

The Myth of Prevention  - absconditus
http://online.wsj.com/article/SB10001424052970204005504574235751720822322.html

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pj
How about not letting the AMA artificially limit the supply of doctors? How
about letting patients care for themselves? Acquire their own medicine? Ask
for their own blood tests and monitor their own hormone and chemical levels
without having to go to a doctor? This guy is a doctor, no wonder he doesn't
mention allowing people to not need him. Imagine if we forced companies and
individuals to go to people with computer science degrees to get help with
their computers.

Seems like if we'd remove the medical doctor gatekeepers and allow people to
care for themselves, then health care costs would go down.

It seems so strange that in a free nation, it is illegal for citizens to care
for their own health.

~~~
logjam
Disclaimer: I am a physician.

There are greedy physicians. There are bad physicians. These physicians can
drive up health costs. I do not find, however, much evidence to support the
idea that physician reimbursement has anything to do with our high national
health costs.

Most I know are neither bad nor greedy. Generally, my colleagues are the best,
most compassionate, smartest humans I know. The physicians I know have worked
60-80 hours a week for their entire professional lives, went into enormous
debt to finance their professional educations and make between $140-200K
annually before paying for their own expenses, health care insurance, sick
time, vacations, etc.

I understand what you are saying about taking your health destiny into your
own hands. Most physicians, including myself, want you to do just that, and
will work with you to encourage you to efficiently and cheaply monitor and
care for your own conditions. Most of us feel that has to be the future. Most
of us believe strongly in preventive medicine, and feel caring for chronic
disease is like trying to put the toothpaste back in the tube.

I'm with you, notwithstanding your hyperbole about the illegality of caring
for your own health in a free nation.

But I think you might agree that when your 9 month old starts wheezing one
February day in the midst of a common respiratory syncytial virus outbreak,
despite all the self-learning you did on the Internet, you're probably best
advised to seek counsel, evaluation, and treatment from someone who has seen a
few cases of RSV, seen a few more cases of how fast children can go down with
something so seemingly simple, and can treat it effectively.

~~~
bokonist
The problem is not with physicians, rather its a structural problem with the
American political system.

I have no doubt that you and many of your colleagues are compassionate and
well intentioned. But you also pay dues to an organization that has a
political lobbying arm. This is of course, entirely understandable. Washington
has a ton of power, power which can be used to steam roll you. Thus you
support an organization that has a goal of looking out for your interests in
Washington. It does so quite well. Too well, in fact. As a result of AMA
lobbying, America has far fewer doctors than most other developed countries.
The result is higher prices for consumers, and no evidence of better care.
See: [http://blogs.law.harvard.edu/philg/2009/04/05/the-
futility-o...](http://blogs.law.harvard.edu/philg/2009/04/05/the-futility-of-
trying-to-control-health-care-costs-in-a-country-short-of-doctors/) Again, I
don't blame the doctors, I blame the design of the political system that
creates constant factional fighting over the resources of the country, with
some factions getting screwed and others doing the screwing. ( Oh Madison, how
wrong you were ... )

Part of the way the restrictions of new doctors work is by restricting medical
schools. This of course drives up the price of medical schools, sending
doctors into massive debt. Frankly, there is no reason that doctors need four
years of college on top of four years of college on top of four years of high
school. I'm sure the whole thing could be compressed into eight years, as
other countries have done.

For new doctors, loosening the barriers to entry would be a Pareto optimum
improvement. Salaries would fall, but so would the costs of schooling. Overall
the public would benefit without harming new doctors.

But existing doctors would get screwed, as you point out. To be fair, any
reducing of the barriers to entry should include compensation for current
doctors.

~~~
netsp
Often, when laws are changed, some people lose out. Easier
entry/certification. Changing trade laws can put whole industries out of
business. Zoning laws can make your property double of half in value quite
easily. Emission controls can make your car worthless.

Every time a politician sneezes someone get screwed. You can't compensate
everyone.

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giardini
We need to change all parts of the system:

For most situations most doctors are over-educated: why should a podiatrist
require 8 years of schooling to remove bunions or do surgery on an ingrown
toenail? Does a general practioner need 12 years of training to prescribe an
antibiotic for a severe infection? Are economics, politics, physics, calculus
and other courses really necessary for a brain surgeon to do his job or for a
nurse practioner to give tetanus shots?

1\. Break the entire medical profession down into smaller specialties and
provide only the necessary training within those specialties. Sure, some
should take the entire 12 years college + med school + internship + specialist
training, but most won't. This would open the profession to competition and
provide thousands more medical workers.Doctors won't like this: they'll fight
it every inch of the way, down to refusing to train people. But it must
happen. Perhaps only a massive natural or man-made disaster can overcome the
resistance of the AMA and doctors and cause this to happen.

2\. Mandate that statistics be maintained and published, complete with names,
so you can judge who's good and who isn't; who takes risks and who doesn't;
who's pricey and who is cheap. That way you can choose better and
practitioners can be more easily regulated.

3\. Eliminate HMOs and private insurance companies: they just don't work. The
only insurance solution that will work is one wherein the government maintains
the insurance pool. As long as insurance companies exist they will continue to
cherry-pick patients and use legal tricks to eliminate patients who develop
costly medical conditions.

4\. Eliminating the HMOs and insurance companies immediately gives a gain
equal to the profit of those firms. Increasing efficiency (automation of
paperwork, scheduling, etc.) gives further gains. Improved technology can also
reduce costs (something rarely pointed out about medicine). And we haven't
brought up the drug companies yet.

There's lots of room for improvement in the current system, but the doctors,
insurance companies, drug companies and the HMOs don't want to change the
status quo. And they're the only ones with representatives (their lobbyists)
in Washington.

------
geezer
My solution: Free market. Let anybody practice medicine. No state licenses, no
medical school degrees required. No controlling number of physicians entering
the system each year. If you are good, you will stay in business. Let free
market weed out the good from the bad.

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mblakele
"It means that all of us—doctors, hospitals, pharmacists, drug companies,
nurses, home health agencies, and so many others—are drinking at the same
trough which happens to hold $2.1 trillion, or 16% of our GDP."

16% of GDP? Other developed nations pay much less: on average 9% of GDP
(<http://opencrs.com/document/RL34175>). Health care in the US isn't 67%
better than in other developed countries.

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octover
I have experienced health care in the US and now Sweden. I can say whole
heartedly that I prefer the Swedish system. Perhaps that's cause I have a
chronic condition that is costly. I could never get insurance on my own in the
US, at any price. I pay more in taxes in line with what my perfectly healthy
friends in the US have paid to get comparable insurance (of course if they use
it for much they risk rescission and will have to fight the insurance company
to pay the bills they should).

In Sweden they worked quickly to put me on a safer and cheaper drug, one that
most of the US is dragging its heels to get into place, why cause it costs
less than half to treat a patient this way. Office visits go down because it
is entirely self-administrable, instead of an IV that has to be done in a
clinic.

No matter what medical system you choose there are going to be mistakes and
deaths, I just prefer the Swedish system that seems to triage and try and use
resources wisely.

I've had things in the US turn into unnecessary tests and hospital stays, in
Sweden they recognize this and treat me appropriately. Of course I can't blame
doctors in the US, they have the fear of a big malpractice suit if anything
unordinary were to happen.

~~~
berntb
The problem in Sweden is (a) queue time and (b) the administration burden
disincentives doctors from finding complex problems that aren't obvious.

About (b), I think it might be better in the rest of Scandinavia. My personal
experience -- I had a simple knee problems for decades (the sport doctors
finally fixing that said it was common to drag them around for that long...)
My experience here isn't that atypical.

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Retric
This is written by someone who in their own words is more focused on treatment
than success.

 _“The Doctor” happens to be my favorite painting, mostly because of the story
behind it: Sir Luke Fildes lost his oldest son_

 _I have a print of the Fildes painting close at hand, a reminder that all the
marvels of science, all the advances of medicine don’t replace what patients
want of their doctors and what most of us wanted to offer when we felt the
calling to medicine: the opportunity to be fully present at the bedside, to
bring the human comfort that only the presence of an attentive physician can
bring, to convey to patient and family the unspoken promise, “I will stay with
you through thick and thin.”_

I don't care if it's a person, robot, or pill, just fix me.

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jsz0
Sounds like fear mongering to me. If a doctor wants to spend time with their
patients having electronic medical records shouldn't stop them from doing so.
I don't think I even agree with the premise that people want their doctors to
be their buddies holding their hands. I think most sick people want to be
cured. The days of having one family doctor are gone. You'll get bounced
around to various specialists if you have any serious problems anyway. As
we've seen in other areas technology has an incredible ability to get results
if used correctly. I have faith most medical professionals are smart enough to
use a computer or electronic testing equipment.

Either way the status quo is unsustainable. If something isn't done about it
now we'll have a medical crisis in a few years/decades that is every bit as
bad as the credit crisis was. And we'll sit around and say gee, someone should
have done something about it sooner. It's too bad everyone was so terrified of
change and willing to let the rich & powerful con them into thinking
everything was just fine when it really wasn't.

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zmimon
I liked it up until the part about cost-cutting:

> Which brings me to my problem with the president’s plan: despite being an
> admirer, I just don’t see how the president can pull off the reform he has
> in mind without cost cutting.

This suffers from two fallacies - the first is that this is not a zero sum
game. We may spend just as much on health care but get more value for the
dollar and thus live healthier lives and thereby be more productive.

The second problem is the "broken window" fallacy. Doing unnecessary
healthcare is a not a reasonable thing to keep people employed. If you take
that money out of healthcare it won't just vanish, it will go elsewhere and be
productively employed to generate real value for the economy. Far from being a
problem with the plan it is the most powerful argument in it's favor.

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varaon
Refreshingly honest.

I'm impressed to see this sort of viewpoint in the WSJ.

~~~
adamc
Not sure why you got downrated (I had exactly the same thought, based on years
of reading the WSJ). I found the piece thoughtful and plausible.

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edw519
I'm glad someone else finally said it: Early detection is neither.

