The future of medicine


Category : General, Medical Rants

Blogging is an interesting experience. Some weeks I struggle for content, and never feel that I have said anything substantial – all solid, but modest nonetheless. This past week, I dealt with some very important issues. As I pondered these rants (which I rate as better than usual), I understood that they share some commonality. I am ranting about the current problems in delivering high quality medical care – and how I would change things were I given the power.

In many ways, Saturday I summarized a major concept of this blog – The Starling curve and patient volume. In this rant, I postulated the obvious. We function best with enough patients, but not too many. Using reductio ad absurdum, everyone will agree that I cannot effectively see 1 patient each minute. Thus, there must be a number of patients which leads me to compromise good care. It is harder to prove that I am a better physician seeing 10 patients each day, then only 1, however, I believe most readers will accept that postulate.

Given these absurd anchors, we must work to estimate the appropriate amount of time to allocate for each patient. I am not aware of anyone doing research in that area, and yet I am happy to argue this question as fundamental.

One way to increase patient contact – while controlling time – is through technology – An idea whose time has come.

Our current reimbursement pays physicians for each visit. It does not consider the time needed for a visit – but rather arbitrarily designates a set fee. These fees have no relation to expenses, or increasing overhead. The office visit is the big loser in this system. Thus, primary care becomes less attractive every year – Why students do not elect primary care careers. Our lack of sufficient high quality primary care leads to excess ER visits – The ER is full.

Medicine really does take more time in 2005 than it took in 1975 (my internship year). We can, and should do more at each visit. Yet in 2005, we have too few physicians – No doctor glut — Oops!

As a physician with 30 years experience, I continue to be astonished at the lack of logic in considering health care. We have planners who make pronouncements without understanding the moving target of health care. We have insurers who undervalue the doctor patient interaction, almost forcing physicians (for financial reasons) to spend inadequate time with each patient.

Our health care system needs a dose of common sense. Unfortunately, I doubt that our political processes will allow us to develop a thorough consideration of these issues – thus, we will limp along – from crisis to crisis.

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Comments (2)

db, I do seem to remember predictions of a significant physician shortage back in the 1970’s and early 1980’s. This was followed by predictions of a physician GLUT in the 1990’s. And that glut was not predicted, it was demonstrable at the time. Academics were seeing their trainees having a hard time finding suitable employment, and those that found employment found the terms of employment were onerous to say the least. No offers of partnership, drastic restrictive covenants excluding the new doc from entire metro areas, etc.

The reason we got shortages of some specialties (anesthesia, radiology for example), came from medical students seeing the FACT that their immediate seniors were having such a hard time in the 1990’s that they stayed away from those fields in droves…..leading to a shortage.

The glut was written about, backed with data, in the major journals just a few years ago.

Now we see predictions of shortage……AGAIN.

So maybe the predictions of shortage are correct this time. Maybe not. We’ve seen the prediction cycle go back and forth, and we’ve certainly seen what happens to doctors when there is a glut, even if just for a couple years.

db: I agree with you that our health care system is riddled with illogic and, at times, sheer absurdity. You must realize, however that our health care system IS a political process.
How else can you explain such arrangements as the Medicare Reform Act of last year with the new prescription drug benefit. The federal government, BY LAW, cannot set or negotiate the price of covered medications for subscribers (do you think the PAC money from the pharmaceutical industry had anything to do with that?)
At the same time, reimbursement rates for Medicare payments to physicians (your office visits) are scehduled, BY LAW, to be cut 5% a year from 2006 to 2012. Who sets these rates anyway? A bunch of people sitting around a room in Washington D.C. How can you expect logic from this kind of arrangement?
As respect to physician shortages or gluts, arf’s comments above offer some insight. I don’t think you can really talk about surplus or shortages of physicians as a whole but rather you have to look at specific specialties. These will always vary with MARKET conditions. Med students will not enter areas of medicine iin which they cannot find employment or resonable compensation.
I am not of big proponent of free market theory for medicine but if you look at the one area of medicine that is completely in the free market (cosmetic procedures, some bariatric surgery) this system works very well. Which leads to an amazing clash of cultures. The same people who will willingly pay thousands of dollars, up front, for plastic surgical procedures feel very put out when they have to pay a ten or twenty dollar co-pay to see you in the office for real medical care. Talk about absurd!
I don’t think we’ll see common sense in medicine in our professional lives.

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