Thursday, March 25, 2010

The decline of medicine


There has been much talk of people leaving the medical profession if government further bureaucratizes health care. But the odds are great that there won't be any dramatic job stoppage. No medical "Galt's Gulch" will form where masses of physicians on strike will live in peace and solitude, some building cars and others mining copper, all vowing never to return to medicine until their demands are met. Such is the stuff of fiction. But the reality is much worse.

What will happen is more insidious, though over time no less damaging. There will be an increase in early retirement, as more physicians tire of their jobs. More physicians will take time off and let their practices suffer at the margin. Patients will have slightly more difficulty making appointments . . . each year . . . year after year, though never so quickly as to lead to mass complaints or a recognition that things are obviously worse.


The filter of who gets into medical school will change. Fewer will enter the field due to intellectual curiosity. More and more people who cannot tolerate bureaucracy will be weeded out. Questioning authority will become as dangerous in medicine as it is in policing or the military. The 40-hour physician work week, on the other hand, will become commonplace, and the type of person attracted to medicine will not be the type who is willing to work any longer, or any harder.

Health care will be less a service than a commodity. All your complaints will have answers, if not always the right answers. Workups will be standardized by "expert panels" allegedly educating physicians as to "best practices." And if the "best practice" is to not treat you because it is not cost-effective to society, the fact that you want and are willing to pay for the treatment will be seen as a problem rather than a solution.

These panels are designed to save money by making workups more efficient and uniform, but the reality is different. More expensive imaging tests routinely substitute for less expensive physical exams because the quality of physical exams varies and doctors have little incentive to improve their own abilities at examination. Not only is it becoming something of a lost art ("Why use a stethoscope to listen for a heart murmur when we can just see it on a cardiac ultrasound exam?"), but it takes time. And since doctors are paid by third parties more concerned about efficiency than quality, taking time with patients—improving one's diagnostic exam skills—is a luxury fewer and fewer physicians can afford.

Does this sound unbelievable? It is happening already. In the 1990s the Office of Inspector General investigated major teaching hospitals in America. Taxpayers are billed by such institutions for training new generations of physicians. PATH (Physicians at Teaching Hospitals) audits found patients in these hospitals were commonly evaluated by medical students or interns only. Attending senior physicians were fraudulently simply "signing off," saying, "I agree," without ever seeing the patient. The University of Pennsylvania Hospital settled a PATH dispute for $30 million, and Thomas Jefferson University Hospital did so for $12 million. Anecdotes describing such problems abound, including hospital charts saying, "Physical exam shows both pupils equally reactive to light," when the patient had actually been blind in one eye for decades, a mistake much more easily attributable to the exam's never having been done than to error.


Pharmaceutical innovation, produced by those evil for-profit companies that even doctors love to denounce, will drop off. Not precipitously, but eventually. And people will die, as they have died since time immemorial, without anyone ever knowing what drugs might have improved or extended their lives, if only there had been greater incentives to produce them.

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