Tuesday, May 10, 2016

Doctored: The Disillusionment of an American Physician

My takeaways from reading Doctored:
1) The American medical system is a big mess
2) Doctors like money. They will exploit any rules for their benefit.
3) Most doctors like to help people. However, they are constrained by the system (and they like money).
4) Doctors used to be respected. Then they got paid well and got greedy. Now they are not paid as well and are not well respected.
5) It is expensive to live an upper-middle class life in Manhattan.
The book chronicles the author's midlife crisis and disillusionment with the medical field. He was a cardiologist working in a nice hospital in Long Island and writing a column for the newspaper. However, he was not earning enough to support his Manhattan lifestyle, especially with private nursery school tuition. To get more money, he worked on the "speaking bureau" for a drug company. However, he felt like he was a shill for the drug company so he left that. Later he moonlighted in a private practice. There he felt he was just doing a whole bunch of tests so they could earn money, rather than because the patients needed them. Finally, he just decided to sell the apartment in the city and move out to the suburbs, thereby lowering his expenses and allowing him to work without the need for the additional income.

Along the way he encountered and chronicled many deficiencies in the medical system. Doctors used to be members of the community, and make house calls to many of their patients. Their customers would pay them directly. They were like the highly respected "plumbers" that would take care of people's health. Health Insurance (both government and private) came along and doctors entered the golden age. Now there was tons of money in the system and doctors could get super rich. Alas, the managed care systems realized this and begin to try to control costs. Now doctors have to spend a huge amount of their time dealing with insurance companies and billing. House calls are nearly non-existent. Doctors in private practice can have more control over their work, however, they must also work a lot more to make ends meet. (Thus the propensity to engage in "high value" work.)

Doctors are also distanced from their patients. They can often be encouraged not to admit mistakes (for both liability and respect). New residents are encouraged to just "go home", rather than see a patient through the process.

What is the solution? Take the money out of health care. Start with education. A new doctor typically is saddled with a huge debt after four years of college and another 4 years of medical school. After that, the practical education begins in the residency and follow-on training. And then the doctor must stay current on new advances during the career. Do doctors really need all this training? How much of it is used in their career? What about an easing in to medicine? Require initial training and work as an EMT and other related medical fields before admitting to medical school. Let people discover they don't like it before they've committed 4 years and hundreds of thousands of dollars. Create alternate, shorter tracks for different specialties. Have greater availability of "community care" options for loan forgiveness. Encourage more non-traditional routes. (A parent may realize they have a passion for pediatrics after raising their young children.)

Then move to practice of medicine. ObamaCare pretty much got everything backwards. We need to move insurance out of the everyday picture instead of mandating it. The tax system needs to change so that people getting insurance through work and on their own have the same tax structure. People should be able to pick insurance on their own. Insurance should be just that - insurance for unexpected medical conditions. Routine care should be covered out of pocket. People and doctors should have a direct relationship. Medical liability should be reformed. Criminal courts could handle gross misconduct (with the higher bar for conviction.) Doctors should be experts, but are still likely to make mistakes. This needs to be managed so as to not punish the innocent. Having the direct patient-doctor relationship will also limit the excesses of money-making testing.

Can medicine be reformed? It would be nice, but I wouldn't hold my breath.

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