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I think it's funny that the first picture in the article is of a doctor taking a patient's blood pressure. It's a little ironic because I've never actually had a doctor take my blood pressure (in the US). I'm not even sure if I've had a nurse do it, but more likely a physician's assistant or phlebotomist. Just like other industries medicine has been turned into an assembly line where patients are herded through the system with professionals at each level of the training pyramid doing their part. We do this to be efficient and cost effective, but speaking from personal experience, the side effect is that information gets lost from transfer to transfer and a patient has less time to bond with a doctor. I'd like to believe that many doctors would be happier working with a patient from start to finish like in the old days.

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What has always confused me is that the perceived gap between doctors and nurses is so big. I have the impression that nurses could benefit a lot from better training and there could be a good case for positions somewhere between a nurse and a doctor. Considering the effect that _care_ (time with patient) has on patients the current model with a demi-god in white just does not scale.

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.

Here in the UK, in addition to Nurse Practitioners we also have Surgical Care Practitioners - non-doctors who are trained to perform a specific subset of routine surgeries, or to assist in more complex surgery. It really doesn't make much sense to have a highly trained cardiac surgeon spend half an hour stitching up a patient after a surgery.

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.

> positions somewhere between a nurse and a doctor

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).

Not to be too pedantic, but the profession is "physician assistant", not "physician's assistant." They typically have master's degrees (and all will be required to have master's degrees by 2020), can practice medicine in most specialities (including surgery, pediatrics, etc.), and can prescribe medicine in all 50 states.

Note: I work for the Physician Assistant Education Association.

"positions somewhere between a nurse and a doctor"

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.

I have relatives that are nurse practitioners. Even at that level, there are a lot of doctors that view nurses in the way that you would expect a character on Mad Men to view a female secretary (below them, just there to do their bidding, don't know anything, etc).

In order to understand the US, you have to go back to the formation of the country. The US was started because of distrust in the British government. The constitution was setup on a system of distrust, not trust.

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.

I'm a leftie socialist tree-hugger American who thinks taxes (on the wealthy and corporations) need to go up quite a bit... but I still think a system of distrust is the way to go, because humans, while generally more good than evil, are inherently selfish and flawed and can too easily rationalize injustice in the face of personal gain and that makes them worthy of distrust, especially when organized.

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'm a leftie socialist tree-hugger American who thinks taxes (on the wealthy and corporations) need to go up quite a bit...

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.

Well, Buffet is in the process of engineering movement of Burger King to Canada in part b/c of tax considerations.

> 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 go to a doctor who always takes his own blood pressure readings. He also goes over every word that the nurse has charted, to make sure that he's not missing anything.

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.

My primary care physician and my neurologist both would personally take my readings and do even the most basic of exams themselves. They were extremely thorough, and had the utmost respect for their patients. Maybe this was the case because they were both 60+ years of age and had their own practices -- maybe this allowed them to buck the trend by having established their business before things got really bad.

They both retired earlier this year, and I am like a lost child again, having had so much trust in these two doctors :(

...I've never actually had a doctor take my blood pressure...

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."

At my doctor, the nurse takes my blood pressure and then then my doctor takes it again when he first sees me.

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