More Doctors Giving Up Private Practices
nytimes.com
nytimes.com
If more doctors could open practices, there'd be more choice for consumers.
I mean really, why do we even let the AMA -- doctors themselves -- artificially limit the supply of doctors? Of course they are going to keep the numbers low. 11,000 (the last number I found) new doctors every year is simply NOT enough. It may be a little bit higher, but last I researched, for years it was 10,000 and only after a lot of controversy did they increase it to 11,000.
The system is designed to force doctors into debt so they have to be money focused and charge a lot and keep rates high for all the other doctors. The doctors, many of whom are my long time friends, are not happy with the system. They want more freedom. They feel like slaves to debt. One good friend left grad school with over $250,000 in debt! It takes a long time to pay that off. She can't take on more debt to open a private practice, nor would she have the experience really -- she's forced into the big hospital system that she knows is flawed, but she's powerless to change it because the huge medical institutions call the shots, not the doctors. We think doctors are invincible and make tons of money, but if they lose their jobs -- it's a horrible experience, because it'll be very difficult for them to find another job -- doctors talk and bankruptcy doesn't clear student loan debt, so even that isn't an option.
Add to that, the fact that individuals aren't even allowed to care for their own medical well being and you have a system that is way unfairly balanced toward doctors and away from patients. Not even the doctors really, the hospitals.
Why, in the "leader of the free world" are individuals not free to care for themselves? Prescribe their own medications? Order their own labs and CAT scans and the like?
Why do we give the AMA so much power? Why don't patients have any over their own lives?
I suppose patients do have some power -- over the doctors. There are doctors out there who send patients with viruses out with antibiotics because the patient wants something. They prescribe drugs from tv commercials because the patient wants something. Why do we let them do this? There should be laws against prescribing antibiotics for people who don't have bacterial infections. I know that and I'm not a doctor, but doctors still do it.
There's really something wrong with our system. It's completely irrational. There's simply too much money in it and people go crazy.
Not really. If you increase the requirements for entering a profession and limit the supply then you can increase you earning potential by a lot. That trick is highly rational and it works great, just not for you. Because it's not meant to work for you. Monopolies are not put in place for your benefit.
> There's simply too much money in it and people go crazy.
I think the violent regulation is more of a problem than that.
Uh... Dude, I would never prescribe my own medication. Unless you yourself are a pharmacist or physician it would be insane. Best case you get better (long shot), more likely placebo/neutral, worst case suicide. The best you yourself can do regarding self prescribed meds is whatever you can get over the counter at CVS. Also, according to my MD brother, half the reason we are in the predicament we are in is what is known as "defensive medicine" which he describes as performing unnecessary tests, "CT scans and the like", on the 1% chance that it might be helpful - specifically to curtail any potential malpractice.
Face it, there is a reason people can not self prescribe, self order tests or conduct their own operations. Although you would like to blame the AMA (and I do fault them for the lackluster MD minting volume), by and large non healthcare professionals don't know what the hell they are doing/talking about.
There are lots of conditions where it is easy for the individual to maintain their own medications.
If you would never prescribe your own medications, that's fine, you can continue to go see a doctor. For those of us who are educated, inclined, and motivated enough to care for our own bodies, we should have the right to do so. I have the right to life, liberty, and the pursuit of happiness, except that I am required, by law, to go to someone else to make sure I have the life part.
I can build my own house too. I can change my own oil and fix my plumbing, but that doesn't mean everyone has to do those things. They can still buy existing homes, take their car to the shop, or call a plumber.
Imagine if the law required you to call a plumber or take your car to the dealer to have it serviced.
It's my body and my life. I accept the responsibility for it and for knowing how much of which medications I need to take and when.
Doctors know a lot, but all doctors don't know everything about every medical condition. With chronic illnesses, sometimes the patient actually knows more than the doctor. Have you ever watched that show on TV about medical conditions people have for years and years? They go see doctor after doctor and they never get a diagnosis and they have problem after compounding problem.
Until one day, they go to the internet and do some research and figure out what they have, print out the papers, go to a new doctor and show them what they have and then, finally they get the treatments they need. I argue, that person should just be able to order the treatments they need without having to go to a doctor at all. Forcing people to go to a doctor, or multiple doctors, who don't know what is going on and who don't care enough to research the condition can make people sicker or at least not better.
I can sort of buy an argument for NP or MD prescribing initial medication, but cheap testing should allow followup care to be much better and cheaper (send a complete blood panel, urinalysis, and basic info to the doctor over the internet every week, from home, etc.)
The current "doc in a box" style clinic (largely to get around prescribing requirements) is doing more to provide affordable access to health care than anything in the new health care bill.
Chronic diseases account for 75% of the healthcare costs.
A big fight is going to start between physicians and "doc in a box" clinics in the future.
In many states (California is one) you can by certain brands of insulin OTC. The limitation is more a decision of the manufacturer than it is codified into law. Pharmaceutical companies are well known for milking their patents as long as they can and then lobbying hard for OTC status as soon as the end date on their patent is coming up. This gives them the opportunity to continue to push their brand and squashes any competitors who are still behind the counter.
You need look no further than allergy medications for an example. Claritin and Allegra were the biggest brand names in prescription allergy medications just a few years ago. But as Claritin's patent protection period was ending, its makers pushed hard to go OTC. And they did. The result is that Claritin dominates the OTC allergy medication category while Allegra is no longer covered by insurance plans because an OTC alternative is available. It's easy to guess what this did to Allegra's market share.
> There are lots of conditions where it is easy for the individual to maintain their own medications
Maintain is the key word here. OTC availability is only half the story. Your comment makes the assumption that someone knows that they're developing some sort of condition, say diabetes, in the same way they know they're coming down with a cold. How do you know you're becoming diabetic without a doctor's examination and follow up? Are you just going to know think one day that "Hey, maybe I'll google why I feel tired all the time and have been bruising easily lately..."
I know that the medical system is under a lot of fire these days and it's everyone's favorite axe to grind, but some good reasons that prescription control is necessary is to (1) control easily abused substances (this means narcotics as well as antibiotics, though the litigious culture here in the US is quickly rendering traditional antibiotics useless) and, probably most importantly, (2) maintain communication with your healthcare provider. Doctors use prescriptions in order to monitor your compliance and require (at minimum) annual visits so they can check up on you, even if it is only for 5 or 10 minutes. Maybe that decrease in energy is a side effect, or even that occasional but not cold related cough. Your doctor will recognize this and will be able to suggest changes. You probably had no idea a cough was a related side effect. Even if you did, did you keep up on any of the literature for the class of drugs you're taking in the past year? I doubt it. You have better things to do with your time.
> Doctors know a lot, but all doctors don't know everything about every medical condition.
You're right about that. But that's why we have a system of specialists. Even a less than average doctor will refer you up and down that chain until you're dead, out of money, fixed, or have found a way to live with it. It's like throwing a reverse exception where it gets passed from the most general to the most specific handler. Or a search tree where the root is the most general case and the leaf nodes the most specific. Of course it could be more efficient: science could be more advanced, doctors could be smarter, insurance companies more willing to pay, and patients less litigious. But the way doctors handle medical cases has evolved this way because it can solve the most common cases the fastest. And the rare cases, the exceptions? Well, they're rare and the exceptions.
The reason you see so many cases of patients out diagnosing doctors on TV is exactly because they're the rare, man-bites-dog kind of story. How many lottery losers do you see on the nightly news? Safely landing planes? How about stories about cars not piling up in bad weather? My advice to you (though you don't want it) is to stop watching TV. Or at least, stop watching TV and then using what little information is conveyed to make generalizations about the world and how society should be run.
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What became obvious to me from reading your comments is that you don't know what you don't know and that you assume that what you don't know is trivial. There is an unprecedented wealth of information at our fingertips. That's a cliche. But no number of articles read on Wikipedia, no number of Google searches, or stays at a Holiday Inn Express can replace the actual practice of medicine.
I don't think it would necessarily be the case that a smart person with access to a good library couldn't do a better job self-diagnosing for a wide variety of routine conditions, especially since they would be willing to put in more research than the average doctor does. We're not talking about performing your own heart surgery, but more like the 80%+ of cases where the correct thing to do is a relatively routine decision that depends more on diligence in research and being informed about current best practices, than on any specialized skill. There are computer programs that can outperform the average physician in many areas (though not necessarily the top doctors; but you aren't likely seeing the top doctors, either). The self-diagnoser also has one key advantage, in that they are (presumably) only interested in their own well-being, not in defensive medicine and fear of malpractice suits.
Of course, it does require being a relatively level-headed person who knows how to read the relevant literature. Excitable folks, people who have never read an academic-sounding paper, and hypochondriacs are probably all better off not self-diagnosing.
Routine conditions are a case where self-diagnosing will yield adequate results most of the time. But outside of the most common conditions, a smart but not medically trained person will end up treating symptoms rather than causes. A good example is blood pressure. You can walk into any pharmacy and find out within a minute if you have high blood pressure. For 80% of cases, you could probably just look up the most popular generic medication, start at a low dose and adjust a month at time until your blood pressure is normal. But what about the underlying cause? It could be an endocrine system problem, enlarged heart, arterial narrowing of the blood vessels from the kidneys, or ion channel exchange imbalances, to name a few. It is routine for a general practitioner to check for these and other causes and interpret the results of their tests, but is decidedly not routine for most smart people.
So collaborating with your doctor seems like a better path(especially since he has access to various tests).
It's really easy to say "just order my own tests" but the reality is that it would be pointless for most people except... trained medical staff!
This is only an argument for requiring prescriptions for narcotics and possibly viagra. This argument is completely invalid for any drug which isn't fun to use, such as birth control, amebiasis pills, anti-fungals, etc.
(2) maintain communication with your healthcare provider.
This argument is completely invalid for any drug which doesn't require long term uses (e.g., anti-inflammatories, amebiasis pills).
Many other countries allow many drugs to be safely given out OTC with no adverse side effects. The only reason for maintaining our current system is to preserve the privileged status of doctors and regulators.
As others, and I, have said in other comments, prescriptions are not required in all countries and people aren't rushing to the pharmacies to OD on viagra. I don't know why the argument that we need to protect patients from themselves is so popular, because it simply isn't true and that has been proven practically in many countries around the world. I don't know if you know this, but the law requiring prescriptions was only created in the 50's and it was created because of a couple of people making some mistakes and hurting themselves and that case was used to justify the huge, sweeping law that we have today. In effect, a tiny outlier was used to justify massive change to the general population, which didn't have the problem.
Lots of people continue to die from misusing OTCs, everything from Tylenol to Lidocaine to Aspirin, yet we don't put those back behind the counter. Parents kill their own children by giving them aspirin when they have a virus, here's info on that: http://en.wikipedia.org/wiki/Reye%27s_syndrome If your child has a cold, don't give them Aspirin!
People actually do care about their lives and their health. Yes, there are some that are going to abuse drugs, but requiring prescriptions for them doesn't stop that abuse. People don't stop abusing cocaine, marijuana and heroine even though you can't even get them with a prescription (outside some progressive states anyway). Many argue marijuana is still illegal to protect pharmas, but I don't know. Anyway, it's moot, because I don't care if people abuse drugs. No one seems to care that people abuse money or sex or food and those cause lots of problems for entire societies -- much more damaging than someone popping some pills and going to a rave -- which actually may be good for society.
For the record, I don't watch that much tv, but that's beside the point.
The point is, the individual should be sovereign over the self. No one else should tell me what I can and can't do to maintain my own life and no one should be able to force me to give someone else my money in order to maintain it. If I want to continue living, I should be allowed to obtain the drugs I need to do that as long as I'm not hurting someone else.
For over 15 years I've been a victim of this issue, I've studied this issue, and I've traveled to other countries where this isn't an issue. All the arguments I've ever seen supporting the status quo in the U.S. simply aren't valid. The claims that are made to support it have been tested in other countries and the facts contradict them.
Also, what's with the trend lately of people telling me they know more about what I know than I know? You don't know what I do and do not know. Seriously, you need to stop being so arrogant. It just may be that I know a lot more about this topic than you do. One thing is clear to me: I don't need your advice.
Final point, practice does make perfect, but you could say the same thing about computer programming: No amount of wiki or google will replace the actual practice of computer programming, but for people who have chronic illnesses or well known conditions, they have years, sometimes decades of practice managing their illnesses and that could, in fact, be longer than many doctors have had practicing medicine on their condition, which supports my argument.
And what about right of the human being to own necessary emergency supply of medicine? I'm not even talking about equilibristics you would have to perform to stock pile Relenza or Tamiflu in US.
There are many nations which don't have our overly restrictive systems. Iran and India sell birth control in stores, India and Egypt sell amebiasis pills, etc. As far as I know, they don't have an epidemic of people dying from self prescribed medicine.
Yes, it's shocking: Iran has more medical freedom than we do.
It's interesting to me that by combining the health care industry, doctors are also becoming assembly line workers.
Go to the second floor for heart, third floor for feet, etc...
I have not decided if I like this or not.
People have been saying that for sixty years. It's less true than ever, at least for good programmers, as more and more of the accidental (in Fred Brook's sense of the term) gets automated away, leaving ever-more-refined essential behind.
If you really want to make me laugh, why don't you go design the language+framework+environment that will complete the task of making programming assembly line work. You can call it "5GL". (Google it.)
I would expect doctoring to go the same route over the next 30 years. More routine may be shoved onto checklists and perhaps even robots, but that will just make the non-routine something that becomes an even larger part of a given doctor's time.
Although we may end up having more technicians and fewer doctors. Arguably computer programming has gone this way too.
Imagine the furniture artisans from the 1800's looking at the quality of furniture sold in the stores today... shoddy materials, weak joints, poor finishing. It's almost the same today in software -- or at least the trend is in that direction.
You can still get quality furniture today with solid wood, great finishes, and sturdy construction, but you have to pay 10x or 20x the price of something from IKEA. Same is true of software. So you could say it is less true for "good" programmers, but it's also less true for good furniture makers. If it is true that abundance creates scarcity, the abundance of bad software and programmers has created a scarcity of good software and programmers, just like every other industry.
Besides, saying it isn't true for good programmers is a like the No True Scotsman fallacy. What is a good programmer? Is a good programmer someone for whom it isn't true? Can you quantify what it is that makes a good programmer? Can software users tell the difference? I don't think they can.
No, because I can point to the people I'm referring to. In 1960, we did not have a lot of dedicated QA staff, dedicated sysadmins and IT, dedicated server farms, and so on and so on. Programmers have grown up auxiliary support personnel around them. The same has been true of doctors for a long time ("nurses") and will be more true, but the core doctors will actually be dealing with less and less of the routine.
The problem with your "software is getting crappier like furniture" theses is that it's flat-out wrong. If software was today as crappy as it was in 1980, the Internet would not work. We can't have the same bug-count-per-feature we had back then, we've got a crapload more features for bugs to be in! What is true is that we've got frameworks and libraries of a quality the programmers of the 1980s could only dream of, and a programmer can take these and trade technical quality for speed of development, and while the result can still be quite messy it is simply an option that didn't exist in 1980. On the whole though, software is radically better now than it was then; the alternative is not even technically feasible, it wouldn't even begin to work.
Seriously, if you think I'm on crack, go back and find the oldest source code you can. What you remember as a shining example of bug-free code will be revealed to be code that by modern standards is barely holding together and fails to exhibit bugs only because the task it takes on is so small there's hardly any room to trick it into doing something wrong. Not a viable path going forward.
Also, I just built my kitchen out of IKEA. If anything IKEA kitchens are the closest equivalent to todays software. Different, but interchangeable parts that fit a standard (the API). The cabinets that were replaced were 30 years old. And what you see is what you got. A little bit of rot meant the whole thing had to be torn out. If I needed to replace a door I would have to have one custom made; same for the drawers.
Now, not all IKEA is great. I had a cheap IKEA office cabinet and compared to the kitchen cabinet of the same dimensions it was 1/3 the weight. But the price reflected the quality of the goods and sometimes all you want is a cheap office cabinet, other times you want a sturdy kitchen cabinet with a 25 year warranty.
Going even further, I'd be happy to see computers do more routine medical work. It's been 35 years since the system MYCIN beat most physicians in its (admittedly narrow) area of competence, and yet we still have huge amounts of automatable stuff being done by fallible humans attempting to recall something out of a med-school textbook.
A better way to diagnose is using improved molecular tests, and new imaging methods. those have a few benefits: 1. Higher accuracy. 2. Sometimes you can diagnose in a very early stage of the disease , with no apparent symptoms(i.e. screening) 3. You can diagnose by the cause , not by the symptoms. when you have the exact cause you can give much better treatment.
Molecular methods probably have easier acceptance by doctors vs expert systems , probably because they don't seem as a direct competition.
When the knowledge(and tools) on how to diagnose and treat a certain condition gives better results then the average doctor , it's best for the patient that the doctor would follow protocols.
But there are areas in medicine we don't know enough on best diagnostics and treatments. here we need the best doctors thinking, collaborating , experimenting and innovating both as part of giving best care , and as part of advancing medicine.
And when talking about surgeries , moving the treatment to an "assembly line" type of work, with the surgical team doing the same surgery in the millionth time , is even more important , since it can give much better results.
Doesn't mean the whole industry has. It has just gotten much larger, and does obviously now include some assembly line type places.
It would be a great place to do a startup (there are a bunch of niches which could easily support multiple companies) -- it's mainly implementing open but antiquated specs from the late 1980s, doing interop testing with existing vendors, and being able to go through the long sales cycle. You would want some MDs on the team, which makes it kind of expensive (young MDs need to pay off their schooling, and older ones would be giving up profitable jobs).
The $40-80k per EHR thing is a big market opportunity.
There are a lot of legal issues too, so the risk can actually take you negative very easily -- like jail time or fines, so it's a different equation for investors, entrepreneurs and programmers.
Thankfully, I work with really smart people who are all motivated and our company has a few unique strategic advantages. If any great rubyists want to join a company that is iterating our test-driven way to launch, my contact info is in my profile.
The EHR itself is the black hole of suck. It almost always ends up being like an ERP package, with either an off the shelf package (e.g. SAP) where the workflow is changed to accomodate the package, or a semi-custom consulting product built around specific workflow.
Luckily, the more specialized stuff is actually vastly simpler.
Once you have to handle anything workflow-ish or manage any sort of business process, or any time you have to handle integration to arbitrary external systems, it's very difficult to make anything that doesn't suck. The "right" thing becomes very fuzzy, and there's no one purpose or problem you can use as your rightness criterion, so it all becomes very fuzzy. Things then get worse when some standards committee tries to please everyone, or when business users insist that they want everything to work exactly the way it used to just, you know, with a computer know. And since there's no easy criterion against which to judge the solution, it's an easy slope down towards even more suck.
There's also the "sell it outside the USA, then sell inside the USA" model.
Does the integration problem steel exist for web based software?