08 September 2007

The problem for American docs

We don't talk very often about the role that physicians play in our sick healthcare system. Most of them are unhappy with their loss of control and the fact that they can't just concentrate on healing patients — but instead need to be businessmen and now employees of the HMOs and PPOs, getting permission for every procedure.

Statistics show that a majority of medical students begin idealistically, planning to be primary care physicians. By the time they graduate, however, faced with medical school debt of more than a quarter million dollars, most decide they need to go into a specialty, where they will earn more money.

This article, about an opinionated older physician, quotes him saying that "the amount of money involved in the system brings out one of the more negative human attributes -- greed.

"'Unless and until these extraordinary costs unique to the United States are squashed into manageability, there is too much greed and too little control of greed being exercised,' said Bennett, a Harvard Medical School graduate, who operates a practice that bases its fees on the ability of his patients to pay. 'It does not matter what politician suggests what plan --- Republican or Democratic, that plan will fail.'"

He goes on to list four specific physician-related issues:

• the educational debt carried by new doctors;
• the practice of hospitals "owning" the physicians who are affiliated with them;
• extraordinarily high prescription drug costs; and
• the advent of health management organizations, which have assumed a middleman position between patients, health care providers, pharmaceutical companies and hospitals.


1 comment:

Andrew Oh-Willeke said...

A few more issues are relevant when it comes to "physician issues".

One of the really important ones is that physicians are routinely self-employed, and routinely fail to delegate administrative tasks to the extent possible. The trouble is, that few physicians are qualified by training or temperment to be good administrators.

Take routine long waits at doctor's offices. No one waits for an appointment at a doctor's office because a doctor is busy -- people wait at doctor's offices because doctor's do a poor job of realistic planning for the events that routinely come up.

This does help make doctor's rich, but it also makes them unhappy.

Also, most doctor's are, by training and disposition, too sure of themselves and too individualistic -- which produces mediocre quality of care even for those with good health insurance. This is related to the first point. The doctors that perform the highest quality medicine in this country, at places like Mayo Clinic and the Veteran's Administration, are rarely the best paid. Instead, they have competent doctors, with very good systems within which they operate, and work on a salary in an environment where all non-medical work is delegated to professional administrators.

One can criticize HMOs all day long for imposing medical requirements without having the qualifications to do so, but the reason that this even comes up is because (1) a minority of doctors consciously abuse the system to drive up their revenues and (2) studies have shown that very few doctors systematically take all the steps that the literature proves work. Doctors are trained to be individual professional diagnosticians who place a high premium on memorization, not to develop good systems in an overall practice context that integrates doctors and non-doctors and equipment and documentation.

By the book, systems oriented medicine may not be as exciting to do, but the results are reward enough. This is particularly a problem with generalists who encounter all sorts of situations. Until generalist physicians start to conceptualize themselves as engaged in just another highly specialized role, rather than as true generalists, there is going to be an institutional fight against the routinization that is necessary to get high quality care every time.