not get my needs adequately met and walked away from conventional medical treatment for my condition.) So, a lot of people assume I am very anti medicine. They think I am some crazy who just hates modern medicine.
This is absolutely not true. But I do hate certain aspects of the system. I think Direct Primary Care would be a step in the right direction.
If you are interested in reading a bit about that, I have written a few pieces about Direct Primary Care.
http://micheleincalifornia.blogspot.com/search?q=direct+prim...
If all this administrative work needs to be done, do surgeons necessarily need to do it? Can we hire more clerical specialists to offload that work onto, or more PAs or RNs to handle less specialized work?
A few measly hundred million in the federal budget could probably be dredged up to subsidize medical school tuition and take some of the sting out of the long, expensive marathon of medical schooling, maybe?
I think the part that struck me the most was his comments about time. I have diverse academic interests. I studied math and bio in undergrad. I love machine learning and software development (esp python). I lived in China to study the language for a year. All that gets sucked out of medical school though. We are expected to learn a ton of material in the first two years. Then in the second two years, we are basically working a full time job in the hospital/clinics while also studying. We are constantly evaluated. We are also expected to do research and publish papers. I've forgotten what a guilt-free day off feels like.
This isn't true of all doctors, but you'll probably find that ones that suffer through like what the author (Dr. Levi) discusses find that their practice is a calling, not an occupation or job. As a calling, it's part of their identity, giving up on it just doesn't make sense to them.
* Golden handcuffs
* Sunk cost
* Rewarding mastery
* Deep specialized knowledge with no other remuneration prospects for that knowledge.
I don't think that we're heading into a zombie apocalypse level destruction. Highly skilled people will always have one of the best lives. But it gets harder for everybody, and no matter how much we complain there isn't anybody who can give us a better life at the moment. Everybody is losing something.
In Canada, we have a fair number of people in certain specialties that cannot find work - think a radiation oncologist who needs some pretty specialized and expensive equipment that only exists in a few places to be useful. But also even more basic... gastroenterologists who can't get enough OR time to do scopes on their patients.
The managing class (Company CEO, Hospital/University administrators) is ever in the pursuit of more profit, euphemized as "efficiency" or "optimization", at the expense on everything else. How can we squeeze the employees a little harder so we don't have to hire as many? How can we increase "productivity" so more patients can be seen(and pay up)? How can we eliminate waste (lower cost of care as much as possible so we can make more) to the patient? How can we make more money by tweaking our charging model (Insurance rewarding loyal customer by charging them more, Hospital Chargemaster etc)? Oops, I see people are complaining a lot. Let me pay some lip service about appreciating our employees and valuing our customer/patients. Heck I am feeling extra generous right now , let's put up some cheap program they can participate in. There, they should feel happy now.
This is all too familiar in the corporate world. Any employees with a half a brain will get the message loud and clear: employers do NOT care. Or maybe they do, just nowhere near money. See, their incentive is aligned quite nicely: cost cutting/profit increasing actions are how they justify their pay and the profit it generates is how they pay themselves. Everything else can be sacrificed.
Caring for a patient is a very intellectual, specialized and dare I say it creative task. Doctors are paid well above many other professions though one can argue it is not for the years they have to invest into training and the work hours. The point is, at the end of day they are glorified laborers, being told by their boss what to do, just like the rest of us. Prestige has shielded the medical profession for decades but now the grip of corporate America has finally caught up. And lo and behold, what scant voice and influence do we have!
We absolutely do need managers/administrators. We need them to make sure companies/hospitals are running smoothly, is well funded and serve the customer well. But the lack of voice and the power imbalance in employment is suffocating. We are partners not servants or slaves. And the all consuming focus on money has got to stop. Human welfare deserve to be at the top. not profit.
Innovation in Health IT happens usually because CMS (Agency that administers Medicare, Medicaid etc) looks at the landscape and comes up with a carrot / stick rewards system to force Hospitals and practices to update their software. They generally do things like:
* Hey you need to store records electronically. If you do this by X, you will get Y$. If not, you will be penalized Z$ every year after X.
* Hey the system you built - It needs to actually be able to talk to other systems. If you do this by X.. you get the point.
* The data you're collecting in your system is stupid. We need X, Y and Z reports to ensure you're actually using the system as we meant for you to use the system. Do this by X.
Several other misc things I noticed:
The industry by itself is extremely complex with business requirements that vary between hospitals, practices, labs and so on. This makes connecting systems together a nightmare. Even when you manage to integrate systems, each hospital and practice has a set of business practices (forms they collect, the way they organize information etc) that make rolling software out very hard. Configurability is king. Making everything configurable and having configuration engineers set things up makes automated testing very hard at a UI level. This leads to some sharp corners and contributes to bugs and general UX clunkiness.
UX design isn't generally valued and suits / "business requirements" / timelines are prioritised over usable, stable, secure software. This is a typical UI: http://uxpajournal.org/wp-content/uploads/2014/07/smelcer3.g...
Standards are out of date and the only thing pushing innovation here is CMS doing its best. The problem with this is that they're a govt agency, so they're generally slow and they're an insurance company, so their primary motivation is to cut cost of care.
Doctors are generally smart, and you can sometimes get good feedback from them, but they're already overworked and can't really vocalize what they find frustrating about software.
I hate to generalize, but in my experience atleast, all other people (middle management, front-desk staff) are useless. By that I mean they just don't understand how software works.
There are some smart CIOs, but they care about their position and the hospital bottom-line, so trying to sell them something that doesn't exactly line up with the CMS carrot / stick model is basically impossible.
*Probably would need to be government as would need exceptions from tons of laws.
Read the comments and listen to the debates, and understand that it isn't going to get better until Americans believe that the availability of healthcare shouldn't be solely dependent on income, and that "freedom" around payment and insurance shouldn't be the primary value.
That being said, it's a difficult profession. Not a lot of people want to do it. Even fewer in such specialised positions as surgery, where mistakes literally cost people lives. There's no rolling back to a previous release or taking a break. Everything that happens, happen on that table with that body open.
Tack on the insane costs, at least in America, for going to school to be a doctor and you also have a situation where few people feel they can afford to be GPs (even though that might be what they really want to be; and the world needs more GPs desperately) and you also have doctors who are now locked into a profession to simply paid their debts.
> I just recently had a friend completely burn out of medicine, sell his house, and start traveling the world.
I don't think this is a bad thing. Everyone who can afford to should really save up and take a sabbatical every few years: http://khanism.org/perspective/minimalism/
Of course, I'm no expert in this stuff, this is just my hot take. I'm sure it's hugely more complicated.
I don't think a sabbatical is a bad thing at all. But this is more than that, and it's driven by burnout rather than a simple desire for refresh and reflection. That's what I think is negative here.
I recommend reading "When Breath Becomes Air". The author's friend (a general surgeon) has a patient die on the table. He goes into great emotional distress, eventually committing suicide.
Brilliant, good hearted people being pushed to self destruction. Not the way an industry should want to behave.
Cuba decided they wanted more physicians, so they invested in them to the point that they could use them as an export. If we have a shortage of doctors (which I think we do), the people with the power to change that either don't believe we have a shortage or have a vested interest in keeping a shortage.
It is, however, subject to stricter licensing/certification constraints which are mostly in the hands of the existing body of practitioners ...
Scalable work, where tools multiply worker effectiveness exponentially (tech, finance, manufacturing),
Non-scalable work, where tools multiply worker effectiveness linerarly/constant (everything else).
It is a little bit of a Taleb's world where exponentials live side by side normal distribution.
Scalable work is much more profitable than linear work. Where I work, being scaleable is a requirement. If it is not scaleable, we are not doing it.
This creates incentive to make everything scaleable. Which is a big problem for those whose work is inherently linear: teachers, doctors, waiters. They get put in optimization straightjackets for marginal improvement. And it sucks the soul of what they do. It makes world a less happy place, filled with 15min doctor appointments, restaurants where tables must be turned every 2 hours for profitability, etc.
The compound problem for doctors has been that they have to perform highly creative, high impact tasks while inside the optimization straighjacket. That's got to hurt.
Many medical specialities have concerns with depression and suicide. ER and ICU are among the two with which I have personal experience that face these issues quite acutely. If you have a loved one in one of those departments, the last thing you want to hear is that your physician may be dealing with depression and suicidal thoughts.
Personally, I don't think the advantages outweigh the disadvantages. I suspect removing the shift schedule nature of emergency medicine may have a remarkable improvement. Many ER nurses and clinics have already moved away from a rotating shift schedule, and I haven't heard of any serious repercussions. I really hope emergency physicians follow suit someday. Or, find an alternative model that doesn't incur such health issues.
Now, that doesn't seem to justify the fact that long hour shifts are placed so close together. It seems like you could give doctors a longer break in between shifts than they have. Residents have the worst of it. The attending actually do get a fair amount of time on/off. Residents already work a lot less than they did 50 years ago, some think that their training should be extended to cover the loss of density.
I hate when this gets brought up, because it inherently implies that we can't improve them. Everyone talks about increases in handoffs causing increases in medical errors. I think handoffs have a long way to go, and we need to better utilize technology to help in this (ie make better EMRs).
The overworked doctor is just as bad IMO. I've been there on solo 28 hour calls going on my 11th admission. In the morning I'm next to useless and my handoff to that team was less than stellar.
A couple thousand hours of flying, many of which can be paid work (like flying an add banner).
A few possible conclusions. I don't have enough knowledge to pick one. Some of my speculation might even be wrong.
(A) DOs and MDs filter through different or mostly different residency pipelines. Thus, residency limits for MDs don't affect DOs, so the DO population can grow more quickly.
(B) DOs and MDs do filter through mostly the same residency pipeline, and the increasing number of DO graduates is causing an increasing number of residency applicants to not be admitted to any residency program. (This malicious situation would be similar to the situation with law schools, which admit and graduate far more lawyers than the industry can possibly sustain and support in its current state.)
(C) There's enough non-government funding of residency slots that residencies are not as bottlenecked as the first answer claims. If so, this re-raises the question on whether MD admission is being rate-limited to increase scarcity and thus salaries.
(D) Perhaps something else I'm not thinking of.
Question: Why do we need the government to fund residents? The fact that every single going-to-be physician must do so through government funding boggles my mind.
On top of that, depending on the number of hours worked, many residents barely make minimum wage.
It's quite clear to me what needs to be done here. America needs to import medical professionals. They're out there, they're needed here.
Or at least, more practitioners. We don't need doctors with huge amounts of training to do every evaluation.
I think knowing a doctor, or someone becoming a doctor, has changed my perception of doctors entirely.
The scariest thing in med school is how vulnerable you are to someone with authority screwing over your entire future. Piss off an attending? Well, they could right a terrible letter for you that hurts your ability to match into the specialty you want. You could straight up witness mistreatment of a patient by a superior, report it, and have your entire future altered forever because of people above being petty or vindictive.
This is something I don't understand. I'm a medical student, and the amount of time I've seen wasted watching older physicians type notes is staggering. Just have them dictate the notes and hire a secretary. Perhaps for legal/liability reasons doctors need to write their own notes but it's just such a waste of time, and we pay a lot for it.
Do we really though? I'm assuming a doctor is a salaried position so the more busy work they get the more hours they work? Doesn't this mean their time becomes less valuable?
I used to work at a medical lab and there were transcriptionists, billing dept, a dept. for quality assurance of every report a doctor wrote, customer service, etc. Hospitals have all of that plus nurses (RNs, CNAs, etc.), physician assistants, and probably many others.
Part of the problem is how much paperwork/procedures/diagnostic reporting is legally mandated to be done by doctors. The other part is...money. Businesses want to/need to squeeze as much money out of the doctors and that requires seeing as many patients as possible.
Are you referring to:
> In the mean time, I field 12 phone calls from ED, GP and other units. … I get called four more times between midnight and 6am.
These are clinical calls: the other units need information about previous treatment, or clarification about current treatment, or updated instructions due to a change in conditions.
E.g.
> Ring, ring
> Hello, this is the Levi residence, Dr. Levi speaking
> Hello Dr, patient XXX's vitals have changed/is reporting discomfort, do you want to change treatment?
> Yes, administer X ccs of Drugaline and call back if their situation doesn't improve in 2 hours
> OK, thank you Dr
A tremendous amount of stuff that normally only doctors do can be done by a nurse practitioner, and since it's much easier to train them, (because they don't need as much schooling) there are far more of them.
Basically give them the "easy" stuff and reserve the harder stuff for the Dr. Or have a Dr. consulting for a team of nurse practitioners and they go to him with questions and summary.
A facility generating large numbers of fall investigations that don't lead to ongoing medical care seems like it would be pretty easy (potential) fraud to go after though.
However, medical expenses are top heavy. Some of those falls probably cost 200,000+$ because they cause long term medial issues. If a faculty is spending ~1,000+$ on an a median fall their average is going to be much higher than that. Which is a sign they really are providing unnecessary procedures.
Anyone who has participated in a root cause analysis at a hospital knows that.
Where all those hospital-acquired infections come from?
I've heard a few other similar stories from him as well. Doctors have immense political power; if hospitals are grinding them to dust, it's because doctors as a group are letting them (the good old 'seniors don't care that juniors are getting crushed' problem). From my own limited experience working with them as a neuro tech, doctors will close ranks quickly against outside forces, but plenty will sell each other out within the profession. For every haggard ED doctor, there's a specialist somewhere making cushy deals with the administration.
FWIW: I advocate single payer (Medicare for All), but not single (sole) provider.
and pharmacology, and physiology, and several years on the wards watching the meds go in, watching the pee go out (or not), seeing what happens to the patient, sorting through laundry lists of meds at admission and discharge, losing arguments with pharmacy about why that max-concentrate K-Phos is a bad idea considering the patient's CCr was 1.1 yesterday and now it's 1.4, etc, etc.
If you're a doctor who is "doing it for the money", you have simply not understood the concept of opportunity cost. :)
Congratulations to your partner (and you)! I for one still think its a noble and altruistic calling.
If you have to be a member of this, and that's government mandated, then them profiting from that arrangement is a blatant monopoly isn't it?
I actually attended the ICOSET conference for 2 days prior to the ACS and there was much discussion over it.
For example, compared to the US situation, where surgical training is run by the universities, surgical accreditation is done by the Board Examinations, and the ACS is essentially just a bit of a union/membership organisation (You can not pass your boards and practice surgery in the US although it cant be good for your insurance), RACS is both trainee selector and accreditor.
There is talk about accreditation being devolved (Macquarie University Hospital is apparently trying to do a course for Neurosurgery) and the Orthopaedics guys left the RACS a few years ago to start their own body (but with similar principles, ie they select trainees and accredit). The MUH model seems interesting but has it's own problems because rumour is they want to charge ~$150k to do their training course. So essentially we have the americanisation of our quaternary training, which I don't agree with.
It's hard to see a real way forward; and even if another organisation came around and said they were going to start training surgeons, they have a couple problems: getting surgeons to say that they are happy to be the Trainers for them and getting hospitals to allow that organisation to train them.
A similar problem exists with the RACGP and it's (my opinion) much better, more nimble and beneficial to the Australian Population Australian College of Rural and Remote Medicine. ACRRM has been steadily building up to become a formidable training force for GPs particularly in rural and remote australia wityh a focus on TRUE generalism, ie GPs that run scope lists, minor surgery, obstetrics and aesthetics. The RACGP has a firm focus on city GPs and City training despite a desperate need for ACRRM/rual generalists. RACGP this year has put the state governments over a barrel and said that trainees must now do X amount of time in a big city, and that rural training is not going to count for as much; with the result that current ACRRM trainees may not make cutoffs in terms of time worked in city practices and fail to achieve their final qualifications. So basically RACGP is making moves to push ACRRM out of the way by introducing changes that benefit it over ACRRM.
all terribly interesting/boring, depending on how much you care about petty politics :)
Much of the time, on their own dime.
They also generally work hard enough in high school to get excellent grades (do flight instructors check transcripts or just if the check clears?).
It's easy to imagine doing 250 hours over 3 or 4 years while doing something else most of the time.
Obviously they're pretty different career paths, but they're both effectively 'trades', in a more traditional sense, that require obscene amounts of training.
There's no law that says private hospitals can't fund residency slots - in fact they fund many of them - but, as the source you're commenting on says; "[medicare is] the principal source of residency funding".
I rather wish software engineering had a professional association with the lobbying power of the AMA.
Incompetence on a national scale.
That claim was never made by OP. Can we have a discussion without attacking a straw man, please? You yourself acknowledge you only know one side of equation. If the other components are larger it would not matter that you have shown one aspect - that nobody disputes, incl. OP! - to be negative.
https://news.northwestern.edu/stories/2016/02/longer-shifts-...
> A new [...] study [...] showed allowing surgical residents the flexibility to work longer hours in order to stay with their patients through the end of an operation or stabilize them during a critical event did not pose a greater risk to patients.
> “It’s counterintuitive to think it’s better for doctors to work longer hours,” said principal investigator Dr. Karl Bilimoria [...]. “But when doctors have to hand off their patients to other doctors at dangerous, inopportune times, that creates vulnerability to the loss of critical information, a break in the doctor-patient relationship and unsafe care.”
I have no doubt that overall the long hours are bad, I only respond because you attack a position OP didn't take. Also, the long hours may still be a logical conclusion and even beneficial - within the twisted logic of dysfunction in the larger system: "For evil to triumph, all that is required is for good men to respond rationally to incentives."
> Also, on what basis do you say that longer hours with fewer tradeoffs don't improve patient outcomes? You frame it as though it's obvious but is there any evidence to back that up? My wife and most other doctors I know all claim they'd rather have longer hours with fewer handoffs.
I responded with evidence.
And yeah, I've seen the FIRST study. The control group, in this case, is working a 16 hour shift. Even if they only need one hour on either side of that shift to go from asleep to work and then back to asleep (which is not what I have seen), that control group is maxing out at 6 hours of sleep, well below the level where all but a tiny percentage of the population starts to see serious performance declines. https://hbr.org/2015/08/the-research-is-clear-long-hours-bac.... A more useful study would look at residents who are actually well-rested - who have gotten the consistently required eight plus hours of sleep over a significant enough period of time to have eradicated their existing sleep debt - and then compare their performance going forward while they continue to get enough sleep to residents working 16 or 28 hour shifts.
> The idea that doctors ... are somehow immune to those effects defies logic.
That claim was never made by OP.
It doesn't matter that you responded with "evidence" to a claim you yourself made-up. Just stick to the topic and don't invent stuff.
https://www.medicare.gov/hospitalcompare/readmission-reducti...
In general, Medicare pays a certain amount of money for a patient with a specific diagnosis. So if 70-year old woman X is admitted with condition Y, the hospital will receive $Z for treating her -- no matter what it costs. Hospitals don't love that since having patients in beds is expensive, so they would often times discharge patients before it was medically appropriate. They would take $Z and then when the patient came back in a few days, they could bill for follow-up services.
With the ACA we started tracking hospital readmissions to see how big of a problem that really was, and if hospitals underperformed their peers (aka they saw a lot of readmissions indicating that patients were discharged too early), they would either not pay for the followup visits or just lower the overall reimbursement for future patients.
Another good example was the Hospital-Acquired Condition reduction program. There is an enormous amount of cost associated with hosptial-acquired infections and the US was particularly bad in terms of modern systems. If patients in your hospital are consistently catching bugs, Medicare will dramatically reduce your reimbursement rate.
http://www.beckershospitalreview.com/quality/769-hospitals-s...
Since the 1990s though, Docs have been working with P4P -- whether it's increased reimbursement from insurance companies for prescribing an appropriate ratio of generics vs. brand name medicines, to the lump-sum payment per patient, to bonuses for hospitals adhering to best-practices (what % of patients with chest pain get an aspirin with 30 minutes or what % are cath'ed within 90 minutes of presenting).
(1) The supply of doctors (and other health professionals) is restricted by licensing, not driven by the demand for their services.
(2) The price of health care is not determined by supply and demand, but by various regulatory arrangements and bulk agreements which often do not involve either the producers (doctors, hospitals, etc.) or the consumers (patients) of the services. So the parties who are determining the prices are the ones with the least possible stake in the outcome.
(3) The consumers of health care, patients, are almost always unaware of the cost of the services they are getting, so they have no way of knowing whether those services are worth more than they cost, and hence no way of signaling where health care is being inefficiently provided.
(4) What the US healthcare system calls "health insurance" is actually a combination of insurance and prepaid health care. Insurance is supposed to be for unforeseen costly events, but most health care does not consist of unforeseen costly events but of predictable expenses (annual physicals, shots) and unforeseen not very costly events (you go to the doctor with the flu, get an exam, and are told to rest and drink lots of fluids).
(5) Prescription drugs are regulated by a regime (the FDA) that is heavily penalized if an approved drug has any bad effects whatsoever, but suffers no penalty whatsoever for keeping helpful drugs off the market for years while they undergo "testing" and hence depriving large numbers of people of their benefits.
I'm sure there are more, but those are just the ones I came up with off the top of my head.
I myself would prefer the one time cure, and would be willing to pay for it.
In a perfectly free market, my demand for the one time cure would be represented by market forces.
Now ask yourself, what is it about the healthcare market, that PREVENTS my market demand for a one time cure, as a consumer, from effecting the market?
It's not just hard work to become a doctor. It's hard work and sustained excellence. You don't just put in the hours, you have consume an enormous amount of information and are tested on it constantly through the education process. You have to take on enormous personal risk financially in loans. You very frequently have to make large personal sacrifice in your life to get to the point of board certification.
Some get paid great, most get paid well, but if you know more than a few doctors you would probably be less glib. /me not a doctor.
Why can't this be automated?
Before we had kids, my wife's shift schedule wasn't too bad. I owned my own business and could take time off when she was free during weekdays.
Now that we have kids, the shift schedule is tougher on her. Kids don't work on a shift schedule, and when they make demands of her time and I'm unable to help, she ends up sacrificing her sleep. That happens often enough that it makes any jokes about startup founders being sleep deprived, well, a joke.
Somehow, she's able to rally herself and get enough energy to work through a string of night shifts, even after having to take the toddler to the pediatrician during the day if I wasn't able to.
My wife also moonlights at another hospital (something she did back when I was getting my startup going and we needed the extra income). She continues to do this because she enjoys the work there (it's higher acuity).
That's just our personal experience. Colleagues of hers have solved this by hiring help (au pairs, nannies, etc), which we intend to do soon.
She's told me stories about some of her colleagues that don't have kids and have their own share of difficulties. One of them recently dealt with a particular tough case where a 3yo died. There's a culture in the ED where you don't take time off unless you're truly dying. Got the sniffles? Suck it up and come to work. Dealing with a traumatic experience and can't sleep because you've been crying all night? Suck it up and come to work. Hopefully that colleague finds a way to cope, because it's kind of frightening to me, as an outsider, to think of my ED doctor being that person.
I can only speak to the ED specialty. I'm clueless about other medical specialities and any potential health issues around them.
I'm only a med student right now, but I have spent a year rotating through all of the most common specialties. I have to say that the culture you describe isn't unique to the ED. I've seen it throughout the hospital. Taking time off isn't easy in any specialty. I've found this to be especially true in the niche subspecialties (especially surgical subspecialties). I work with a colorectal surgeon who is the only colorectal surgeon at her particular hospital. She's responsible for all of the patients she's ever treated and any emergencies that may need a colorectal surgeon. It's nearly impossible for her to ever take time off or even leave the city for more than a few days. An advantage that I see for ED physicians is that they're not directly tied to patients. Any ED physician can fill in for another when the need arises. I can't speak to whether that actually happens, but theoretically it's possible in the ED.
I heard the story of a good neurosurgeon who, one day, made a serious mistake during a surgery and paralyzed his patient. It haunted him so much that he eventually took his own life, after he dealt with the malpractice lawsuit.
I have 250k in debt from undergrad+medical school, almost all of it loaned to me by the department of education. If I saw some international position open that was high paying and I could just desert my debt and the US, would that be right? I don't think so, that seems like a morally bankrupt thing to do.
Keep in mind that medical software isn't written with the latest and greatest frameworks and UX designers.
(1) Pages v and 14: http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Re...
There's 31,757 positions offered. However, if you are applying into a specialty, you apply simultaneously for a PGY1 and PGY2 position, so those people are being double counted.
As a result, you need to subtract 2,677 advanced positions from the 31k positions, yielding 29,080 PGY1 + PGY2. There are 18,539 US MD applicants, but with the merger of the ACGME and COCA, DO applicants must be counted, adding 3,590 to the US graduate pile. That gives 22,129 US graduates competing for 29,080 spots. Yeah we take a lot of "foreigners" but a lot of them are actually American citizens who went to school in other countries and many of whom have US medical education debt, 5,069 in fact (look on page 1, "IMGs"). If you add in the IMGs, that's 27198 US graduates and US citizens applying for 29,080 spots. Only space for about 2000 Foreign Medical Grads.
[1] - There are 5346 osteopathic graduates per year. http://www.osteopathic.org/inside-aoa/about/aoa-annual-stati...
See this to understand why the bottleneck is residency positions, not how many US medical students there are: https://www.nytimes.com/2014/07/20/opinion/sunday/bottleneck...
Dr. Emory Brown's work out if U Mass in anesthesia is a data point for this. He claims to have a working general anesthesia machine. From the talks and data of his I have seen, it really does work. Yes, it's not good for a pediatric car accident victims, but for tonsillectomies or proctology exams, you know 'routine' general anesthesia, the thing works great. He says that he uses it in his own surgery suite with better 'results' than a human can obtain.
Yeah, it's 10 years out, maybe 20. But this trend of replacing doctors with robots (and getting better outcomes) is not going away. So, that there is a current bottleneck may be true, but in the near future, we just won't need doctors for a lot of areas of medicine.
Control of consciousness is only one part of the intervention. Much of it is physical intervention with intravenous cannulation, intubation, extubation, ventilation management, and management of cardiovascular dynamics. Closed loop systems for sedation/unconsciousness may make inroads in the next 10 years but general anaesthesia will require physically capable robots.
Doing this everyday and knowing technology and robots the capabilities are a long way away.
Most health issues are not emergencies. I as a consumer would be perfectly happy to shop around the market, and find the best deal on healthcare, if my efforts were rewards.
Unfortunately, prices are not transparent, and the costs are not payed directly by me. They are paid by my insurance provider, so why would I bother trying to reduce my bill by thousands of dollars, if someone else is paying for it anyway?
I've heard that people with high-deductible plans are now finding it advantageous to just say they are self-pay to get the discounts.
For comparison shopping, healthcarebluebook.com can give an average price for a certain procedure in your area.
Also food is cheap and plentiful to create.
And most importantly, food is easy to steal; the one important factor in a functioning free market libertarians tend to forget about is the natural control at the bottom, for the poor: if the poor need something in order to survive and can't afford it, they act as a check on greed and neoliberalism run amok by ignoring the fake magic pieces of paper that the wealthy wave around as tokens of power and take what they need.
It's a lot harder to steal health care so there's no incentive for the rich to modify the system to help the poor like there is with food.
Yes, and this is a bug, not a feature. Food would be cheaper if this were not done. The "subsidies" are to the food producers, to artifically keep prices up. The equivalent for health care would be subsidies to health care providers.
> and food for the poor
Yes, with food stamps. But nobody tells the poor what they have to spend the food stamps on, and nobody regulates grocery stores up one side and down the other telling them what food items they have to provide if they accept food stamps and what they have to charge for every single item. So this regulation is nothing at all like US health care regulation.
The equivalent of food stamps for health care would be to give poor people a flat sum of money per month on a "health care spending card" that they could use at any health care provider they wanted, for any service they wanted. And then no other regulation of health care providers--no rules about what services they have to provide, no regulation of prices, etc. I personally think this would be a significant improvement over the current US system.
> food is cheap and plentiful to create
Yes, and it would be cheaper if the government did not subsidize producers, as above. The reason for this is, of course, that there is a free market in food (or at least much closer to one than the market in health care) and so producers are competing on price, therefore driving them to make food production more and more efficient. A century ago in the US, food was not cheap and plentiful to create. Technology and production processes improve over time if they are forced to by competition. I see no reason why the same would not apply to health care, if it were competitive the way food production is.
> food is easy to steal
This is an interesting point, but I'm not sure how much difference it makes in itself, because even the richest person in the world can only consume a limited quantity of food. So it makes no difference to rich people whether the poor can steal food or not; even if they do, the rich won't be the one to suffer, someone much further down the income ladder will (if anyone does).
A more interesting aspect is this:
> It's a lot harder to steal health care
I would rephrase this as: health care is much less fungible than food is. You and I can trade lunches, but we can't trade, say, gallbladder operations or physical exams. I agree that this is potentially a valid reason to treat health care different from food. What might be helpful is to look at other goods or services that are not fungible and see how they are handled in comparison with health care.
Also once "the system" has its claws in you, you can't leave in practice even if its theoretically legally possible. My MiL goes in with stomach upset vomiting urgent care, next thing you know she's getting admitted something to do with gallbladder removal. In theory she legally could have vomited her way out of the hospital with an IV attached into the parking lot to another, cheaper hospital to have her gallbladder removed (or whatever it was) but in practice this isn't happening.
Emergency care, yes, that's unpredictable, and that's the sort of thing that health insurance should cover.
End of life care is not always unpredictable. In fact it rarely is in terms of the general need. Yes, you can't predict the exact point in time at which an 80-year-old person, say, will have an event that makes them require assisted living or a nursing home, but you can certainly foresee well in advance that such a need will arise at some point around that age. So this is not an unexpected need in the sense that emergency care is. And there's no reason why the same health plan should have to cover both needs, yet that is what the US health system does.
> you can't leave in practice even if its theoretically legally possible
Yes, this example of yours is an case of an unexpected need that health insurance should cover. However, I don't know of any "health insurance" in the US that only covers cases of unexpected need like this, and does not also cover everything else that is in any way involved with health care.
It doesn't read, "You saw 100 patients at $100/patient, here's $10,000."
It's more like, "You saw 100 patients, here's your per-patient fee of $50. You prescribed 87% generic medicines, which for a doctor with your patient population in your area underperforms by 2 percentage points, this equates to a $1,400 bonus -- if you prescribed 91% generics, this bonus would be $2,500. Only one of your patients required an off-formulary medcine, your bonus here is $500."
There are a lot of competing interests right now, the formerly independent doctor groups are all merging together, insurance companies are merging, hospitals are merging. There's also a big push for risk-based reimbursement:
http://www.mckesson.com/bps/blog/riding-the-shifting-landsca...
https://www.nrmp.org/wp-content/uploads/2016/09/Charting-Out...
IMGs have the advantage of speaking English and have no potential visa issues.
This distinction will matter more and more as the race for residency spots tightens and the US becomes more insular, because a lot of IMGs have US educational debt. It also matters where the person went to medical school, e.g. US citizen who went to Israeli medical school vs someone who went to the Caribbean vs an Indian national vs an Iranian national who now will have visa issues with trump. Visa issues are huge, because no one wants to match someone who can't show up for work 2 months later.
These subtle distinctions are not easily sussed out by NRMP data, but the trend is that in the current era, IMGs have a slight advantage.
The reality is the unified vocational training and the court system and malpractice insurance system and fluidity of employee transfers and government licensing standards mean the variety in care available is more like the difference between McDonalds and Burger King and this aspect is extremely carefully avoided in the debates. Price competition simply will not happen in medical care, theres a lot more required to initiate it than merely messing with the insurance system, it goes very deep.
I think you miss the difficulty of walking out in mid treatment. Yes sure in theory its possible for people to get reservations at three restaurants and eat appetizers and drinks at one, the main meal at the second, and desert at the third. In practice roughly zero people do this even though in the restaurant marketplace they're hopefully not in pain or dying or semi-senile or some other medical distress, and their family isn't panicking. To get the restaurant marketplace analogy correct above, you'd have to use McDonalds, Burger King, and Wendys as your examples, so even if you wandered back and forth between restaurants, the bill would be about the same in the end if not higher on a system perspective from all the paperwork and increased transactional costs. The main, possibly only, effect of playing patient "hot potatoe" would be increasing suffering of sick people.
In other words, regulations, mostly from the government, prevents competition from resulting in variety. I propose to fix it by less regulation--letting more of the benefits of competition be realized. You propose to fix that--how, exactly? With more regulation?
> Price competition simply will not happen in medical care
In the current regulatory regime, you are correct, it won't, because there is no incentive for it. But that's not because price competition is inherently impossible in health care? Or is it because the regulations are removing the incentives for it?
> I think you miss the difficulty of walking out in mid treatment.
I agree that it's hard to change providers in mid treatment when it's urgent, yes. But urgent care is not the only opportunity you have to evaluate providers. In a competitive environment, smart providers would view ordinary care like annual physicals or shots as opportunities to show potential patients their competence, and smart patients would take such opportunities to evaluate the competence of providers. Plus, families and friends can pool information--people do that now. The value of such information is limited now because there is not much choice in the marketplace, yes (hence your McDonalds vs. Burger King analogy). But, once more, why is there such limited choice? Because competition is inherently impossible in this domain? Or because it's regulated out of existence?
Food is heavily regulated, including the food bought by stamps. The government decides what can be purchased by the stamps, and every item of food sold in any store across the country is approved for safety and health. Without these regulations we would have massive constant food related deaths as producers compete on price and compromise safety to the detriment and possibly death of any customer who cannot afford the high quality "market regulated" product which is exactly what has happened in every unregulated industry in the history of the world. And for higher end products: the calculus of a PR cover up operation and possible civil suit vs. actually safely creating food is done by companies, and currently federal regulators weigh in on the side of 'you had better make this safe or else'. You are proposing pushing the balance here towards "well, if we can save a buck, screw it, we can tie the victims up in court until they go bankrupt and die anyway or blame it on the supply chain and promise we will do better" which makes safety much less important.
A health care spending card is perhaps a natural suggestion but is made all the more insidious because it is so. It is, in reality, an atrocious and murderous idea; the entire crux of health care is not only that it is essential to living and therefore has an infinite price and that quality is almost impossible for consumers to accurately assess but that needs for different people are drastically different, usually for reasons that have very little to do with their choices or desires, which is why it is generally taken care of by insurance while people do not buy "food insurance". Health care spending cards (or HSAs) are essentially a euphemism for condemning any poor person who gets sick to death.
And of course it makes a difference whether poor people can steal the food. Remember that unfettered free market capitalism is the system where a rich man's dog eats 5 course gourmet meals while his poor neighbor's child dies of hunger. Putting something necessary for survival behind an arbitrary chalked in line and saying "sorry, you don't get to have that because you weren't born rich and the neoliberal market economy has transitioned and has no room for your skillset, enjoy your one free death, maybe when you are reincarnated your father will be named Koch" is a very fast way to start riots and anarchy. The only reason the rich are rich is because the poor believe they are and act accordingly, we call this belief structure market society and government; shattering that necessary illusion will likely hurt everyone, but it most definitely hurts the rich. The point is that if food is available but inaccessible to the poor the free market and governmental structure in place will cease to exist -- the market and government have evolved in a very careful way to prevent this from happening.
I'm sorry, but I don't buy this assertion of yours, and since we disagree on something so fundamental we're unlikely to be able to have a useful discussion.
> which is exactly what has happened in every unregulated industry in the history of the world.
This is an extremely strong claim which requires extremely strong evidence. Do you have any?
> the entire crux of health care is not only that it is essential to living and therefore has an infinite price
By this logic any action which carries any risk of reducing your life span and is not absolutely necessary should not be done. Do you live your life that way? Does anyone?
> unfettered free market capitalism is the system where a rich man's dog eats 5 course gourmet meals while his poor neighbor's child dies of hunger
This certainly happens in systems that are regulated by governments--such as ours. Where is your evidence that it happens, and is worse, in systems that are not regulated by governments?
> if food is available but inaccessible to the poor
In a free market, what would prevent the poor from producing their own food? In the US, historically, this is how most people got their food--they grew it or hunted it or fished for it themselves. Or they lived in small communities where everyone knew each other personally, so they knew the people producing their food. Our current system, in which almost all of us are dependent on a small number of food producers whom we don't know and cannot influence on our own, is, as you appear to agree, a product of massive government regulation--combined, as you conveniently forgot to state, with massive regulatory capture on the part of the corporations that own most of the food production capacity.
Yes, the government inspects food to see that it doesn't contain harmful microbes--but people knew how to do that before the government got into the act (if not, humans would have gone extinct long ago from food poisoning). The government also subsidizes the production of high fructose corn syrup and factory farmed meat and poultry. It subsidizes wheat and corn so that most of the US's acreage goes to those crops instead of a greater and healthier variety. (And then it subsidizes ethanol from corn so that we can burn food in our cars while poor people starve.) I could go on and on. Why does the government do all these things? Because it has the power to do it, and that power can be bought, and has been.
Of course this system, now that it exists and we are all caught in it, is by no means simple to escape from. But that does not mean it was inevitable, nor that it is good.
I'm actively against the "bowel run" mentality. I do my best to avoid even the CYA test ordering, though I'm not in the ED where this can be the most rife. I see first hand the "ponzi scheme" (though IMO it is not the correct term) of the system and I chose to go into primary care because I actively want to fix this in any way I can, and being a specialist was not the way I thought would be best to do this.
Medicaid does.
Medicaid is the payer of last resort for nursing care though, not Medicare (which doesn't really cover long term care).
Capital gains costs bases are currently "stepped up" during the estate transfer. No need to pay anything to lawyers. If your estate is below $10.5M (or thereabouts, I forget what the exact number is since it's now inflation adjusted), you won't be liable for any of that capital gains, nor will you owe any estate tax since you're within the exemption.
Despite this, do read "House of God" --- it's a terrifying and eye-opening book!
In the past, transferring assets to such a trust entailed gift tax, but since the estate tax and lifetime gift tax exemption are now bundled together, you can basically "use" the estate tax exemption to fund this irrevocable trust "for free". As a result your personal assets plummet, you name your heirt the beneficiaries of the irrevocable trust, and you (the parent) can take advantage of medicare fully as you describe.
The drawback to this strategy is that you do lose real flexibility in controlling your assets. Also, the legality of this widespread practice is definitely in a gray zone and carries future legal risk. Transferring a significant portion of one's assets to such a complex instrument is definitely not advised.
