More Doctors?

Without really meaning to, I pounded out a totally serious blog about our health care system.  We all do it.  We all think we have the answers.  I know..this is no more than a hit off the crack-bong of American medical politics, but it shuuurrre feels good, man.  

There’s something so empowering about imagining my little ideas solving the ills of the world….

An interesting commentary about the perceived need for more doctors was posted recently at CNN.com

In the article, 3 businessmen who run group called “Innosight” – an organization that attempts to help businesses be more efficient through innovative thinking – suggest that we have as many doctors as we need in the United States. 

Entitled “We Don’t Need More Doctors” – you can read the full article yourself – the authors present a sorta-new perspective on health care delivery in America.  Here’s a summary:

  • Current health reform plans are unlikely to break with the ways of the past.
  • Some advocate need for more doctors, but that’s actually not necessary
  • Nurses can provide quality care at low cost in clinics
  • This would free up doctors to do more complex work
  • Let’s look at some of their other points:

    All parents know the experience of worrying whether their child has an ear infection — treatment involves considerable pleading for a standby appointment at the doctor’s office, followed by a long wait, a 30-second visit with the doctor, and then a trip to the pharmacy for another long wait.

    Throw in the half-day of missed work and the stiff bill, and it becomes clear why many advocate the need for more doctors.

    Ouch.  Can’t really argue with that.  Our clinic has been putting lots of effort into “same day” appointments, and I know this is a push nationwide.  But still, the process is onerous.  Furthermore, a good majority of these cases don’t require treatment (ear infection is a good example).  So, add into all that waiting and effort, a “reassurance” from the doctor that things are fine and there’s nothing to do.

    However, a growing number of visits, incorporating quick and easily interpreted diagnostic tests and algorithm-driven care for conditions such as ear infections, sore throats and minor burns, can be handled better in nurse-run clinics.

    Algorithmic thinking.  I’ve lamented it many times before.  The less a person is trained, the more they rely on algorithms.  What is an algorithm?  It’s a recipie for care: “Does the patient have X?  If yes, do 123.  If no, do 123.”  Algorithms are the “Choose Your Own Adventure” of the medical world.  They provide efficient decision-making, but at the expense of good analysis. 

    Human beings, unlike the computers that generate algorithms, don’t fit well into specific enough categories for most “if/then” treatment plans.  Get yourself involved in any cardiac arrest code – where everyone is trained in ACLS, a completely algorithmic process – and you will see how poorly a care recipie works in the real world.  Furthermore, true thought and real experience provides better, safer and more efficient care over time.

    Nurse training is, by historical design, a non-analytical type of training.  Nurses are trained to react to data, not analyze it (exactly what algorithmic thinking is).  This feathers with analytical physician training perfectly, which is why the system has worked so well for generations.  Both types of thinking are equally important, equally intelligent, and both are required to provide the best care to a patient.

    To cheapen the process, we are now asking nurses to use reactive thinking to provide medical care.  Good care really should be provided through an analytical thought process, supported by reactive thinking (e.g. doc decides the patient needs a shot, nurse makes sure it gets done exactly right).  Remove either one, and inevitably the care suffers.  Even in primary care, medicine is no cookbook. 

    By moving more complex care from specialists to primary care providers, the payments will follow. These changes would make primary care more fulfilling and financially rewarding, while freeing up specialists to do even more complicated work that merits their additional training.

    The problem with specialists in the American healthcare system isn’t that they need to be “freed up”.  Most specialists are perfectly happy with their workloads.  The problem is that they are paid disproportionately, which then drives more med school graduates into those fields when we need more generalists anchoring the medical system.  I agree that additional training merits additional pay.  But not 10 TIMES what a generalist is paid. 

    Another big problem here is that procedures are paid at MUCH higher rates than office visits.  This biases the entire system toward interventions and procedures that cost a ton, are often not proven or helpful, and influence sound medical judgement.

    We don’t need to take patients away from specialists, we just need to pay them more reasonably and make payments for visits and counseling equivalent to procedures.

    We should embrace eHealth initiatives that enable virtual clinic visits and online house calls.

    I absolutely agree.  SO much good medicine can occur online.  To really work, however, solutions to HIPAA hyper-draconian privacy ensurances need to be relaxed.  Additionally, litigation risk needs to diminish so that doctors can make judgement calls without fear of major legal backlash.

    Furthermore, I’ll highly agree with the authors about e-medicine:  We need to move away from the “guild” mentality that has kept boundaries narrow and created regulatory, licensing and reimbursement obstacles to new models of health care delivery.

    Finally, they get it totally right when they sum their opinion with: Patients want correct diagnoses and effective therapies, but they also value accessibility, convenience, transparency, communication and their time and money — none of which have been priorities of the traditional health care model.

    In general I dislike health care reform discussions by non-healthcare providers. I’m a purist that way. I think the discussion should be between doctors and patients and nobody else. You can’t really know how to direct the work, unless you’ve been there doing it. But these guys get it pretty close to right on. Although I disagree with their central idea – that we need more nurses and not more doctors – in general their thinking is innovative and realistic. Maybe someone will listen.

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