Why doctors are sick of their profession
online.wsj.com
online.wsj.com
There are many great examples of socialised health systems in the world, I'm not sure why the US ignores them? Some of the WSJ comments list all the problems inherent in the US system and then blame socialism for them when the problem is completely the opposite?
For example this IT department head of a major district health board who embezzled ~$17 million dollars over a period of 6 years, with which to buy, among other things, luxury vehicles.
http://www.odt.co.nz/news/tags/michael-swann-0
http://www.odt.co.nz/news/dunedin/32268/fake-invoices-made-p...
Can you imagine this sort of thing happening in a free market for healthcare? I can't.
Sure, it sucks that someone committed fraud and got rich in a dishonest manner but preventing that is not the goal. In the end, this fraud doesn't really affect the healthcare given.
That is a pretty big claim... Have you ever actually lived in NZ and experienced the realities of paying for this system via taxes and claiming its services? Have you monitored the incessant demands for more services at better quality, the incessant complaints about being over-worked and underfunded, the endless criticisms and debates about inefficiency, long wait times, burdensome bureaucracy, poor outcomes, and unhappy doctors?
Outright fraud and corruption is just the tip of the iceberg of problems that naturally develop when a society decides to sever the act of consumption from the actual purchase of a service.
Then what about the negative aspects you mention. Well, in the Netherlands we have a similar system and to be honest I don't care about all the whining you mention. Sure, people complain and things probably can be better. There is always room for improvement. Unfortunately people will complain about healthcare if they stub their toe. Fuck 'em, you can't stop these people from complaining and policy should not accommodate their every whim.
Can you support your claim that bad things happen and go unpunished
> when a society decides to sever the act of consumption from the actual purchase of a service.
I'm not feeling them, my family is not feeling them and my MD friends are happy with their jobs. And don't forget: the private sector is still an option so there is a choice.
[1]: http://en.wikipedia.org/wiki/Health_care_in_New_Zealand
Markets are good for determining price. Not finding efficient solutions. You've heard of "rent seeking"?
Single payer systems enable the capitation model of care services. Because wellness is incentivized, vs the treatment of disease.
That's bold.
That's one hell of a lack of imagination. You mean stuff like this, which happens all the time here? http://www.buffalonews.com/city-region/federal-court/william...
http://www.amazon.com/Healthcare-Fraud-Auditing-Detection-Gu...
Also, you misspelled "corporatist oligarchy" as "free market". Easy mistake.
There was a dentist a few years ago who was treating 2,000 patients a day, and stole several million dollars from several insurance companies.
I worked at a midsize company in a highly competitive market... one of the call center manager embezzled something like $75k over a period of 3 years by fraudulently purchasing telephone headsets. He paid for $$$$ plantronics, and delivered $ no-name brand.
You can argue that we haven't been socializing it "properly," but the way we are doing it is just the way government works in the US, and that's not going to change.
In general, we don't have an efficient, honest, effective government, so it can't do anything right on a large scale. Though there are some exceptions, those are exceptions. Look at the Obamacare website scandal. That is the rule.
When was this?
>the way we are doing it is just the way government works in the US, and that's not going to change.
That's some nice fatalism you've got there.
>In general, we don't have an efficient, honest, effective government, so it can't do anything right on a large scale.
Except for all the things you forget to mention, or even to think of as government programs, because they tick quietly away, working perfectly, in the background.
Some systems in the US, especially Kaiser, are basically a socialized system supported by premiums, and seem to work pretty well.
Finally, my anecdotal evidence: I am highly satisfied with the care that I receive at the VA. I have 20% disability due to a significant loss of peripheral vision in my right eye. I am scheduled yearly for an annual physical including urine and blood work, a field scan with my eyes to test regressions, and two general appointments with an optometrist. I also have free access to nutritionists and weight support groups since weight management can be an issue for veterans. Is it perfect, no, but I have never felt that I didn't get the care that I needed in a reasonable amount of time.
[1] http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2537
[2] http://online.wsj.com/articles/no-deaths-caused-by-delays-at...
edit: formatting
I find your statements to be over general to an almost crazy degree -- "the actual experience"? Everywhere? "In general we don't have an honest effective government" -- really? Got data? Etc, etc.
Also, I would be interested in specific metrics of worse and better -- you make the claim it is worse because of regulation, which you imply is basically the same as socialized funding (which it isn't). So where is the data?
No offense, but this sounds like canned right wing bullshit rhetoric straight off Fox News. Granted, there is plenty of canned rhetoric on all "sides" to go around, but that doesn't make this any better.
The problem is that certain sides get way less flak for "canned rhetoric". Particularly populist viewpoints.
As straining-of-credulity as such a bumper-sticker is, isn't that the logical conclusion?
Very Serious People ( with whom I happen to agree) actually say such things in "Fragile By Design". Calomiris/Haber are good writers and good thinkers. They do not call out medical nor political leadership there, but it's not exactly a stretch.
It's a short drop from this to the view of America from "V for Vendetta".
There are a few islands of private industry in healthcare, but between the regulation and the direct payments, it's a government sea.
Barring the most radical dissolution of the current system, the question isn't whether the government should be involved, but how.
Interestingly, the golden age for physicians' personal wealth was during the socialisation phase, as they were able to pocket fees increasingly paid by insurers, leading to a quintupling in income. They went from lower-middle class at $50,000/year in 2010 terms to $250,000 in 2010 terms. Doors anyone seriously suspect that we'll ever get back to $50,000/yr physicians? This illustrates why industries are often keen to socialise: they can guarantee outsize personal success.
What our system absolutely rewrites is radical dissolution.
It's like saying the food/farming industry isn't a free market because "some people will use very little while some [fat people] will use a lot more through no fault of their own." It's a ridiculous argument, and sounds more along the lines of Peter Joseph's "structural violence" mantra. The whole "you're not truly free until you get all this free shit given to you so you can be free to do nothing/be lazy".
Granted, it isn't actually a truly free-market, anyways. Government subsidies, minimum prices, etc, all distort the market and affect peoples' actions.
The "socialism" thing is just spall from decades of identity politics. Pick apart the propaganda aspects of John Wayne's movies, especially "The Alamo". I'm not snarkin' on Wayne, I love his stuff, partly because it's propaganda.
Our cognitive dissonance is best cognitive dissonance :)
I also have to wonder - if the US actually embraces a public health service would that take the pressure off the public health services of the world to keep cost down?
As economics, it's actually pretty difficult to analyze this issue. The assumptions are formidable.
There is, however, a significant minority of really horrible, angry, violent, and generally racist people who feel deeply and ideologically threatened by the social contract on which these systems rest. And because of some unfortunate quirks in the American electoral system, they wield a level of political power that vastly exceeds their numbers. In a properly representational system, they'd be just as aggressive, ignorant, and self-defeating as they are right now. However, the body politic would be largely insulated from their rage, allowing us to safely get on with the design and development of a decent, cost-effective system.
In other words, we're being plagued by a really nasty infestation of trolls, and it's making progress in general pretty damn difficult. The good news is that this, too, shall pass. In demographic terms, this problematic political outlook is the rooted in the reactionary portion of the generation that came of age during the Civil Rights era. Their bigotry translated into a life-long political identity that has done everything it can to resist, if not reverse the "loss" they suffered in the wake of Jim Crow ending.
The Drug War is probably the best example of their continued effort to put a boot on the necks of black people. It's worth noting that the militarization of US police forces, combined with an exploding private prison industry, took root in the former Confederate states before spreading outwards to damage the rest of the nation. And of course, opposition to any kind of drug legalization remains strongest in places with the deepest histories of institutionalized racism.
The same perspective that says the state should be used as a weapon to harm black people also says the state should not be used to protect or help them in any way. Thus, the vitriolic opposition to any kind of welfare program than benefits black people. Keeping them out of the health care system was part and parcel of this larger push for institutionalized white supremacy.
But again, all this is a generational reaction to the 1960s, a particularly divisive and transformative time in American politics. When the generation that dedicated itself to obstructing the movement for greater equality finally passes from the stage, there won't be another one with either the size or the depth of hatred to maintain the current levels of opposition. So even in an electoral system as warped as ours, the certifiably batshit-insane won't be able to maintain their dominance. That's bad news for everyone with a stake in Fox News, great news for everyone else on planet Earth.
At that stage, with the right wing of the baby boom dead and buried, America will be able get on with the long-delayed work of creating a more-perfect union. Given how much pent-up demand there is for policies that reflect intelligence, fairness, humanity, and decency, I suspect demand for change - and the consensus to support it - will appear quite swiftly. So it's nice to know that there are already well-developed models we can refer to when the time comes.
1. The left wing of the baby boom is going to die with the right.
2. The baby boomers were famously a bunch of hippies and radicals. More seriously, they were easily the most liberal-minded generation in America at the time--and they may still be.
3. This country's ongoing demographic transformation into Brazil is not going to help the health care system, or move us toward a "more perfect union", or do anything at all positive in general. It baffles me that people think things like that.
1. The thing that distinguishes the values of the Civil Rights era reactionaries is that they're generally failing to transmit themselves from one generation to a next. So unlike the more egalitarian values of the left - which are actually growing stronger with each subsequent generation - the bigotry of the right is uniquely tied to the lifespans of specific people. When they die, their fundamental opposition to social justice dies with them.
The break isn't perfectly clean, to be sure, but enough to make the retrograde electorally insignificant and that's the real point here.
2. The "hippies and radicals" on the Baby Boom's left were actually a distinct minority in the 1960s. Highly visible, yes, but politically (as opposed to culturally) persuasive? Not so much.
However, unlike the reactionary right - which was entering its last generation of social dominance - the lefties were well ahead of their time. In the long run, their ideas and values are the ones that are becoming mainstream, while the overt racism of the right is what's becoming retrograde. That's why gay marriage and drug decriminalization are happening, while the racist cops freaking out in Ferguson are seen as the bad guys in a dystopian nightmare that causes a general sense of recoil.
3. Not sure what you mean by this. Are you saying America needs a white majority to remain functional and prosperous?
So you know, the demographics I'm focused on are those of the millennial generation, which is the largest in American history. In terms of electoral politics, their preferences are going to dominate everything in the decades to come. And unlike the lefties in the BB generation, this is a generation in which broadly egalitarian and progressive views are, for the first time, held by a clear and ascendent majority.
As far as the health care system goes by the time these people hit middle age, it's safe to assume that sanity will be prevailing. Indeed, I suspect that will be true of politics in general.
>In fact, you would be hard pressed to find any racism in the TEA Party or Republican party.
That's an amusing perspective, given that both parties have members who espouse racist beliefs, with the Republican party having slightly (only slightly) more than the Democrats: http://fivethirtyeight.com/features/are-white-republicans-mo...
Lol.
http://fortressamerica.gawker.com/georgia-lawmaker-vows-to-e...
That confusion may be a product of poor reading comprehension. Notice that my comment was not a direct reply to the article, but one directed to a secondary question raised by the article. (Specifically, "Why, if we know what works, are these known solutions not being implemented in America?")
The answer, again, is that these systems depend on a social contract which is flatly incompatible with the white supremacist ideology that, for a variety of structural reasons, still holds a remarkable and disproportionate amount of power within our political system.
"But, your assertions that the TEA Party and Republicans are inherently racist are misplaced."
Um, no dude. Those are your assertions, not mine. Since I never mentioned Republicans or Tea Partiers at all, I could not have said anything specific about either. Indeed, I can think of many Republicans - some I know personally - who are deeply embarrassed by this concentration of racist, jingoist, revanchism that has not only found its way into their party, but has taken to calling those who try tempering their most toxic characteristics as "RINOs" (that's "Republicans In Name Only", in case you were unfamiliar with the term).
But since you mention history, let's discuss that. This toxic group, as you seem to know, is not new to American life. They were a principle target of Abraham Lincoln and the Republican party of the 19th century. What is (relatively) new is their occupation and transformation of the Republican party, and the way they turned what had been bastion of opposition into their home.
The switch started in the wake of LBJ's "betrayal" in signing Civil Rights legislation. LBJ was, of course, a Democrat. And he was faced with choosing between the people he saw as the future of the party and the Dixiecrats (as they were known), who represented its racist, soiled, and discredited past. He made the right choice, and in doing so, rendered a large block of Southern white supremacists politically homeless.
They didn't stay that way for long. By the 1970s they were staging an aggressive takeover of the once-hated Republican party, employing a heady mixture of religious fundamentalism, supply side economics, and "tough on crime" rhetoric, bringing a messianic zeal to re-establishing the dominance they'd lost with the scrapping of Jim Crow laws.
The GOP managed to temper and accommodate their presence through the presidency of George Bush senior. But his defeat after one term in office signaled the end of the moderation. By the time Bill Clinton was in the White House, Newt Gingrich attained the Speakership, and the extremist elements began calling the shots within the GOP. This marked the completion of an fundamental transformation. Within period of two decades they’d converted the Republican party from the traditional opponent of the Confederacy to the vehicle of its contemporary resurgence.
Getting back to health care, if you didn't see these people coming out in full force to oppose the ACA it's because you simply weren't paying attention. Like, not at all. In reality, the continued political presence and power of these people has an enormous amount to do with the irrationality of our medical system. (The same could also be said of our criminal justice and immigration systems.)
And the existence of these people is hardly a matter of speculation. We've had a number of racially charged incidents that become flash points for the racists to express their views and indicate their numbers. Consider the recent mayhem in Ferguson, where a white K-9 officer allowed his dog to urinate on the memorial set up by the mother of a young man killed by the same police force. It's impossible to chalk up contempt this raw as a rare an isolated thing when a staggering volume of social media posts indicates broad and deep support for this treatment - and worse - among certain quarters. Lynchings, may I remind you, are still a matter of living memory. And as open comment sections reveal, there are still plenty of Americans who would bring them back if they could. Thanks to the distorting effects of Senatorial overrepresentation in predominately rural states and pro-GOP gerrymandering of the House, their electoral power vastly exceeds their numbers. They do not represent America, but they do represent a major problem for America, and have done so since before the Civil War.
But the good news, is that their attitudes are not replicating themselves across generations as reliably as they once did. Given time, this problem will solve itself. For those who can't wait, I recommend a focus on the structural reforms that will accelerate their demise. Specifically, that means an end to closed primaries and partisan redistricting (i.e. gerrymandering) and much greater access to the ballot box.
In any case, if you are going to attempt lecturing people on the history of political alignments, make sure the version you’re trying to push doesn’t conveniently stop in the mid 60s, just before one of the most momentous realignments in American history took place. Being that economical with the facts makes you look stupid, dishonest, or both and HN is not the place to pull that shit.
No, because the Republicans are a national party and the KKK barely has enough members to populate a state fair. In other words, I would not think this because I can do basic math.
>> "But the only KKK member to be elected to the Senate, Robert Byrd, was Democrat, and he retired in 2010, not 1960."
Not exactly true. Byrd dropped his membership in 1952, as he was running for the House, where he served from 1953 until 1959, when he ran for the Senate. But this is hardly relevant, since it all took place a decade or two before the great political realignment triggered by LBJ.
>> "I don't know why you call them "Dixiecrats".
Because that's what pro-segregation southern Democrats are called. And because that's exactly who we're talking about. So you know, "Dixiecrat" was the informal name used by a short-lived, pro- segregationist breakaway faction from the Democratic party. The group flamed out in 1948, but the name hung around, finally sticking to the southern, white, and openly racist Democrats who were vehemently opposed to the Civil Rights Act and who subsequently formed the core of today's predominantly Southern GOP - which is precisely who we're talking about here.
>> “There is simply no evidence there was a mass conversion from Democrats to Republicans in the South."
Um, wow. Where do I even begin? I mean, saying something this demonstrably wrong is a bit like saying "There's no evidence that the Earth is round," or "There's no evidence that the Titanic really sunk," or "There's no evidence that Boston is north of New York City."
I could go on, but you get the point. And yes, there's is lots (and lots and lots and lots) of evidence there was a mass conversion from Democrats to Republicans in the South. Chiefly, the public record of election results for the United States of America.
Here's but one summary of the shift. Scroll down for the helpful charts that document the shift on a year by year basis. The section you want to pay especially close attention to is marked "1964 Election – Regional Realignment".
http://mattsmaps.wordpress.com/2011/07/14/southern-realignme...
Again, this shift started in the Civil Rights era. It grew under Reagan, and it went ballistic in the 1990s, as you correctly note. Like I said originally, this didn't happen overnight. It took about three decades to unfold, by which time the home of southern, white voters who are generally opposed to strong civil rights legislation has completed its swing from the Democratic party to the GOP.
Today, the South is solidly Republican. In general, Democrats don’t have a snowball’s chance in hell of representing these states. Indeed, this is where they face their very toughest odds. And that’s not because there’s been some sea change in the population, culture, attitudes, or beliefs commonly held by white people in the American southeast. It’s because the party that was once aligned with their interests abandoned them, and because the party that once opposed those interests was captured and radically changed by them.
I accept this change, by the way. These shifts are par for the course in American politics. What I don’t accept is present day Republicans who try to deflect well-grounded charges of racism by claiming that they’re members of “the party of Lincoln” while ignoring the near-perfect realignment in the major party’s respective bases that happened between now and then. It's like somebody who has had a sex change trying to insist that they were born in their current state. I don't object to the operation. I do object to the lying.
Seriously, if the point your making only sounds convincing to people with zero grasp of history, then what you're asserting is just straigh-up bullshit, which is like lying, except worse.
http://en.wikipedia.org/wiki/On_Bullshit
So you know, honest, intelligent, decent people who respect the truth don't behave like that. You - apparently - are none of the above.
>> "I think the debate would be better served if you kept to policy arguments instead of attacking your opponents."
Except this isn't a debate. This you not knowing your ass from your elbow, behaving in an intellectually dishonest fashion, and getting schooled accordingly. So you know, debates revolve around opinions, ideas, and perspectives. What we're talking about here are matters of well-established (i.e. non-debatable) fact.
Seek help.
You know what? That's social pathology, and the individual I'm responding to is obviously in the grip of it. I stand by what I've said. He should seek help.
It's happening all over the world. There's a general trend where the right-wing trolls are aligning themselves with the cronies. While the next generation wants to fight the nastiness in racial/sexist/homophobic discrimination, they're not too enthusiastic about doing anything besides paying lip service to structural problems in the way the world works economically.
Bigoted commenter is really a bigot.
Thanks, you saved me from reading your post. If you had something worth saying, you blew your chance by starting out insulting me.
Because debate in this country has been taken over by assholes and idiots. They lie at every turn to justify their position and they don't care about facts or figures, unless they agree with their ideology.
In my dreams I fantasize about what happened in Portugal regarding decriminalization of drugs. In the current US climate, that could never happen. It bums me out, too.
Another problem is creeping fees. Most clinics, hospitals ect all nickle and dime you for fees here which add up even though they aren't supposed to. Some regional health authorities here charge a flat monthly tax, which if you can't pay or are in arrears you're screwed and have to pay cash to these clinics. Because there is a standardized rate you're going to pay $135 just to talk to a doctor for 5 minutes because there's no low income clinics, all rates are the same.
Source: my young, foolish self who had to pay this out numerous times to clinics for being behind on taxes.
It's good that this works where you live but you need to be hyper vigilant on who is elected to govern your health authority, which is a huge downside of any kind of socialization of medicine. Governments are fleeting, the next one could purposely sabotage it to satisfy insurance lobbyists or be so incompetent they accidentally let it all go to hell.
The United States is an enormous country comprised of 50 separate state governments, where the powers of the federal government are extremely limited (both by the constitution itself, and by the fact that it is practically impossible to do anything at that kind of scale).
As a result, it is extremely hard to pass any sort of massive reforms. Can you imagine how difficult it would be to pass one single, uniform system of health care for all Europeans?
Talking about solutions that work well in smaller countries is all well and good, but the reality is you need different solutions if you want them to work at scale. It's the same reason why most of Facebook's backend is now written in C++ instead of PHP. It is much more painstaking to work with and harder to pick up but when you're building a huge system of interconnected parts you want something that isn't going to fall over and die suddenly.
The supposed chaos and gridlock of the US political system is a feature, not a bug. It's the reason why if you look at a list of the world's oldest nations the United States is right at the top, and is one of the largest.
EDIT: Sorry - not saying the US's healthcare system is the best it can be and didn't make that clear enough. Just saying that comparing it to other countries won't help as the US has a unique political reality.
However, I am not buying the scale argument. What exactly makes it hard to scale? The only argument I've heard is that managing all doctors and hospitals, but that is trying to control everything, something that never works when you try to scale out, and isn't necessary either.
If anything the scale enables you to build large and very specialized hospitals that only deal with one particular aspect, e.g. cancer, and do some serious research as well.
The way you keep a political union together without having it break apart is by limiting the amount of things the members of the union have to share. If you start taxing rich states and funnelling the money over to poor states, you give people a reason to want to break out of the union. Ultimately people only stay if they're getting a good deal.
Taxpayers in New York will definitely be happy if their money goes into the military, as having a New York rather than a US military wouldn't work. But to have all their money go into universal healthcare in Idaho would just piss them off, because people in Idaho can pay for that themselves. That's why healthcare is largely a state matter in the US - you'll find some states have great healthcare, others don't.
I'm not saying the US can't do it better (they clearly can), I'm just saying comparisons with other countries are useless because they don't take into account the unique political realities of the United States.
Say you need a trauma center within 1 hour of anywhere in the country. A trauma center in Manhattan is going to see a lot of traffic, while one in Clayton, NM, isn't. But the centers have the same basic cost in staff and gizmos.
The real problem with healthcare is that you can never have enough. Even if everyone paid 100% in taxes it wouldn't be enough.
Hang on: A busier unit is going to have more staff. Staff is not a trivial cost.
I do know that in other similar situations, wealthier, more populated areas end up subsidizing poorer, less populated areas.
If you look at it from a purely financial point of view the problem of the US system is that when given the choice, younger people don't insure themselves because they are healthy and so don't participate in financing those who are sick by costing the system less.
As they grow older and get sicker they end up paying insane prices unless they are paid by employees and even there the quality of the insurance varies and you still have some really absurd pre-existing conditions rules etc. If you don't have an employer to back you up you are basically screwed.
Obama Care is an attempt at solving this issue. It's not single payer but it's closer and hopefully it will help improving the healthcare system for millions of those without either healthcare or proper healthcare.
Now in my mind there is a middle ground where you pay most of your healthcare yourself (the checkups, the sinus infection etc) but you don't end up in endless debt because you become sick, your kid gets born to early and have to stay at a neonathal facility, for a longer period of time and don't have the right insurance.
And having been through the system I must say that if people think it's less beucratic than say they Danish system (which is much more social in its approach) then they would be mistaken. The sheer number of interests involved in any single episode creates complexity way beyond what seems reasonable.
So agree it's not possible to take a small nation and apply what they do, but it is possible to look at the current system and realize that the healthcare system in the US is def not a feature but rather a system with plenty of room for improvement.
You could argue that the healthy subsidize the sick but that's the point of insurance. It's like saying the living subsidize the life insurance payouts of the dead.
Also, Germany is a federal country of 80+ million people, that's surely a better comparison than Denmark.
I'm not understanding the problem here. Run "git clone" on the Canadian model fifty times. All done.
Furthermore we seem to have "no problem" scaling up central federal control of seemingly everything other than health care, so a comparative explanation would seem necessary, as to why federal social security is possible or federal OSHA or federal EPA or federal militarized police or the federal military itself, but for no provided reason federal health care would be impossible to scale.
Hold on, if the U.S. is 50 separate governments, each of which have great power (since "the powers of the federal government are extremely limited"), then shouldn't each state be able to pass effective healthcare by itself? Only 2 U.S. states have populations larger than Australia, and none would make it into the top 5 E.U. countries by population.
Talking about solutions that work well in smaller countries is all well and good, but the reality is you need different solutions if you want them to work at scale.
But you just said each state is separate and the federal government has limited power, so why do they need to work at scale larger than anywhere else?
First, as with the EU, the US is divided into fairly independent states who already manage most parts of their own healthcare/insurance systems.
Second, the idea that 30 million versus 300 million makes a huge difference in scaling healthcare is pretty silly. Sure, a healthcare system for 1,000 people would have different challenges than one for 1,000,000 people, but on nation-sized scales? You have regional divisions to keep it manageable.
What exactly makes Australia or the UK's system unscalable to the size of a US state?
> It's the reason why if you look at a list of the world's oldest nations the United States is right at the top, and is one of the largest.
Massive amounts of minimally populated land to expand into likely played a more significant role, as well as a lack of aristocracy - if you look at European upheaval it's usually an issue of one of the two.
Really? Please can you elaborate on this as it makes no sense to me.
There's plenty of stuff in there to debate (the US did have a rather bloody civil war, so it's not like it's been perfectly stable), but his argument is plausible enough - I'm not sure why it makes no sense to you. Personally, traveling around the United States has convinced me that there's ten countries worth of distinct cultures in it - one-size-fits-all government isn't going to work well.
We've had Medicare and Medicaid for almost 50 years now, and it works reasonably well, despite significant differences in administrative practices between states. So it absolutely can be done.
We've figured out how to build a national road system, healthcare for old people, healthcare for destitute people, a national tax collection system, and 1,000 other examples. It's a solvable problem.
The current US health situation is the end result of a long process of complicated schemes to provide more healthcare to Americans without any clearly visible costs in ways complicated enough that there are no obvious deficiencies. For instance Nixon's scheme[2] to lower costs by preventing competitions between hospitals[3] is still on the books all these years later. Given all the government interventions in the healthcare market combined with an unwillingness to bite the bullet pay for or subsidize most people's insurance directly has left the US with a healthcare system that is neither government run nor free market, but something far inferior to both.
[1] Singapore has a really weird combination of forced savings, mostly private payment, and mostly public provision which is really weird compared to everyone else but somehow gives them really good health outcomes really cheaply. I don't think the US could make that system work, though.
[2] Is there something Nixon didn't screw up? Well, besides repairing our relationship with China.
[3] Back in the day everybody knew that the USSR had a far more efficient economy than the US did (the Soviet statistics said so!), and one way people explained this was that the Soviets weren't wasting resources on competition but instead just figured out the best way to do something and put all their effort behind that.
There is no chance I would do it again.
The good news is that your rights are inalienable, you can reclaim them at any time. The doctors should go on strike and reject the assumption that anyone has the right to their work. As a patient I would support the doctors 100%. Let's see how long medical services last without doctors or how laughable it will be when the govt tries to force doctors back to work. LOL.
Health Care is Not a Right. http://www.afcm.org/hcinar.html
NB: I recently dropped all my medical customers at significant drop in revenue because of HIPPA. You think things are bad now wait until that monstrosity becomes strictly enforced.
What does this refer to?
> (6) The patient has a basic right to have available adequate health care. Physicians, along with the rest of society, should continue to work toward this goal. Fulfillment of this right is dependent on society providing resources so that no patient is deprived of necessary care because of an inability to pay for the care. Physicians should continue their traditional assumption of a part of the responsibility for the medical care of those who cannot afford essential health care.
A bold claim without any backup.
(6) The patient has a basic right to have available adequate health care. Physicians, along with the rest of society, should continue to work toward this goal. Fulfillment of this right is dependent on society providing resources so that no patient is deprived of necessary care because of an inability to pay for the care. Physicians should continue their traditional assumption of a part of the responsibility for the medical care of those who cannot afford essential health care.
FYI, you might want to look into the laws which are just now starting to be enforced. If you are in IT then you are now a covered entity and can be fined directly for HIPPA failures. You also have a legal obligation to document any contact with PHI and you have a legal obligation to report your doctor if you even observe any HIPPA violation, IT related or not. I could not work under these terms so stick to non-medical IT work.
For years, under advice of my lawyer, I operated under a signed contract with all my healthcare customers that included a disclaimer that HIPPA was not my responsibility and I had no HIPPA responsibilities. Recent decisions by the DCR have ruled such disclaimers invalid and defined Business Associates as providers to healthcare providers that have access to PHI and thus to which the HIPPA regulations apply directly. My lawyer said he can no longer limit my liability or responsibility for HIPPA with a disclaimer and advised me to implement full HIPPA compliant policies, procedures and documentation or drop my healthcare customers.
Please feel free to ignore reality if you want to get blind-sided by this.
We've had rights to medical services in most of the developed world outside the US for decades. Doctors have high salaries and reasonable conditions for the most part. Funny version of slavery.
And how long will this system last when the doctors are extremely unhappy now and things will get worse as the govt takes more control away from the doctors? It should give you some concern that 2mur's sentiment is common today among doctors; "There is no chance I would do it again". Do you think doctors can be replaced by govt bureaucrats following the Code of Federal Regulations? Good luck with that but its where we are headed.
Let me ask you a question: If the doctors went on strike and refused to work, what do you recommend that we do? Do you support the doctors and their right to trade their services on their terms or do you support the demand of the public's "right" to their services?
Give an example of a slippery slope argument in economics, social science or politics.
A more sophisticated rhetorician would argue that the various bodies of your society (those who pay for the universal medical services via taxation, those who partake of the medical services offered, those who actually provide the services (i.e. the doctors), and those who administer and regulate the provision of service) have all internalised and unconsciously accept a worldview which debases and discredits the right to free action of individuals in society. You may not be slaves in the classical sense of being enslaved by a third party, but from the perspective of someone with a "strong" view of personal liberty, you are in a sense enslaved to your own lowered expectations and faith in liberty.
So while you might all claim that you are perfectly content with your current system, your critic would view your opinions as hopelessly biased, and point to what they would classify as numerous instances of the poor results of socialised healthcare (incessant arguments about over-spending and budget problems, claims of corruption in service administrators, complaints of high wait time and low quality of service, low morale and satisfaction among service providers) as evidence to strengthen their claim.
This is just disgusting behaviour to see on Hacker News.
> we [doctors] could do a better job advocating for ourselves...
Its all just negotiating the terms of your slavery if you agree that people have the "right" to health care.
The same is true for health care. If you actually had an inalienable right to health care, then you could require a doctor to provide you service whether he wanted to or not. That's slavery, and why it is absolutely illogical that there can be a "right" to something that is material and finite. This isn't politics, it's simple logic.
Putting patients first is the part that seems "right." That's not a coincidence, it's the job.
You claim a responsibility for the trust between the doctor-client relationship but with govt control of medicine its now a three-way and one of the parties is holding a gun to your head. You can't put your client first under govt controlled medical system. The doctors are very unhappy, as 2mur expressed "There is no chance I would do it again" and I have heard from many doctors. Following the regulations or the bureaucrats comes first and you know this because I have yet to hear of a doctor not complain about this.
Also, if you are British you should realize the Empire died a long time ago when they stopped calling the uncivilized peoples savages. Your embarrassment on my behalf is quaint but no longer necessary.
Well, since you're inviting personal criticism, then, and suggesting it might engender more respect for critics and their opposing points than a doctor weighing in on your position...
It'd seem that you suffer from all-or-nothing, black-and-white thinking -- that when confronted with tension between two ideals you don't know what to do except pick a single winner and declare that any attempt to balance tension between the two as an unacceptable compromise against the value you've judged higher.
I'd also guess that if you think that government services are theft, you might have built a philosophy around property rights without ever having thought much about property itself, which is about a real, universal, and solid as the cartesian plane at best.
Finally (and perhaps most specifically and pertinently), while I'd be willing to believe that you may be familiar with the regulatory aspects that directly affect your professional life (and invite you to express your confidence about this by drawing attention to the specific market vacuum you've left behind in case someone else doesn't share your opinion), your summary doesn't seem to me to be a particularly accurate description of the state of values/laws when it comes to health care in the US.
For example, if you're talking about EMTALA as the decades-old invocation of care rights (and I'm not sure what else you would be talking about), there a number of key caveats that I'd think would prevent any sensible person from characterizing it as slavery, perhaps most notably that (a) there's only obligation incurred for institutions that choose to accept medicare payments AND (b) it doesn't compel anyone to into going into providing emergency service in the first place, it compels those who choose to provide emergency service (and accepting medicare) to provide emergency service without regard to ability to pay.
If someone can choose to avoid providing a specific service (or stop when they like), and only incurs obligations by making an agreement with a specific payor, they're not a slave, and it's possibly more disingenuous to invoke the term in this context than it is to invoke the term "theft" when discussing taxes and government services.
> Its all just negotiating the terms of your slavery if you agree that people have the "right" to health care.
People do sometimes speak of the struggle many face for access to health care in terms of rights. Mostly what I think they're trying to express (sometimes poorly) is that they feel the value of giving every member of a society some minimum level of access to health care services is a good on par with the value of property rights, possibly higher. And as such it's worth some limited abridgment of the later.
There are some good arguments for this, even when starting with personal liberty/property rights as a high value: liberty and property don't mean much in a context where life and health aren't protected, and the related risk management and insurance is an area where incentives are screwy enough markets aren't great at the job, which is one reason you see people like Hayek support at least the idea of social insurance.
As smart as they are, the doctors are most clueless regarding the moral issues involved. There is another MD in this thread claiming the essence of medicine is service to others but I think 5 minutes of thought can dismiss that non-sense, even from a doctor.
> It'd seem that you suffer from all-or-nothing, black-and-white thinking --
I don't consider this a flaw in my position. Its called Aristotelian logic either/or, maybe you have heard of it. There is no gray in reality it is in your head.
> that when confronted with tension between two ideals you don't know what to do except pick a single winner and declare that any attempt to balance tension between the two as an unacceptable compromise against the value you've judged higher.
Name those ideals, please. If you boil it down it is not a conflict between two good principle or ideals (this does happen but not in this case) but between a bad one and a good one. Are the doctors free to withdraw their service? Its a simple question. If you believe that medical service is a right doesn't that mean that medical service is an obligation of the doctors to provide? Who, other than a slave, has an obligation to provide service? If you force the doctors to follow the Code of Federal Regulations and limit their salaries are they still really doctors in the proper meaning or are they bureaucrats? Do the good doctors stay under such a system or do they move on? Don't be fooled by nomenclature.
> Finally (and perhaps most specifically and pertinently), while I'd be willing to believe that you may be familiar with the regulatory aspects that directly affect your professional life (and invite you to express your confidence about this by drawing attention to the specific market vacuum you've left behind in case someone else doesn't share your opinion), your summary doesn't seem to me to be a particularly accurate description of the state of values/laws when it comes to health care in the US.
AMA good enough for you? https://news.ycombinator.com/item?id=8248017
HIPPA is Coming!, HIPPA is Coming!, HIPPA is Coming! https://news.ycombinator.com/item?id=8247991 https://news.ycombinator.com/item?id=8248417 You have been warned.
> People do sometimes speak of the struggle many face for access to health care in terms of rights.
Words have real meaning and aren't rubber terms to justify anything people need or want. So where do you draw the line? You and I need food, is that a right too? Your concepts are so confused that I doubt you could even answer that without equivocating and hedging your position but that is a serious question. Every argument you made for health care being a right applies more so to food. So tell me what is different between food and healthcare, shall we enslave the farmers now too? And what about electricity or the internet? I have heard people argue that these are rights too and based on your soft thinking you have no argument against them. If you were consistent, as in my black and white world, you would have to join the hoards demanding these "rights" -- provided by whom?
In particular, it's seldom helpful to cling to specific terms and their supposed definitions rather than look at the actual facts. Who cares whether doctors are slaves? Is there anyone who has any actual disadvantages due to how the system works or not? If everyone, including the doctors, is better off with how the system works, who cares whether they are slaves by some definition? If they have some disadvantages, then that should be addressed, who cares whether it fulfills the criteria for being a slave?
Also, you always have to consider the wider societal context. There might be indirect benefits outside the immediate transactions that arise from how a society is constructed. Where I live, for example, if you see someone in distress and there is no significant danger to you if you were to rescue them, and you are able to, it is a criminal offense not to help. I guess by your standards that would mean we are all slaves - but I think the democracy that created the law is perfectly sufficient to justify this obligation, which as a side effect presumably generates higher safety and a higher sense of safety for everyone.
Your logic reasoning skills may be pretty good, which is a component of reason that many people lack. What you seem to lack is a useful mapping between reality and propositions. And from false premises, unfortunately, even flawless logical derivation cannot produce any useful information about the world.
When wwweston critizes your black-and-white thinking, he is not suggesting (I think) that there is some kinda-maybe-not-quite-true-or-false truth value. Rather, he suggests that the choices you are implying actually have more than two mutually exclusive possibilities. In particular, words don't actually have "real meaning", words routinely have tons of meanings, heavily depending on context, which is why you cannot make a simple binary decision as to whether something is or is not an X. It's somewhat unfortunate, as that leads to lots of confusion, but there is nothing logically wrong with it, it's simply a matter of fact that one has to consider when one wants to construct sound arguments, so as to never equivocate any two different meanings of the same word. The binary determination is only possible either for cases which evaluate to the same truth value with every conceivable definition of a word, or once you pin down the exact meaning that is intended in a given context.
Part of the problem with your arguments indeed seems to be equivocation. There is a definition of slaves that hinges on complete unfreedom, which is roughly what most people think of if you don't specify any specific definition - let's name that a slave1 for the purposes of this discussion. Then, there are definitions based on certain philosophical arguments that try to show how, for example, socialism produces similar power structures to "traditional" slavery in certain regards, we'll call that a slave2. (Similar arguments exist for capitalism, and many other power structures.) Now, you come along and say "requiring doctors to provide a service is making them a slave2", which is actually a perfectly reasonable statement to make - except you obviously imply "which is the same as a slave1, and everyone knows that being a slave1 is bad, therefore, requiring doctors to provide a service is bad", and that's just an equivocation fallacy that you employ to avoid having to justify why one is as bad as the other, where that is not the slightest bit obvious if you look at the actual circumstances that slave1s lived in and that doctors live in nowadays.
This is the analytic-synthetic dichotomy that derives from Kant's false theory of concepts and I reject it. I won't argue the point as my comments are for the Aristotelians in the audience not the Kantians.
Slavery is, by definition, not negotiated. It is a condition imposed upon someone without their choice. There are still actual slaves in this world, and none of them negotiated the terms of their slavery.
In a modern civilization, in a first-world nation, healthcare is a right--if it isn't, then I would like to have back the rights to monopoly of force I've granted to the government.
Also, HIPAA is not that hard.
The one time I had a physician take my blood pressure, he was like a 150WPM typist compared to the hunt-and-peck crowd. He was pumping, releasing, pumping, releasing like a madman, with his eyes fixed on the second hand of a large wall clock. He must have gotten 6 or 7 readings in a minute. After all that, he just said, "hmmm, yeah, let's get you on a diuretic."
My optometrist (the guy selling glasses) measured my eye sight and found that I needed a correction for some corneal irregularity (pardon me if I did not translate the terms right). I had never been given such a reading from my ophthalmologist (eye doctor) who just wrote down dioptry corrections. My optometrist then told me that the specific doctor never wrote down these numbers (i.e. ignoring a condition). This tought me a lot about medical professionals and highly educated doctors. My doctor probably is just a little bored to measure and monitor visual acuity changes in a person with small eyesight issues. That ophthalmologist also had very good reputation working with accident victims, etc.
I think this is what a physicians assistant and nurse practitioners are. At least that's my understanding. They don't have an MD but are able to do a number of diagnostics and can prescribe medicine.
They call that a physician's assistant or nurse practitioner. The latter has the nurse's more user-centric approach but can do pretty much everything a general practitioner does, including writing prescriptions (though not in Texas, yeehaw).
Note: I work for the Physician Assistant Education Association.
Our National Health Service benefits from substantial levels of integration, allowing for Fordist division of labour. The per-capita budget is much lower than in the US, but we can use that budget very efficiently.
Another example is the National Institute for Clinical Excellence, which develops evidence-based care pathways and makes key decisions on drug prescribing and purchasing. Because our drug buying is done centrally (giving the NHS considerable negotiating power), and because NICE are prepared to reject a drug on the basis of an inadequate cost-benefit ratio, we pay far less than most industrialised nations for medicines. It is my understanding that competition legislation would prevent insurers and HMOs from implementing such a system in the US.
As such, mistrust of social systems and government is deeply ingrained in US culture. Contrast this to Scandinavian countries or European countries who fundamentally trust the government.
The problem, IMO, isn't that we set up a system of distrust, but rather that we allowed the checks and balances (originally placed in the system to keep balance) to erode over time so now we have a negative feedback loop where our distrust of our own government is growing ever stronger, but for pretty good reasons (regardless of which "side of the aisle" you are on) -- unrestricted lobbying, mostly unrestricted campaign finance and lack of meaningful term limits on too much of our government increases power imbalance and thus distrust with no counterbalances to allow people to take back any power from the system that is now spinning out of control.
At this point the game is basically lost, I think, and we're just stuck sitting back and watching what happens as the system collapses over the next couple of decades. Hopefully it'll go a bit better than that "Collapse Gap" analysis suggested it will.
I agree with that idea, but guess who also agrees ... billionaire Warren Buffet.
http://www.nytimes.com/2011/08/15/opinion/stop-coddling-the-...
Quote: "My friends and I have been coddled long enough by a billionaire-friendly Congress. It’s time for our government to get serious about shared sacrifice."
And even among billionaires, Buffet isn't alone. Buffet, Bill Gates and other billionaires have agreed to leave most of their fortunes to charitable foundations instead of allowing their children to inherit it.
> who thinks taxes (on ... corporations) need to go up quite a bit...
Many US-based organizations are trying to establish HQ in places like England and Ireland b/c of tax advantages. e.g., Pfizer tried recently and AbbVie (another pharmaceutical giant) is in the process of doing so.
I have moved a few times, and I now happily make the two+ hour journey to see this doctor every time I need anything routine or that my major-city's doctor has a 2+ week waiting list.
This is in sharp contrast to last night, where my significant other visited the emergency room and the doctor came in and asked us why she weren't taking the medicine that our a doctor wrote for her on Wednesday. The kicker: she hadn't been to the doctor on Wednesday -- he completely screwed up everything, and then refused to see her again for the rest of the night, basically, making the OB/GYN nurse come down after surgery to talk to her and then the nurses.
My Small town doctor that I drive two+ hours for is much more amazing, happier, and gives me better care than my Cincinnati doctor. I can say the same about the dentists, and opticians that I've visited in Cincinnati as well.
They both retired earlier this year, and I am like a lost child again, having had so much trust in these two doctors :(
Be a nurse or PA because you have shadowed one, and enjoy the work. Their job is different than a Physicians, and personality (etc.) plays a part in which you'll enjoy. Additionally, the available specializations in medicine are something thats simply not available outside the profession. Don't settle for one or the other, choose the one that suits you.
Doctors are usually on a fixed fee for service arrangement but every year as people get older, the length of time it takes to perform the average "service" goes up. The amount of time and ressources needed to treat older patients is almost exponential with age. Older patients' state of health is often very complex with all kinds of interactions between illnesses and medication side effects to manage. Sick people get more "services" but also each service takes significantly more time to perform. Yet doctors are expected to be able to perform as many of them each year.
There is an oversized population of people in their fifties right now. This is the age where people start to get sick but are still young enough that they are often the main income earner for their family having one or more dependents.
Doctors have to work more hours for less money trying to help families cope with increasingly common and tragic medical conditions. When a family is collapsing because of an illness and people pile up in the doctor's office (justifiably) in tears, there is no ethical way to "process" these patients in the time that is supposed to be allocated to them.
This has already happened to older engineering professions and it has already happened to sectors of the software engineering world that have a different supply/demand balance than the mainstream (see: game developers). It will happen to us too. Hopefully not in the near future.
However I seriously doubt we will run out of work for programmers across all sectors - if we can code some business app to do something ten times as fast as a normal person takes to do it (likely a low bar) then there will always be businesses willing to pay for that.
We won't run out of work across all sectors. EEs still have work. Chemists and Biologists still have work. Aerospace engineers still have work. And lots of it! But the supply/demand balance has shifted enough in their respective sectors to have a very concrete impact on their compensation.
"The theoretic basis of alienation within the capitalist mode of production is that the worker invariably loses the ability to determine his or her life and destiny, when deprived of the right to think (conceive) of himself as the director of his actions; to determine the character of said actions; to define their relationship with other people; and to own the things and use the value of the goods and services, produced with their labour."
Ford exhibited other bizarre managerial tics, but the world was new-and-all...
Ford's hubris was total vertical integration, but that came later. Detroit is not exactly a worker's paradise today, and few people talk about it...
Marx assumed Malthus, and Malthus could not have anticipated the more modern aspects of mass production and mass agriculture.
Just as an anecdote, part of it is the expectations of the patient population in the Bay Area - and I'm only referring to the high income neighborhoods here; the situation differs significantly in low income neighborhoods.
Patients from high income backgrounds tend to be much more demanding than patients from low income backgrounds. At Stanford, the doctors in the emergency department are (informally) expected to stop what they're doing and sing Happy Birthday to certain high income individuals.
A lot of doctors translate this to a lack of respect, which echoes the quoted statement in the article.
Here's another anecdote. While sites like WebMD are fantastic for educating the general public about health issues, it also makes some people falsely believe they know more than the doctors treating them. And I don't mean they simply question their doctors - that is a good practice and everyone should be as educated as they can about their own health. But apparently many people argue and flat out ignore their doctors, even when their own knowledge is tragically incorrect. As one doctor put it, "Why did they come and see me at all, if they are already convinced of what they have? Just to waste their own time and money, not to mention my time?"
Again, there are times when one should definitely question their doctor and be as educated as they can. Second, third, and additional opinions can be very useful. But I'm sure many doctors would appreciate less arrogance and animosity in their attitudes.
One more note. Apparently a very high number (between 75-99%) of all doctors will have faced a malpractice claim at least once in their career. Most of these claims are frivolous, but going through something like this is extremely demoralizing. A couple of doctors I know came close to leaving the profession because of it, even after they were cleared of all wrongdoing.
I once described the job of a project manager to a doctor friend as a "thankless profession," and he immediately said, "that sounds like my job too!"
Does this mean a lack of general respect, the type that all people deserve? Or is this some kind of extra respect and dererence due to their education or profession, which no one deserves?
Because I am constantly disrespected by the medical profession. I am sent email a day or two before each appointment, reminding me that late or canceled appointments are subject to cancellation fees, yet I have NEVER been seen on time by any doctor ever.
I should have added that my friends are specialists, not general practitioners. I've heard lots of complaints about general practitioners too, in terms of late and canceled appointments, little to no interaction, being rushed out the door, etc.
Because I can't write my own prescriptions. Doctors like to abuse this privilege to charge ridiculous 'consultation fees' for giving me what I already know I need. One recent example I had to deal with: travel vaccines. $50 + $10/shot in addition to the cost of the vaccines so the guy could go "uh-huh you do need those vaccines; here you are".
A lot of people are anxious that they are going to lose their jobs to automation. The profession of medicine should be no different. Whatever is happening to them is happening to nearly every single individual on earth.
>>I once described the job of a project manager to a doctor friend as a "thankless profession," and he immediately said, "that sounds like my job too!"
The job of a project manager is probably the job with the highest ROI on earth. Where else do you get paid big money, to do meta supervisory work, forward emails and approve leaves. While not moving a finger towards doing any actual work yourself.
Now the dark side. I cannot imagine how many people are preparing bills, sending them to Medicare and then to my supplemental insurance. And how many questions I have about billing and how many phone calls I have to make. I am sure that the cost of administering payments is much higher than the cost of care. And yet none of that administrative work prevents disease or cures me. We need a single payer system and need to reduce the non-care-related paperwork. And let the healers heal.
The business model for professional athletes devolves to surviving a grueling selection process in the service of building their brand as a performer against which they can charge rents.
The business model for performing musicians devolves to surviving a grueling selection process in the service of building their brand as a performer against which they can charge rents.
This has a personal cost.
Society views doctors as tools that society has a legal right to.
Canada also heavily relies on US medical labs in Houston. I had to have a blood analysis done as part of a health check for a work contract years ago and my provincial health authority shipped my samples there for testing. It's cheaper for Canada to outsource all this work to Americans wonder what they are paying lab technicians.
"Geoff Ballinger, manager of Health Human Resources for CIHI, said the figures represent averages and vary significantly depending on a doctor’s specialty. For instance, the average family practitioner would earn less than a neurosurgeon or cardiologist."
http://www.theglobeandmail.com/life/health-and-fitness/healt...
* More than half of doctors are self employed, meaning that their salaries don't tell the whole story about their incomes.
* Doctors are heavily invested as stockholders in provider businesses (insurance, HMO's, etc.), and the malpractice insurance industry. Until recently, my employer-provided health care was delivered by a large organization that was entirely doctor-owned.
Sorry, no links or evidence for either of these, and I think the gathering of that evidence may be difficult due to the complex financial relationships involved. But it makes me skeptical when I read about doctors struggling against "the system." Who owns the system? It may very well be that medical care costs less overseas simply due to a simpler system where costs can actually be tracked. Medicine might become a better profession in the US if med school were free, doctors worked for a salary, and everything else was owned by the government.
To be fair, it may be doctors exploiting doctors, and your career prospects upon finishing medical school may have a lot to do with how much investment money (e.g., inheritance) you have at your disposal to buy into the portion of the business that ultimately profits.
I encouraged my son to avoid medicine. He followed my advice and is enjoying himself in private equity.
Anyone bright enough to do medicine would do far better in another profession.
Just as a point of reference, I'm in the U.S. and not a doctor. But I've always seen careers in medicine as a kind of social scam. Not necessarily a bad one, but there is or was something funny going on.
A person smart enough to be a doctor could be many things and earn a lot more money doing one of those things. The only thing society can really offer doctors is independence and respect. That's why -- for the longest time in this country -- doctors often owned and ran their own practices. That's why we addressed doctors with the honorific "Doctor." But the first is all but dead in this country and the second, because of some kind of unwashed, egalitarian ethic that only gets worse and worse, is starting to die out too.
We've really fucked up, as a society. No one in his or her right mind is going to want to spend life kow-towing to pervasive regulations and third-party bureaucrats second guessing them and tying their hands, while rushing to and fro like a retail clerk in an understaffed big box store, and all the while having to protect the egos of patients by introducing oneself as Bob or Sally.
Doctors need prestige and independence. Without those, the lure of "doing good" just isn't enough to convince anyone to become one -- at least, not anyone I'd want to have to trust as a patient.
Is that really true? Doctors are most of the best-paying jobs in the US [0] It seems to me that if you're bright, and care about making a lot of money, medicine is absolutely the way to go. Yes, there are some people who strike it rich with startups or high finance, but that's essentially buying a lotto ticket.
[0]: http://www.bls.gov/oes/current/oes_nat.htm#00-0000 (sort by annual mean wage, Anesthesiologists, Surgeons, Oral and Maxillofacial Surgeons, etc.)
"Gilded Paychecks: Lure of Great Wealth Affects Career Choices." NY Times. November 27, 2006.
* Get your M.D.
* Do anything afterward, except practice medicine
* Profit
I think being a doctor is about more than making money. But it isn't simply about helping people and making a good living. Smart people want to be able to exercise their own judgment and initiative. We need to be careful as a society, or the people we want as doctors are going to be the people we chase away.
The thirty somethings in my son's firm take home over 3M a year. One of the owners took home over 800M a couple of years ago.
Compared to remunerations like that, doctors get a miserable pittance.
Or is it just verbiage to shine for the next election ?
Will people suffer from Obamacare ? Are consequences to the whole system really under control (increase of the premiums, ...) ?
"In 1940, in inflation-adjusted 2010 dollars, the mean income for U.S. physicians was about $50,000. By 1970, it was close to $250,000—nearly six times the median household income."
Plenty of SDE 2s make more than 200k a year, and plenty of doctors don't.
I'm not sure if we are overpaid or they are underpaid.
*Edit I am of course being a bit sarcastic. It's interesting to see how shifts in the general economy are changing the medical profession.
Of course, doctors aren't the only professionals who are unhappy today. Many professions, including law and teaching, have become constrained by corporate structures, resulting in loss of autonomy, status, and respect.
Personally I think the history lesson in the article was great. It makes me wonder about programmers. We are riding high now. But if we keep producing software that neglects user intent, then perhaps we will also find ourselves regulated. I'm actually happy that the FTC has stepped in and constrained certain companies.
I work around a lot of physicians, and I've become a bit tired of hearing them complain about their jobs and pay... so I think I zeroed in on that part of the article.
Regulation is why those professions had autonomy, status, and respect in the first place. Without legal protection, a "professional" is just a laborer, and capital always wins out over labor in the end. Temporarily the software industry is growing so quickly that programmers have a lot of leverage, but that will end. The "corporate structure" will absorb more and nore of the value created by the professional.
And that's a good thing, right? Protectionism is bad, leads to higher prices for everyone. Why should doctors or programmers be protected more than Wal-Mart shelf stockers?
Here's one of numerous standards:
http://en.wikipedia.org/wiki/IEC_62304
Here's some FDA guidance covering Software Validation in Medical Devices:
http://www.fda.gov/medicaldevices/deviceregulationandguidanc...
It's absolutely essential that the FDA and international standards be applied when building a medical device, and that means that software must be developed according to the regulations.
Here's one reason why:
We sort of have to develop the habit of classifying producer-surplus-gain ( what people make above the cost of goods and services ) into rents and profits, where profits are proportional to "consumer surplus". "Consumer surplus" is the difference between what you pay for something and your reserve price for it. If you'd pay five bucks but get it for three, you have consumer surplus of two bucks.
Then and only then can we have even a hope of coherent discussion about "profit making enterprises". But one man's rent is another man's profit; it's all pretty nuanced.
I've never seen a doctor research anything either (although I'm sure they do behind the scenes). They seem to be pulling from whatever information cache they have in their head which I often suspect is horribly outdated.
I'd take a crowd sourced db of health info over a doctor's personal knowledge any day of the week.
Point is medical care is only as good as the quality of the "team" consisting of the doctor and the patient. It's a partnership, an expression of the doctor-patient relationship. Not every two people will form a natural team, after all, many marriages fail.
It's kind of a cliche, but still true, find a doctor you can work with, someone you can trust and relate to. More likely than not, that's the the definition of a "good" doctor.
That's a little surprising to me. One of the coolest things about practicing medicine today is that I can pull out my phone in front of a patient and find guidelines that I'm not familiar with, medication side-effects, and other point-of-care resources that really do enhance my clinical ability in real-time.
Granted, I work in a hospital setting. Maybe it's different in the clinics.
BTW, though I feel I'm underpaid for what I do (which many outsiders would find ridiculous), I'm overall pretty happy with being a physician.
> I'd take a crowd sourced db of health info over a doctor's personal knowledge any day of the week.
So would I. But what you'd learn in the first week of hanging out with a doctor in a typical clinical setting is that most patients are frankly too uneducated to be able to use that kind of tool. When I did residency, I suspect most of the patients I saw didn't have internet. Many were illiterate and a disturbing number simply didn't care about their own well-being.
I'd love to build up a practice with patients like you, but people like you tend to be pretty healthy.
> I'd love to build up a practice with patients like you, but people like you tend to be pretty healthy.
There's also the factor that teaching hospitals tend to get a lot of poor and uneducated patients. Private clinics have a different clientèle, and there are definitely plenty of individuals out there who are not in perfect medical condition, yet are educated/informed enough for doctors to interact with on a higher level than they currently do.
Watson thread from <1 week ago: https://news.ycombinator.com/item?id=8237618
Yep. There's apps to do your taxes. But the average person isn't able to understand double entry accounting without doing a year of study on it.
I have. It's terrifying. I recently went to the GP, told them my condition (which had been diagnosed by a different GP) and their first response was to look it up on Wikipedia. Seriously. I understand that a GP isn't going to know every condition you come in with but Wikipedia as the reference material?
Being realistic: yes, it's terrifying. GPs are subject to the same biases and prejudices as everyone else.
To top this all off, a GP is a General Practitioner. Their main role is to filter out the sniffles and the rashes, and keep an eye out for the more serious stuff, which gets passed on to an appropriate specialist. In the GP's case, going to Wikipedia gives a good, quick baseline on what the disease is. A GP shouldn't be prescribing drugs from WP, but if you say you've got McGrady's Syndrome, the GP looks it up quickly on WP (which is a very quick, concise resource), and finds out it's a liver problem of a certain type, the GP now has a base to work with. Liver problems mean X, Y, or Z in general, start looking at those avenues of inquiry.
The other thing is that while it should not be a canonical reference, when it comes to scientific topics, WP is very well written, concise, and quick to access. If you've ever used medical software, you'd know the high variety of quality there is - some is just plain awful when it comes to looking things up. And textbooks by their very nature go out of date.
Yup, they do it behind the scenes. They worry that too many patients would complain and feel insecure about a doctor having to do research in front of them, since the majority of patients want to feel that their doctor is the expert on all matters of their health. If a patient feels the care he/she wasn't up to par, and there are any complications, there is generally a very high risk of a lawsuit. So to prevent that, most doctors will do research outside of the view of the patient.
To be fair, they aren't sitting at their desks pulling up Wikipedia. Their research often consists of consulting with a specialist (or multiple specialists), consulting with colleagues, and searching through the volumes of medical periodicals and databases.
Most do this not just to be thorough and careful, but also because they know they need to practice defensive medicine and, well, cover their butts in case anything goes wrong.
I think it's a great idea, and so I went looking for a StackExchange forum for it. It turns out there is one that is in the staging phase:
http://area51.stackexchange.com/proposals/66048/health
Obviously caveat emptor, YMMV etc. would apply to such a forum, and the other issue is that a patient posting there doesn't have access to all the diagnosis tools that doctors do.
Plumbers and garbage men saved more lives in the past century than doctors. (so I hear)
I'm going to say something controversial here, but please bear with me. Your statement sort of encompasses several parts of this problem.
Some doctors are miracle workers (see [1] below), but most doctors are glorified auto mechanics. I don't say that to downplay the amount of intelligence/skill required for the job, but if you think of most doctors as "saving lives", then you obviously haven't spent a lot of time around doctors/clinics/hospitals.
Most doctors rarely save lives, and often when they do it wasn't them that really did the critical life saving steps, they're just the interface the sick person is interacting with. Most doctors deal with a series of inputs (symptoms and circumstances) and output a solution (diagnosis and remedy), which requires very little critical thinking on their part. Sick kids with the flu. Idiots that took too many drugs that need fluids, benzos, cypro, or an ice bath. People at mid-life who made shitty decisions for most of their lives and now need Lipitor/Coumadin/a treadmill/a gravestone.
The truth is most doctors get paid a lot because people erroneously assign to them the ethos of miracle workers, when most of them aren't. In fact, they often can't even do anything for their patients (see above, such kids with the flu, old people who've made shitty decisions their whole lives). The cures really come from researchers and pharma companies that come up with drugs and treatments for these incredibly difficult problems. If doctors deserve their paychecks, it's because they keep alive the illusion society wants. The illusion that when something is wrong, the doc will fix them up good. And indeed that's basically what the article is about. Doctors demand respect and to be paid to keep up the illusion and to deal with the bullshit.
[1] Obvious and important exceptions to this are ER docs and trauma surgeons, who indeed save lives. There are also clinical doctors, who work tirelessly with armies of researchers to try to find new cures for cancers, autoimmune and genetic disorders (among many other things). There are surgeons who come up with new procedures to reduce the invasiveness and trauma of procedures. These are the people that deserve the lion's share of the praise that goes towards doctors, and they should get the lions share of the money as well (some certainly do).
In this whole rant, I'm not trying to lay blame on doctors for the whole mess, because problems come from all sides, as I've hinted. Patients have unrealistic expectations of what doctors can do, the health industry is trying to low-ball doctors (not always without reason) to maximize profits, and many doctors who thought they would be genuinely helping people are realizing in reality that fate is largely decided before they even meet their patient (as a criminal lawyer friend put it, "90% of my client's case is decided before I ever meet him, but he wants me to work miracles!").
This is specifically why I didn't continue into medicine like so many of my friends. If you really want to help people, you don't become a regular doctor. You become a thoracic surgeon, or you do basic research, or you work in pharma, or you start a biotech. That's how you cure people. But no one will praise you for it.
You are wrong. We do "save lives", and not just in the ED. Every day, if not as dramatically, immediately or even noticeably, our incremental toil helps patients progress bit-by-bit toward better health. Managing chronic, debilitating conditions really does enable patients to live longer and more fully.
You are also wrong regarding income. Doctors in the US are getting paid less and less, while expenses of practice go ever higher. My own income is probably less than most of the people I know in other professions.
The "mess" of the health care system (to the extent it is even systematic) is the result of the constant assault of corporations and governments at all cost to "reduce costs", but the result has been the degradation you and others notice.
The most conspicuous evil has been perpetrated by the insurance industry. For example, amazingly short-sighted insistence on paying for a "generic" medication $3/mo cheaper than the drug already working is an every day challenge. If patients don't get what is really needed, they wind up getting sicker, need more care, the result is more money spent, not saved.
The problem is that the industrialization of medicine makes it increasingly difficult to be helpful. People are not neat little uniform units produced in factories. People are enormously complex organisms that defy all rules we invent to "explain" illness and treatment. People are unique entities that require individual attention and customized approaches if true "health care" is going to be provided.
If doctors are given the resources, time and respect to do their work, I believe almost all will strive to do it right.
Atul gawande, which is a doctor and a healthcare journalist ,and knows the medical system from inside, thinks that industrialized medicine is exactly what's needed:
http://www.newyorker.com/magazine/2012/08/13/big-med
And in general the positive results from decision support systems seem to agree with him.
No doubt there are instances whereby particular "industrial" implementations function well. But there are also many that function poorly. "Industrialization" is a term that can be applied to mean numerous and distinctly different things.
I was referring to situations I've observed where doctors are restricted from taking time when necessary to evaluate complex cases. Facing a patient with several serious conditions interacting and combining is far different than dealing with a patient having one condition.
It's impossible to do the job well when "bean-counters" insist on scheduling tightly and emphasis is on "production". This is particularly problematic in primary care settings.
Having been involved in quality assurance activities for many years, I fully understand the value of consistency, adherence to rational protocols, etc. But the ability to deal with "outliers", especially when the exception is the rule, is where "industrialization" is at risk of failing.
But i wonder:
On what sources do you rely when it comes to managing complex cases ? is it only known hard coded medical data in books and databases ? or also some intuition ?
And if it's intuition , how can you form intuition for such complex cases where really each case is pretty unique , as you said ?
Evidence is necessary but by itself insufficient. We must use our own power of observation combined with what we know and what we've learned to decide what to do.
So your question is indeed profound, cuts to the core of the issues. Intuition is one way to phrase it. I once heard a colleague say we're not paid because of what we know, but for the judgement we exercise about advice or treatment to offer.
Each human is indeed unique. Even identical twins are in fact not exactly the same. Rules have limits when no two cases are precisely the same, it always comes down to that very intuition you are intuitively aware of.
After all, we frequently wish to have a second opinion. I do often enough too. I like the saying, get 5 experts in a room, and you're likely to get at least 6 opinions on any subject.
Who said decisions should be easy? I sweat over each and every one.
True medicine is a really hard job.
So maybe the way decide in medicine should be changed ? maybe they be done remotely but through a recommendation system so that each doctor would get plenty of nearly similar cases - so he could practice and hone it's intuition ?
Or since the complexity is really too great (and as a patient hearing that "this is art not science" isn't that encouraging , even if true) maybe the overarching goal of medicine should be to remove the art, and we finally have the tools to do it(watson, machine learning ,remote diagnosis , etc...) ?
And if we agree that that's a good goal, maybe the current way we try to do it (evidence based medicine) , is a bit clumsy due to both the science and the resistance by doctors , but at least it's going in the right directorion.
Pardon my ignorance, but aren't generics chemically-identical compounds that simply don't carry the brand name? My "generic replacement for Norco" is still acetaminophen and hydrocodone. Indeed, the Wikipedia article on generics notes that "A generic drug must contain the same active ingredients as the original formulation", and that it must be "comparable in dosage form, strength, quality and performance characteristics, and intended use".
What am I missing that makes generics a problem?
They get paid a lot because they have the training to both recognise and know what to do with the edge cases. Yes, the bulk of patients can be treated with the same steps, and the nursing staff can do most of that stuff without problem. But doctors are there to watch for the edge cases, and for odd cases, discuss it with their peers. Regular meetings where doctors go over uncommon issues patients are having - you may not see it when you're on the ward itself, but it's part of the process, spreading the diagnostic load, keeping skills up, and improving outcomes for the patient.
If you really want to help people, you don't become a regular doctor.
A friend's father stopped being a gynaecologist and returned to family-practise GP, because he felt like he could help people better that way, and keep himself more interested in medicine because it was more diverse an environment. In neither environment was he saving lives, but he was still helping people. The two are not synonymous.
Your comment comes off as personally bitter, and I think insulting to folks like GPs who do help people even if they aren't literally saving lives as part of daily practice. You also seem to have conflated 'finding new cures' with 'what a doctor does', the latter of which has a lot of 'applying found cures' to it, and certainly helps people.
You can't enter a profession on the basis that it will be personally rewarding. You can only leave because it turns out not to be.