
More Doctors Giving Up Private Practices - jamesbritt
http://www.nytimes.com/2010/03/26/health/policy/26docs.html
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fnid2
Free education for doctors and _more_ of them besides the arbitrarily limited
11,000 or so a year medical school seats mandated by the AMA would do a lot
for increasing the supply of doctors and reducing costs.

If more doctors could open practices, there'd be more choice for consumers.

I mean really, why do we even _let_ the AMA -- doctors themselves --
artificially limit the supply of doctors? Of course they are going to keep the
numbers low. 11,000 (the last number I found) new doctors every year is simply
NOT enough. It may be a little bit higher, but last I researched, for years it
was 10,000 and only after a lot of controversy did they increase it to 11,000.

The system is designed to force doctors into debt so they have to be money
focused and charge a lot and keep rates high for all the other doctors. The
doctors, many of whom are my long time friends, are _not_ happy with the
system. They want more freedom. They feel like slaves to debt. One good friend
left grad school with over $250,000 in debt! It takes a long time to pay that
off. She can't take on more debt to open a private practice, nor would she
have the experience really -- she's forced into the big hospital system that
she _knows_ is flawed, but she's powerless to change it because the huge
medical institutions call the shots, not the doctors. We think doctors are
invincible and make tons of money, but if they lose their jobs -- it's a
horrible experience, because it'll be very difficult for them to find another
job -- doctors talk and bankruptcy doesn't clear student loan debt, so even
_that_ isn't an option.

Add to that, the fact that individuals aren't even allowed to care for their
own medical well being and you have a system that is _way_ unfairly balanced
toward doctors and away from patients. Not even the doctors really, the
hospitals.

Why, in the "leader of the free world" are individuals not free to care for
themselves? Prescribe their own medications? Order their own labs and CAT
scans and the like?

Why do we give the AMA so much power? Why don't patients have any over their
_own_ lives?

I suppose patients do have _some_ power -- over the doctors. There are doctors
out there who send patients with viruses out with antibiotics because the
patient _wants_ something. They prescribe drugs from tv commercials because
the patient wants something. Why do we let them do this? There should be laws
against prescribing antibiotics for people who don't have bacterial
infections. I know that and I'm not a doctor, but doctors still do it.

There's really something wrong with our system. It's _completely_ irrational.
There's simply _too_ much money in it and people go crazy.

~~~
siculars
>Why, in the "leader of the free world" are individuals not free to care for
themselves? Prescribe their own medications? Order their own labs and CAT
scans and the like?

Uh... Dude, I would never prescribe my own medication. Unless you yourself are
a pharmacist or physician it would be insane. Best case you get better (long
shot), more likely placebo/neutral, worst case suicide. The best you yourself
can do regarding self prescribed meds is whatever you can get over the counter
at CVS. Also, according to my MD brother, half the reason we are in the
predicament we are in is what is known as "defensive medicine" which he
describes as performing unnecessary tests, "CT scans and the like", on the 1%
chance that it might be helpful - specifically to curtail any potential
malpractice.

Face it, there is a reason people can not self prescribe, self order tests or
conduct their own operations. Although you would like to blame the AMA (and I
do fault them for the lackluster MD minting volume), by and large non
healthcare professionals don't know what the hell they are doing/talking
about.

~~~
fnid2
There are many cases where individuals are totally capable of caring for
themselves. For example, diabetes patients test their own blood. If they need
more insulin, why does a doctor have to prescribe it? They know they need it
and will always need it. Same is true for synthetic thyroid hormone and other
endocrine issues. Birth control pills are another example.

There are lots of conditions where it is easy for the individual to maintain
their own medications.

If you would never prescribe your own medications, that's fine, you can
continue to go see a doctor. For those of us who are educated, inclined, and
motivated enough to care for our own bodies, we should have the right to do
so. I have the right to life, liberty, and the pursuit of happiness, except
that I am required, by law, to go to someone else to make sure I have the life
part.

I can build my own house too. I can change my own oil and fix my plumbing, but
that doesn't mean _everyone_ has to do those things. They can still buy
existing homes, take their car to the shop, or call a plumber.

Imagine if the law _required_ you to call a plumber or take your car to the
dealer to have it serviced.

It's my body and my life. I accept the responsibility for it and for knowing
how much of which medications I need to take and when.

Doctors know a lot, but all doctors don't know everything about every medical
condition. With chronic illnesses, sometimes the patient actually knows _more_
than the doctor. Have you ever watched that show on TV about medical
conditions people have for years and years? They go see doctor after doctor
and they never get a diagnosis and they have problem after compounding
problem.

Until one day, they go to the internet and do some research and figure out
what they have, print out the papers, go to a _new_ doctor and show them what
they have and then, _finally_ they get the treatments they need. I argue, that
person should just be able to order the treatments they need without having to
go to a doctor at all. Forcing people to go to a doctor, or multiple doctors,
who don't know what is going on and who don't care enough to research the
condition can make people _sicker_ or at least not _better_.

~~~
andymism
> diabetes patients test their own blood. If they need more insulin, why does
> a doctor have to prescribe it

In many states (California is one) you can by certain brands of insulin OTC.
The limitation is more a decision of the manufacturer than it is codified into
law. Pharmaceutical companies are well known for milking their patents as long
as they can and then lobbying hard for OTC status as soon as the end date on
their patent is coming up. This gives them the opportunity to continue to push
their brand and squashes any competitors who are still behind the counter.

You need look no further than allergy medications for an example. Claritin and
Allegra were the biggest brand names in prescription allergy medications just
a few years ago. But as Claritin's patent protection period was ending, its
makers pushed hard to go OTC. And they did. The result is that Claritin
dominates the OTC allergy medication category while Allegra is no longer
covered by insurance plans because an OTC alternative is available. It's easy
to guess what this did to Allegra's market share.

> There are lots of conditions where it is easy for the individual to maintain
> their own medications

Maintain is the key word here. OTC availability is only half the story. Your
comment makes the assumption that someone knows that they're developing some
sort of condition, say diabetes, in the same way they know they're coming down
with a cold. How do you know you're becoming diabetic without a doctor's
examination and follow up? Are you just going to know think one day that "Hey,
maybe I'll google why I feel tired all the time and have been bruising easily
lately..."

I know that the medical system is under a lot of fire these days and it's
everyone's favorite axe to grind, but some good reasons that prescription
control is necessary is to (1) control easily abused substances (this means
narcotics as well as antibiotics, though the litigious culture here in the US
is quickly rendering traditional antibiotics useless) and, probably most
importantly, (2) maintain communication with your healthcare provider. Doctors
use prescriptions in order to monitor your compliance and require (at minimum)
annual visits so they can check up on you, even if it is only for 5 or 10
minutes. Maybe that decrease in energy is a side effect, or even that
occasional but not cold related cough. Your doctor will recognize this and
will be able to suggest changes. You probably had no idea a cough was a
related side effect. Even if you did, did you keep up on any of the literature
for the class of drugs you're taking in the past year? I doubt it. You have
better things to do with your time.

> Doctors know a lot, but all doctors don't know everything about every
> medical condition.

You're right about that. But that's why we have a system of specialists. Even
a less than average doctor will refer you up and down that chain until you're
dead, out of money, fixed, or have found a way to live with it. It's like
throwing a reverse exception where it gets passed from the most general to the
most specific handler. Or a search tree where the root is the most general
case and the leaf nodes the most specific. Of course it could be more
efficient: science could be more advanced, doctors could be smarter, insurance
companies more willing to pay, and patients less litigious. But the way
doctors handle medical cases has evolved this way because it can solve the
most common cases the fastest. And the rare cases, the exceptions? Well,
they're rare and the exceptions.

The reason you see so many cases of patients out diagnosing doctors on TV is
exactly because they're the rare, man-bites-dog kind of story. How many
lottery losers do you see on the nightly news? Safely landing planes? How
about stories about cars _not_ piling up in bad weather? My advice to you
(though you don't want it) is to stop watching TV. Or at least, stop watching
TV and then using what little information is conveyed to make generalizations
about the world and how society should be run.

\--

What became obvious to me from reading your comments is that you don't know
what you don't know and that you assume that what you don't know is trivial.
There is an unprecedented wealth of information at our fingertips. That's a
cliche. But no number of articles read on Wikipedia, no number of Google
searches, or stays at a Holiday Inn Express can replace the actual _practice_
of medicine.

~~~
_delirium
I agree on the last part there that there is lots the average person doesn't
know. But one can also easily overestimate the knowledge specialists have, as
they often don't have that knowledge either. Most doctors I know _shudder_ at
the thought of entrusting their lives to many of their med-school colleagues,
and will off-the-record go on and on about how many doctors are 10+ years out
of date with their knowledge of current medical literature, and how much
cargo-cult "well this is how we do things" medicine is still prevalent,
despite the attempts of EBM to wipe it out. Most also recommend that I do my
own research before believing any doctor, though that isn't the advice they
give their own patients.

I don't think it would necessarily be the case that a smart person with access
to a good library couldn't do a better job self-diagnosing for a wide variety
of routine conditions, especially since they would be willing to put in more
research than the average doctor does. We're not talking about performing your
own heart surgery, but more like the 80%+ of cases where the correct thing to
do is a relatively routine decision that depends more on diligence in research
and being informed about current best practices, than on any specialized
skill. There are _computer programs_ that can outperform the average physician
in many areas (though not necessarily the top doctors; but you aren't likely
seeing the top doctors, either). The self-diagnoser also has one key
advantage, in that they are (presumably) only interested in their own well-
being, not in defensive medicine and fear of malpractice suits.

Of course, it does require being a relatively level-headed person who knows
how to read the relevant literature. Excitable folks, people who have never
read an academic-sounding paper, and hypochondriacs are probably all better
off not self-diagnosing.

~~~
ippisl
I think you overestimate the ability to self diagnose objectively. i heard
that medical students , while learning about medical conditions , start to see
symptoms in themselves , and believe they have all kind of illnesses.

So collaborating with your doctor seems like a better path(especially since he
has access to various tests).

~~~
yummyfajitas
Or, we could give patients direct access to various tests without the
permission of a doctor.

~~~
HeyLaughingBoy
How would that help? How would you know what tests to order? How do you
interpret them? How do you know that if test A has a certain result, then test
B should be ordered to check for cross correlation with something else?

It's really easy to say "just order my own tests" but the reality is that it
would be pointless for most people except... trained medical staff!

------
vinhboy
The other day I was having a discussion with some other programmers about how
our profession is slowly becoming a production line... pretty soon knowing how
to program will be like working on a production line putting together a car.
Only a couple of smart people need to design the specs, and the rest just
repeat the steps.

It's interesting to me that by combining the health care industry, doctors are
also becoming assembly line workers.

Go to the second floor for heart, third floor for feet, etc...

I have not decided if I like this or not.

~~~
jerf
"The other day I was having a discussion with some other programmers about how
our profession is slowly becoming a production line..."

People have been saying that for _sixty years_. It's less true than ever, at
least for good programmers, as more and more of the accidental (in Fred
Brook's sense of the term) gets automated away, leaving ever-more-refined
essential behind.

If you really want to make me laugh, why don't you go design the
language+framework+environment that will complete the task of making
programming assembly line work. You can call it "5GL". (Google it.)

I would expect doctoring to go the same route over the next 30 years. More
routine may be shoved onto checklists and perhaps even robots, but that will
just make the non-routine something that becomes an even larger part of a
given doctor's time.

Although we may end up having more technicians and fewer doctors. Arguably
computer programming has gone this way too.

~~~
fnid2
I think it is increasingly true over time. The amount of software use is
increasing and the quality of programmers required to solve problems with
software is declining. There's a lot of open source out there, so you can see
the code and see that it isn't _that_ great a lot of times, but it gets
proliferated with marketing, much like factory goods.

Imagine the furniture artisans from the 1800's looking at the quality of
furniture sold in the stores today... shoddy materials, weak joints, poor
finishing. It's almost the same today in software -- or at least the trend is
in that direction.

You can still get quality furniture today with solid wood, great finishes, and
sturdy construction, but you have to pay 10x or 20x the price of something
from IKEA. Same is true of software. So you could say it is less true for
"good" programmers, but it's also less true for good furniture makers. If it
is true that abundance creates scarcity, the abundance of bad software and
programmers has created a scarcity of good software and programmers, just like
every other industry.

Besides, saying it isn't true for good programmers is a like the No True
Scotsman fallacy. What is a good programmer? Is a good programmer someone for
whom it isn't true? Can you quantify what it is that makes a good programmer?
Can software users tell the difference? I don't think they can.

~~~
jerf
"Besides, saying it isn't true for good programmers is a like the No True
Scotsman fallacy."

No, because I can point to the people I'm referring to. In 1960, we did not
have a lot of dedicated QA staff, dedicated sysadmins and IT, dedicated server
farms, and so on and so on. Programmers have grown up auxiliary support
personnel around them. The same has been true of doctors for a long time
("nurses") and will be more true, but the core doctors will actually be
dealing with less and less of the routine.

The problem with your "software is getting crappier like furniture" theses is
that it's flat-out wrong. If software was today as crappy as it was in 1980,
_the Internet would not work_. We _can't_ have the same bug-count-per-feature
we had back then, we've got a crapload more features for bugs to be in! What
_is_ true is that we've got frameworks and libraries of a quality the
programmers of the 1980s could only dream of, and a programmer can take these
and trade technical quality for speed of development, and while the result can
still be quite messy it is simply an option that didn't exist in 1980. On the
whole though, software is radically better now than it was then; the
alternative is not even technically feasible, it wouldn't even begin to work.

Seriously, if you think I'm on crack, go back and find the oldest source code
you can. What you remember as a shining example of bug-free code will be
revealed to be code that by modern standards is barely holding together and
fails to exhibit bugs only because the task it takes on is so small there's
hardly any room to trick it into doing something wrong. Not a viable path
going forward.

------
aaronblohowiak
The EHR money is a game-changer. There is SO MUCH waste in prescriptions,
labs, dicom and billing.. once easy and affordable EHR is viable for the "long
tail", we will enable the solo / small practice physicians.

~~~
rdl
I agree -- and it's amazing how bad the existing software is. (I work in this
field).

It would be a great place to do a startup (there are a bunch of niches which
could easily support multiple companies) -- it's mainly implementing open but
antiquated specs from the late 1980s, doing interop testing with existing
vendors, and being able to go through the long sales cycle. You would want
some MDs on the team, which makes it kind of expensive (young MDs need to pay
off their schooling, and older ones would be giving up profitable jobs).

The $40-80k per EHR thing is a big market opportunity.

~~~
aaronblohowiak
Antiquated? but HL7 is XML!!! ;) The barriers to entry are pretty high just to
have a baseline solution, and then you have to figure out how to reach the few
people that have decision making authority to implement this kind of system. A
lot of interesting things were discussed at HIMSS, very exciting things are
happening in this space.

~~~
nradov
In particular, anyone who wants to sell a complete EHR product will generally
need CCHIT certification. That isn't easy or cheap even if you have smart
developers and good tools. [http://www.cchit.org/certify/2011/cchit-
certified-2011-ambul...](http://www.cchit.org/certify/2011/cchit-
certified-2011-ambulatory-ehr)

~~~
iends
Hopefully this is not the case. With the interim final rule all but ignoring
CCHIT (<http://edocket.access.gpo.gov/2010/E9-31216.htm>) there is hope that
somebody comes up with a real certification rather than a list of functional
requirements for EHRs.

~~~
nradov
The regulation can't specifically delegate certification authority to a single
private organization, but it is highly likely that CCHIT will end up being one
of the certifying bodies. HHS may include other organizations as certifying
bodies but I don't think anyone has really stepped forward yet with a complete
proposal.

