Can the quality of health care be improved by getting worse doctors?

[Mr Skeptic]

Can the quality of health care in the US be increased by lowering the qualification requirements to provide medical care? It might seem counter-intuitive at first, but not if you think through it carefully. Of course, a better doctor would provide better treatment. However, a doctor is limited in the number of patients he can treat, and furthermore even having to wait for treatment can exacerbate any harm. Furthermore, with a shortage of doctors it becomes necessary to ration out care or to increase the price to the point where people forgo treatment due to the price. Thus, conditions could worsen or go untreated altogether. At some point, even if the fewer doctors can provide better treatment, the waiting and expense of such care would overwhelm any such benefit.

 

For example, if you take things to the extreme -- suppose we will have nothing but the best, so that only the very best person in the US is allowed to practice medicine. He'd have to take care of millions of people, at least tens of thousands of patients per day, which would be ridiculously impossible for him to treat. The point of this example is that it must be true that quality of care can be increased by reducing the qualification requirements. My question, then, is: Is the US past that point? Would we be better off with more, less qualified, doctors?

 

My suggestion: replace certification requirements to perform medicine, with requirements that the patient be informed if any practitioner is not certified and given the choice to opt for a certified one. Me, I don't really care whether my doctor has a doctorate degree if all I need is a few stitches, or something like that.

[lemur]

My suggestion: replace certification requirements to perform medicine, with requirements that the patient be informed if any practitioner is not certified and given the choice to opt for a certified one. Me, I don't really care whether my doctor has a doctorate degree if all I need is a few stitches, or something like that.

Maybe you could also offer certifications for nurses, PAs, medical assistants, etc. to perform specialties such as wound care so that they could practice independently in that one area without being able to practice other aspects of medicine. Then part of their general training would include in-depth concentration in their specialty area. Still, doctors would probably have to go around evaluating quality of care at such facilities. I wonder how many people would refuse to have a wound stitched by someone because "they're not an M.D."

Edited February 24, 2011 by lemur

[jackson33]

A Nurse Practitioner (NP) is an Advanced Practice Nurse (APN) who has completed graduate-level education (either a Master's or a Doctoral degree). Additional APN roles include the Certified Registered Nurse Anesthetist (CRNA)s, CNMs, and CNSs. All Nurse Practitioners are Registered Nurses who have completed extensive additional education, training, and have a dramatically expanded scope of practice over the traditional RN role. To become licensed to practice, Nurse Practitioners hold national board certification in an area of specialty (such as family, women's health, pediatrics, adult, acute care, etc.), and are licensed through the state nursing boards rather than medical boards. The core philosophy of the field is individualized care. Nurse practitioners focus on patients' conditions as well as the effects of illness on the lives of the patients and their families. NPs make prevention, wellness, and patient education priorities. Another focus is educating patients about their health and encouraging them to make healthy choices. In addition to health care services, NPs conduct research and are often active in patient advocacy activities.[/Quote]

 

http://en.wikipedia.org/wiki/Nurse_practitioner

 

 

Can the quality of health care in the US be increased by lowering the qualification requirements to provide medical care?[/Quote]

 

Skeptic; Certification of Medical Attendants/Practitioners for the most part, if not in total, are done at the State level. NP's the highest level of nursing in many States, do many of the jobs/treatments and RN's can do their share. In been a few years, but married to a Nurses Aid, about the lowest level for medical treatment, in Texas they did a lot of things, drawing blood to vaccinations. Very few doctors actually do much more than the highest levels of(diagnosis/treatments) to begin with and emergency rooms often have no MD's on duty, usually on call, interns or just happen to be in the hospital.

I suppose States could qualify more treatments for those with lesser qualifications, but there really isn't much room in many States to further expand duties. I seriously doubt many the average stitching is done by anyone with an MD Degree and certification, but I'm sure you would prefer someone with some experience.

[lemur]

I suppose States could qualify more treatments for those with lesser qualifications, but there really isn't much room in many States to further expand duties. I seriously doubt many the average stitching is done by anyone with an MD Degree and certification, but I'm sure you would prefer someone with some experience.

I think the big issues people are concerned with are long wait times in the ER because "the masses" go there when they have a cold OR the high bills that are high because of the relatively few people who pay anything at all. So, I'm guessing that having more private practices (i.e. non MD) on call (possibly doing house calls) and charging affordable fees would satisfy people. I think the big gap is between what people want to pay for health care and what people want to get paid for working in some part of the health care industry. People view any kind of health-care related job as attractive because of high earning-potential, so that translates into high bills for those who pay, whether that is patients privately, through insurance, or through government.

[zapatos]

I don't think we need less qualified doctors, but instead a better distribution of the workload. If someone less qualified than a physician can take over less difficult tasks currently performed by doctors, then doctors can spend more time on difficult tasks.

 

My wife works at a hospital and several years ago the nurses were pushing hard to take on more challenging work for themselves, work then only done by doctors, which they felt they could readily handle. The Doctors felt the risk to the patient would be too great. Interestingly, several years later healthcare workers a step below nurses were pusing hard to take on more challenging work for themselves which they felt they could readily handle. The Nurses felt the risk to the patient would be too great.

 

As in any field, people tend to defend their turf.

[lemur]

As in any field, people tend to defend their turf.

In any other science, that's just interest-bias; but in medicine it can be a fundamental conflict with the best interest of the patient, couldn't it?

[zapatos]

In any other science, that's just interest-bias; but in medicine it can be a fundamental conflict with the best interest of the patient, couldn't it?

I would certainly think so, although I don't believe that will stop them from doing it. It's too easy to make a good argument to support your position. In the case of the nurses trying to take over some work of the doctor:

Doctor -- "If you let the nurses do this the patient will have a less qualified person caring for them, thefore I should keep the job."

Nurse -- "If you let the nurse do this the doctors can concentrate on the truly difficult work, therefore I should do the job."

 

I guess we need those pesky administrators to decide which is better, given all the factors involved.

[lemur]

I guess we need those pesky administrators to decide which is better, given all the factors involved.

Or juries and lawyers. Plus, it's going to ultimately come down to people choosing what level of medical advice to base their decisions for self-care on. People have to become their own first-line of medical authority, in most cases.

[Marat]

Before the Flexner Report at the beginning of the 20th century there were many more doctors per capita in the U.S. but there was no regulation of their training or quality. The Soviet Union similarly greatly expanded the number of doctors by cutting down on their training, as did China during the Great Leap Forward. A few Soviet-trained doctors I have gotten to know who came from Russian diploma mills were actually quite good, but they had learned most of what they knew on their own. Unfortunately, because of North American licensing restrictions, one could only be admitted to practise as a nurse and the other was a radiologist. In rural India people actually proudly post on their wall an announcement such as 'St. Thomas's Medical School, failed exams with a near pass on January 12, 1988.' Given the poverty in rural India, people are still willing to pay someone with such 'qualifications,' reasoning that he is at least better than someone who never attempted medical school, and his prices are within range.

 

Perhaps the best solution would be just to train several different gradations of doctor, make sure that the patient was notified of their qualifications before treatment, and allow the patients to select, according to availability and fee, which type of 'doctor' he wanted. We have already started doing this in some jurisdictions with specialized nurses who have augmented powers, with some countries allowing pharmacists to prescribe medicines, or with paramedics, and state-licensed naturopaths.

[Mr Skeptic]

Perhaps the best solution would be just to train several different gradations of doctor, make sure that the patient was notified of their qualifications before treatment, and allow the patients to select, according to availability and fee, which type of 'doctor' he wanted. We have already started doing this in some jurisdictions with specialized nurses who have augmented powers, with some countries allowing pharmacists to prescribe medicines, or with paramedics, and state-licensed naturopaths.

 

Ah, going back a little towards how it used to be. Part of the reason we have so few doctors is that the AMA worked really hard to eliminate the competition. This was done in the name of improving patient's lives, but it seems it included some components such as requiring a limited number of students.

 

http://www.healthe-l...id_history.html

Claiming to have investigated nearly every school in the country, Flexner rated them on suitability. Schools he praised received lush grants from the Rockefeller and associated foundations, and almost all the medical schools he condemned were shut down, especially the "commercial" institutions. AMA-dominated State medical boards ruled that in order to practice medicine, a doctor had to graduate from an approved school. Post-Flexner, a school could not be approved if it taught alternative therapies, didn't restrict the number of students, or made profits based on student fees.

 

Why the opposition to for-profit schools? If an institution were supported by student fees rather than philanthropic donations, it could be independent of the foundations. The Rockefeller family had invested heavily in allopathic drug companies and wanted doctors to use their products.

 

 

 

 

http://reason.org/bl...he-ama-monopoly

 

Milton Friedman warned back in 1961 that the American Medical Association was a government-sanctioned guild or trade cartel that would raise health care costs and diminish quality. Today, most economists agree with him. That's because the costs of AMA's aggressive tacticts to keep physician wages up by, among other things, imposing onerous licensure rules, capping the number of new doctors, and harassing nurses, midwives etc. who can treat certain routine conditions more cheaply than doctors have become painfully obvious:

[jackson33]

I think the big issues people are concerned with are long wait times in the ER because "the masses" go there when they have a cold OR the high bills that are high because of the relatively few people who pay anything at all. So, I'm guessing that having more private practices (i.e. non MD) on call (possibly doing house calls) and charging affordable fees would satisfy people. I think the big gap is between what people want to pay for health care and what people want to get paid for working in some part of the health care industry. People view any kind of health-care related job as attractive because of high earning-potential, so that translates into high bills for those who pay, whether that is patients privately, through insurance, or through government.[/Quote]

 

lemur; Your scenario could only happen, if the Federal Government took over Health Care in total and since implementation is a State Right and it's extremely unlikely any State would allow less than a certified MD, possibly PN to diagnose or independently make decisions on treatments.

 

Actually, few Doctors are all that well paid, think the average is around 180K$ per year for MD's, much less for the rest in the industry. In fact most MD's contract with Hospitals or Clinics. Remember aside from the normal K-College and 2-6 years for Medical School and very expensive, they intern from 2-4 years and at anytime can be found unqualified. What cost today is simply preventing law suits with over testing, in turn the cost of those suits (Insurance) for every person in the practice along with some very expensive equipment, not to mention regulations or compliance to, reporting, known as administrative.

[lemur]

lemur; Your scenario could only happen, if the Federal Government took over Health Care in total and since implementation is a State Right and it's extremely unlikely any State would allow less than a certified MD, possibly PN to diagnose or independently make decisions on treatments.

 

Actually, few Doctors are all that well paid, think the average is around 180K$ per year for MD's, much less for the rest in the industry. In fact most MD's contract with Hospitals or Clinics. Remember aside from the normal K-College and 2-6 years for Medical School and very expensive, they intern from 2-4 years and at anytime can be found unqualified. What cost today is simply preventing law suits with over testing, in turn the cost of those suits (Insurance) for every person in the practice along with some very expensive equipment, not to mention regulations or compliance to, reporting, known as administrative.

I was just brainstorming to add something constructive to what others were posting in this thread. It's not "my scenario." It just made sense to me that the problem of high costs and inaccessibility of health care could have to do with legal restrictions on medical decision-making, as you describe. What is wrong with MDs making as much money as they want as long as people without much money to pay can legally accept care from less qualified professionals? Of course it would make sense for government to limit provision of such services to forms of care that don't require MD-level expertise to make. But the question is why doctors couldn't, say, set up a franchise of walk-in clinics to provide basic medical services for bargain prices. If I know popular culture, it would scoff at the idea of McMedicine, but maybe that is the best way to deal with the largest volume of health qualms and let the doctors deal with really serious issues. The hard part, imo, would be preventing such care facilities from becoming drug-dealerships for coveted prescription drugs, which is the reason a lot of people currently go to the doctor/hospital now anyway - only doctors have more to lose by selling unnecessary prescriptions.

 

 

 

[SMF]

Mr Skeptic, my response to your initial post is that your question presupposes that the pool of students that would make good doctors is tapped out and that the selection criteria are appropriate. My response to your second comment (#10) is- right on! If there were many more physicians their exorbitant salaries would come down (Jakson33, $180K is what the lowest tier physicians average), service would improve, and the ones that cause lawsuits wouldn’t be able to compete. The reason that clinics in most rural, inner city, and other undesirable locations have to use imported physicians is that there just aren’t enough US trained ones to go around. This is not a free enterprise system.

 

Lemur, I think your idea is a good one but with the physician shortage I don’t think that there is any pressure to make less money in order to provide lower cost services.

 

I also have to say that the entire US health care industry is sick because it is a cash cow for so many interests that are able to influence our government. I would really like to see a good cost analysis done in order to see where all the money goes.

 

I agree with the idea of using more nurse practitioners and physician assistants. SM

 

 

[jackson33]

Medical doctors or MDs in the US earn about $200,000 annually which is 2 to 5 times higher than what doctors make in most other countries. The crucial factor contributing to higher physician salaries in the US is the restriction on the number of medical schools and medical students resulting in a limited number of physicians. MDs, occasionally referred to as allopathic physicians, may specialize in a number of fields including general medicine, internal medicine, anesthesiology, obstetrics, gynecology, pediatrics, surgery and psychiatry. Almost 90% of American MDs are reported to be directly involved with patient care.[/Quote]

 

http://www.kaycircle.com/How-Much-Does-An-MD-Make-Per-Year-Average-MD-Salary

 

 

SMF; It has been a couple years since I've researched MD pay, but I have no reason to believe pay has increased. On the above link. I'd like to point out many of those Countries where averages are "2-5 times less", work under some form of Nationally Controlled HC system. Below is a very comprehensive breakdown and roughly going over the math, 180K would be nearer the average. At any rate, those with the intelligence and drive to go though the process, education to certification are extremely limited, since those same people would likely succeed in any field.

 

http://www.payscale.com/research/US/Degree=Doctor_of_Medicine_(MD)/Salary

 

I also have to say that the entire US health care industry is sick because it is a cash cow for so many interests that are able to influence our government. I would really like to see a good cost analysis done in order to see where all the money goes. [/Quote]

 

I really don't think the American HC system is "sick" to begin with, even the idea is subjective to some political viewpoint. As for lobbyist trying to influence Government "cash cow", I hardly think they account for much of the 2.5T$ spent on care in the US and suggest just covering the regulations and *mandates* placed on the industry is where much of the perceived problem exist.

[SMF]

Jakson33, I was on the Tenure and Promotions Committee and the chair of the Salary Committee at a medical school and had access to LCME data. This site is more in line with the books I saw- http://www.merritthawkins.com/job-search/job-search-results.aspx?profession=Physician&specialtyId=9&regionId=-1#jobGridResults and these are actual advertisements for jobs nationwide. Family Practice is the lowest paid specialty and my current family practice physician in a rural area makes $180K. I know a medical student who paid off most of his student loans while a resident by moonlighting in an undesirable clinic. I know a resident (internal medicine) who started his first job in a practice at $235K. Keep in mind that the stated salaries you see often don't include “benefits.”

 

The sickness I alluded to is reflected in the recent statistic that puts the US 33rd in the world for infant mortality (just below Cuba, Channel Islands, Brunei, Cypress, and New Caldonia), that our health care costs two to four times that in many other developed nations, that drug companies have been criticized for spending nearly as much on unethical practices intended to influence physicians regarding their products and paying them outright to hype their products than they spend on direct advertising and product R and D combined (story here- http://www.medicationsense.com/articles/jan_apr_06/conflict_of_interest_020306.html JAMA article here- http://www.nhmrc.gov.au/_files_nhmrc/file/health_ethics/hrecs/Health_Industry_Practices_that_create_conflicts_of_Interest.pdf ), that there were physicians lining up to collect from the drug companies and didn’t think that there was anything wrong, that people have to sneak across the border to find the very same drug sold in the US but at affordable prices, or how about medical insurance companies that cut off member insurance for arbitrary reasons when their costs are high. Blaming the above on mandates and regulations sounds a bit political to me. SM

 

 

[jackson33]

I know a resident (internal medicine) who started his first job in a practice at $235K. Keep in mind that the stated salaries you see often don't include “benefits.” [/Quote]

 

SMF; I'll concede your in a better position to understand the situation and respect your comments. My contact with Medical people, go back some years, but I could offer you a list of MD's in Texas, Wisconsin, Arizona, Missouri and where I retired here in New Mexico, whose net incomes are/were far from 180k$. I'm sure you understand those in Private Practice, groups (Clinics) or working through Medical Facilities all have personal expenses related to their practice and of course there are no benefits in Private Practices or some groups.

 

Then would come the point of even mentioning earnings and that is the cost and time required to even be certified by a State, which many of those trying never get to. There is simply little incentive for the brightest in the US to make the effort.

 

R & D in both Medicines, Vaccines and Diagnostic/Treatment Equipment, might be questionable to some, but not to me. This work has been the backbone of Medical service/treatments around the world and I'm sure you would agree has advanced cures for many previous medical problems, both preventing illness, curing illness, prolonging life. Yes, Americans have always indirectly paid for much of this and probably always will. Those same folks finance all kinds of humanitarian efforts, including selling bulk to Wal Mart (truck loads can save millions over small individual shipments) or Countries that distribute there products, traveling testing equipment, many times free of charge and are the first industry to go into hot spots requiring medications.

 

As far as statistical differences between Countries, I have little faith in there value. Aside from different reporting systems and compliance to those systems, the US has 311 Million People and by far the most diversified demographics. Massachusetts and Washington State for instance are on par with most the world and the South East US would seem to be in the third world, until you go to the demographics. By the way in the US, that figure goes up to the age of one year, not the birth.

 

 

Infant Mortality Rates By Country;

 

http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate

 

Infant Mortality Rates BY US States;

 

http://www.statehealthfacts.org/comparemaptable.jsp?ind=47&cat=2

 

Infant Mortality Rates By State and Race;

 

http://www.statehealthfacts.org/comparetable.jsp?cat=2&ind=48

[SMF]

Jackson33, if you are interested in more on how the US compares with other nations on infant mortality and the problems of gathering international health statistics, here is a National Center for Health Statistics (NCHS) brief on the Center for Disease Control and Prevention (CDC) website. It appears that we in the US need to do something about prenatal care. SM

 

http://www.cdc.gov/nchs/data/databriefs/db23.htm

 

 

[jackson33]

Jackson33, if you are interested in more on how the US compares with other nations on infant mortality and the problems of gathering international health statistics, here is a National Center for Health Statistics (NCHS) brief on the Center for Disease Control and Prevention (CDC) website. It appears that we in the US need to do something about prenatal care. SM[/Quote]

 

SMF; I believe we're going around in circles here, but I serious believe the US HC system has been the best on this planet at least in my years on it.

 

Your link is interesting, but can as all of them, can be accepted with other finding as questionable. I'll simply ask a couple questions based on your prenatal care.

 

1. If preterm rates are in fact lower in the US (your link), then what would additional prenatal care accomplish? Then consider that late fetal mortality rates have decreased from 14.9/K from 1959 to 3.2 in 2002, as have others terms in all demographics.

 

http://www.infoplease.com/ipa/A0779935.html

 

2. Since welfare reform (think 1990's), adding PN care for more people there has been no significant additional decline. Why, if PN cares would make a difference?

 

I don't doubt there may be factors being over looked that might help the general society, possibly involving obesity, drugs or unhealthy activity, even possibly above other Societies, but it's not the HC System itself.

[SMF]

Jackson, you say-

 

SMF; I believe we're going around in circles here, but I serious believe the US HC system has been the best on this planet at least in my years on it.

 

Your link is interesting, but can as all of them, can be accepted with other finding as questionable. I'll simply ask a couple questions based on your prenatal care.

 

1. If preterm rates are in fact lower in the US (your link), then what would additional prenatal care accomplish? Then consider that late fetal mortality rates have decreased from 14.9/K from 1959 to 3.2 in 2002, as have others terms in all demographics.

 

http://www.infopleas...a/A0779935.html

 

2. Since welfare reform (think 1990's), adding PN care for more people there has been no significant additional decline. Why, if PN cares would make a difference?

 

I don't doubt there may be factors being over looked that might help the general society, possibly involving obesity, drugs or unhealthy activity, even possibly above other Societies, but it's not the HC System itself.

 

I am not going in circles. I wasn't arguing. I just thought you were interested in the problems regarding reporting of infant mortality in different countries. The CDC piece examines some of the problems, reduces the comparison countries to just Europe where it is easier to make comparisons, and tries to illuminate some of the real differences. The differences in the US deficits appear to be due to more preterm births.

 

As for your point #1, Figure #3 in the CDC article, that I linked, with the title "The percentage of births that were born preterm was much higher in the United States than in Europe" shows that the US is the highest among the comparable European nations in preterm births. Rates are higher not lower, so what are you talking about? The next heading after this figure is- "Much of the high infant mortality rate in the United States is due to the high percentage of preterm births." The article also discusses the fact that we are doing better with later term births. Did you actually read the article?

As for your #2. You are changing the subject to welfare reform and prenatal care. If it doesn't work, relative to other nations, then it doesn't work. What is your point?

 

 

If you seriously believe that the US health care system is the best on the planet, you have to explain the low rank on infant mortality rate AND, I will add, the rank of 36 on overall life expectancy. http://en.wikipedia....life_expectancy

 

What? SM

Edited February 28, 2011 by SMF

[lemur]

If you seriously believe that the US health care system is the best on the planet, you have to explain the low rank on infant mortality rate AND, I will add, the rank of 36 on overall life expectancy. http://en.wikipedia....life_expectancy

I find it callous when people compare infant mortality rates without discussing specific causes of infant mortality. Babies don't die due to general causes. They die because of the specific details of their situations. You can't simply correlate their mortality to societal factors. You need to do individual case studies.

Edited February 28, 2011 by lemur

[SMF]

Lemur. Don't you agree that premature birth increases infant mortality regardless of what the specific ultimate cause of death may be? Why is being concerned with a primary risk factor callous? Do you think that the Center for Disease Control brief that I linked (post #17) is callous? SM

 

 

[Marat]

While overall access to some form of healthcare could be improved by having a larger number of doctors with some trained to a lower standard than others, this gain might be offset by undertrained doctors generating more health problems by their misdiagnoses or improper treatments. Both of these types of error can magnify medical problems by delaying proper intervention or applying harmful intervention, and the negative impact of such undertrained doctors might outweigh any benefits they could provide.

 

I know of a case in which an entire public school was in panic because the school nurse diagnosed a large number of the students as suffering from ringworm because of the blue discoloration of their hands, when in fact it was just a prank in which some students had applied blue dye to some of the school's door handles. Flu is also a great imitator of other diseases and a common one at that, and for undertrained clincians it is easy to mistake flu as a more serious illness, or a more serious illness as flu.

[lemur]

Lemur. Don't you agree that premature birth increases infant mortality regardless of what the specific ultimate cause of death may be? Why is being concerned with a primary risk factor callous? Do you think that the Center for Disease Control brief that I linked (post #17) is callous? SM

It's callous when the primary concern is statistically differentiating between ethnic populations. It is not callous to investigate a risk factor, but then you could just be concerned with ways to prevent early labor. OR you could be concerned with means to better care for premature infants. Comparing death rates is just a dramatic way to make the research more about comparing different populations than about studying and promoting better health care, imo. I didn't mean so much to accuse anyone of being callous - just to note that it is implicitly so, imo.

Edited March 1, 2011 by lemur