THE PROBLEM WITH DOCTORS

Overtrained, overpaid, and overrated.

It’s easy to find reasons for the current health care shambles in the USA. The heavy reliance on insurance fogs over what should be a high-visibility nexus of prices and services. The malpractice lawsuit industry essentially encourages doctors to be ignorant and profligate—to let expensive technologies do the diagnostic work, and deflect the blame for them when things go wrong. Patients are a significant part of the problem too; they overeat, under-exercise, take too many drugs, and believe in $19.99 miracle cures advertised on late-night TV.

But what about doctors?

I don’t think that I’ve ever heard anyone criticize MDs as contributors to the problem. They are commonly supposed to suffer along with the rest of us. Sure, they make a lot of money, but—the assumption seems to be—amid the vast explosion of health care costs their fees are hardly noticeable. Besides, they have to run the gauntlet of med school, internship, residency—nearly a decade of hard work and sleep loss, on top of college.

However, I think that doctors definitely are part of the problem, and that readjusting their status (and thus their pay) could be the single most important step towards fixing the health care system.

The expense of making doctors, and the high status we grant them, mean that in many and perhaps most parts of the country, there are just not enough of them. MDs often emerge from med school needing to repay huge debts as swiftly as possible, and even if they are debt-free, the culture basically tells them that they are schmucks if they don’t earn vast sums. Thus many communities effectively can’t afford to pay doctors what the doctors think they should be earning. Primary care facilities in these areas are swamped with patients, even when they try to bulk up their staff with physician’s assistants (who are still largely dependent on doctors for decision-making). Specialists are typically booked for months in advance. If you go to a rural or semi-rural ER and do not have swiftly deteriorating vital signs, expect to wait four to eight hours before anyone will see you.

This situation is the result of tradition, and presumably a dose of doctor’s-lobby rent-seeking. But it doesn’t have to continue. We as a society grant doctors the special status of health care gatekeepers—usually only they can order tests or prescribe drugs—but we may choose to extend such powers to less-trained, lower-paid people too. A person does not really have to go to med school and then wade through an internal medicine residency to know how to diagnose, say, Lyme disease—or any of the handful of disorders that account for the vast majority of primary care visits. In my opinion, a person does not even need a college degree. A year or so of focussed study, plus a year or two of apprenticeship, should be sufficient to learn the basics of primary care: which means, taking a history, doing a physical exam, ordering basic tests, making a tentative diagnosis (of one to two dozen common ailments), getting treatment started in uncomplicated cases, and referring patients to specialists.

The amount of information that one needs to have onboard for this is just not that large. Almost all of it is online and easily available anyway.

I think it’s worth pointing out too that in many other countries, common drugs are available without a prescription, and people routinely diagnose and treat themselves. Moreover, in such countries, one generally can get adequate primary care from physicians who are much less intensively trained—and also are paid much less—than their American counterparts.

Won’t the practice of lesser-trained caregivers be imperfect? Of course—no one is perfect. On the other hand, a caregiver with a less lofty status should be more humble and more willing to be seen cracking the clinical books, searching on Pubmed, or even googling when confronted by less-than-obvious cases—as I believe American MDs do routinely, when their patients aren’t looking. An objective provider-rating system would help as well.

I think of the overblown status of doctors today and I think of what Henry Ford did for car production or Ray Kroc did for fast-food production. Far from exalting one type of worker with presumed expertise and status, these innovators broke the production and service system down into small, easy tasks, any one of which could be performed by relatively lightly skilled people.

Obviously one can’t break down health care so much that it’s delivered principally by minimum-wage workers. But non-emergency diagnosis and care could be delivered by relatively lightly trained people (relative to the absurd twelve-year ordeal of college plus med school plus internship/residency), who could then hand off patients, if they have something complicated, to specialists—and even these specialists in many cases could have narrower, more manageable specialties than they do today. The point is that health care givers at many levels, especially the primary level, would require significantly less training, and so there could be many more of them. They would require lower salaries too, and so they would be much more affordable. They might even resume living in the communities where they work—a practice that used to be common but is now almost dead.

Thanks to heavy demand from an aging population, health care as an economic sector has been growing despite the heavy constraints put on it by outdated rules and practices. Weakening the status of doctors would really free up this sector, fixing a lot of what is wrong with healthcare provision at the same time that it boosts employment.

A point that bears repeating here—because a lot of people don’t want to believe it—is that basic medicine is largely “cookbook” stuff. If you are intellectually curious enough to be reading this essay, you’d probably be bored pretty quickly as a general practitioner. A fairly well known neurologist once told me that even his relatively challenging specialty bored him. A few years out of med school, he had realized that diagnosis in his daily practice was just too easy. He moved on to research and teaching, and never looked back.

What I’ve sketched out here is really just a special case of a broader argument that I’ve made before about modern education: People need less time-consuming (but more focussed) formal school-type training, and more apprenticeship-type training—and they generally should not be paying for non-work-related courses, e.g., in English lit or philosophy, at lawny, beer-soaked, four-year colleges. Stuff that you don’t need for work you always can learn on your own—and you’ll probably learn it better that way.

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Postscript: This New Yorker piece by Atul Gawande appeared shortly after the above essay was posted. Gawande, a surgeon at Brigham & Women’s in Boston, deals with the related issue of “big med” chains’ care optimization and cost-saving (he uses the management of The Cheesecake Factory as his paradigm). A central theme is that individual doctors’ egos are apt to get in the way of progress. Key quote: “We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change.” But his argument begs the question: where is the equivalent of the MD at a Cheesecake factory? My answer is that there isn’t, because such organizations don’t need and can’t afford people who have such bloated amounts of training, compensation and authority.

Post-postscript: “When the doctor is not needed.” (NYT editorial, 16 Dec 2012)

THE PROBLEM WITH DOCTORS