Free Market Medicine - Is it Rational?

This weekend J, who is an ER doc, said that universal health care would not be a good idea. His reasoning was straight-forward: if you provide the public with something free they will exploit it. By not providing things for free we encourage people to work and plan for what they want and need. This encourages responsibility and industriousness.

I agree with this. Except that J is not talking about a typical consumer good like a car or computer. Health care is different, and for two basic reasons.

1. People don't think of their health like their cars. Any American will agree that if your want a car, work hard and save the money. If your car breaks down, you'll be responsible for fixing it. No money, no repairs. But disease is different. If someone has diabetes they expect to have some level of care regardless of they ability to pay. Many Americans - especially those with chronic diseases - would think it is unfair that a diabetic who needs to see a doctor could not do so because they had no way to pay.
2. Doctors don't think of medicine like a mechanic thinks of repair work. A mechanic can be successful if he follows the basic principles of business: provide good quality at a low price. Profits shape his business and motivate him to work. Although many doctors too are motivated by profit, the large majority are more motivated by their professional code of ethics. This code is about caring for the patient, not making money from him, and as a society we allow people to practice medicine because they follow this code rather than chasing after profits. If my car breaks down perhaps I will chose to go to the mechanic who, though not the best in the city, is good enough and inexpensive to fit my budget and the value I place on my car. If I get sick it is unlikely I will use the same thinking: no, I don't want to see a doctor who cuts corners to save me some money. I want the security that I am getting the best care I can get. Yet on the other hand I don't want to get gouged or spend money on my car repairs than what is really necessary for my needs.
   

When it comes to medicine we have a "spend whatever it takes" attitude about solving problems about our own health of that of those we hold dear. This is untenable from a public health standpoint, but it is nevertheless our attitude about the matter. There is nothing else - save national defense - about which we would think the same.

We drove down to Eugene to see mom for mother's day. It was pretty nice weather so she took us and the dogs to a large pond outside Springfield. It was a relaxing 1.5 mile walk around with the trail to ourselves. Afterwards we had lunch at the Outback. Mom had steak and Naomi and I shared some baby back ribs. I was happy that she didn't break out a smoke during the walk - in fact I think she only had one the whole time we were there. Naomi thinks she had lost weight, but I think she has been pretty thin ever since I came back from Japan in 2003. She was happy about her recent outpatient surgery to remove a basal cell lesion on her eyebrow - although I find it amusing that she is so concerned about how she looks after the surgery (it was pretty minor in my view) but continues to trash her lungs and voice. Over lunch we talked about Alan Jr., my cousin, and his unorthodox views religious views. Mom and I last saw Alan and his family at Ty's wedding a few years ago.

Friday I took the day off and went mt biking in post canyon Hood River with Jon and Cam. I had a pretty nasty fall - nothing spectacular, but ended up with a painful goose egg bruise on my left thigh. Cam also fell a few times - once off one of the narrow bridges - and was a little shaken.

I rode my bike to Powell's on Hawthorne to browse some books - one on Lance Armstrong and Malcom Gladwell's Blink before Jon and Cam picked my up to go to Sinju in the very So-Cal Bridgeport mall. Pete tried to put Jon in a headlock and spilled a cocktail in Cam's lap. Cam then threw a glass of water into Peter's lap. Classy guys, but good carousing fun. We headed back into town after that for beers at Life 'o Reilly's where we meet a group of girls working for in the pharma industry. For some reason Peter took an extra toilet paper spindle from Shinju. Being a married doctor with bike shoes, in turns out, makes you a chick magnet in this city (haha).


From what I could gather about Blink - snap decisions based on intuition can be effective and efficient or disastrous. One way to stack the odds in our favor is to place ourselves in situations - created environments, that is - where our intuition can work uninhibited by prejudice and noise. For instance, in evaluating a musician we should blind ourselves to the person. Studies show that what we know about a person affects the way we hear, thus potentially misleading our intuitive sense of their quality.

This Naomi and I attended the clandestine marriage of two friends in the Rose Garden. Stupidly, I thought the ceremony was at the Rose Garden arena, which was unfortunate since we decided to ride bikes. I nearly took us over the Hawthorne bridge when Naomi finally stopped me to ask where the hell I was going. She rightly pointed out too, that had she made the same mistake I would have been more mad that she had been. She wasn't so much mad actually as annoyed that I led us all the way downtown only to climb back up to the park.

We saw the newest film by Kore-eda, Hana, an unusual variation on the 47 ronin theme, at the Portland Art Museum.

Saturday I joined about 20 other medical students for the Community Health Fair in the Columbia housing development in North Portland. As brainy and snobbish as I can be, I actually had a pretty good time meeting with people in the community. The kids, especially, were fun. On my way home I stopped in at Powell's for a coffee and some time with new books that looked interesting - Deep Economy (McKibben), The God Delusion (Dawkins), and Collapse (Diamond). One (at least I) doesn't have enough time to actually read full books outside one's profession anymore - unless on vacation. But I find that the introductions/prologues/epilogues do just fine.

Doctors push law on clinics in stores | Chicago Tribune

Doctors push law on clinics in stores | ChicagoPublish Tribune

Young, Gifted, and Not Getting Into Harvard - New York Times

Young, Gifted, and Not Getting Into Harvard - New York Times

This short story describes rather well the difference between today's college-bearing kids and those when I was finishing my high school years. Recently it seems a lot has been in the media about how pressured adult adolescents are at being over-successful, much of which is a matter of class and income.

As for myself, I took the SAT the end of my junior year. That was it as far as college resume crafting went. No Kaplan review, not even a pre-SAT, no tutors, only 2 AP classes (biology and european history - but I didn't take any of the AP exams). I played sports every season and was involved with the music and drama department. I played in a rock band. I didn't work really at all during summer. Life was pretty easy-going for a high school kid back then when you look at how middle and upper-class kids are raised today. Of course we were on the bottom end of middle class I think. Probably I would have been pressured a little more to achieve if my parents had been professionals, or at least college degrees for known schools.

The bottom line, however, is that the competition for achievement that we push for in our kids today is more for us than them. It is placing our fantasies and insecurities on their shoulders while robbing them of the freedom to be who they really want to be.

Future of primary care

The OMA House of Delegates meeting was this weekend at the Salishan lodge. We, the students, proposed a resolution to establish a student leadership fund with a $10000 budget and to change our membership status to full members. The delegation approved the budget, which is great news for future students who will have plenty of seed money to grow interest in the OMA.

There are a lot of gray hairs in the organization, which is all the more reason for students to get involved. The more I consider the various stresses on the profession and how it is changing, the more I believe that doctors need to get their crap together and start advocating for their own interests and for their patients.

Saturday night was spent over some beers thanks to some former presidents of the OMA and a continuation of the heated discussion about compensation parity between primary care and specialists.

The larger question beyond income parity is access. Fewer med school grads are choosing primary care - I put myself in that category right now. But it is not, I believe, due to low income as many people argue. $150K may be a fourth of a cardiologist's income, but this is still enough money to make a good living, even with a large loan debt load. People who really want to do primary care are going to do primary care; the main reason (there are many, including income and loan burden) I think many do not is because the biomedical sciences for a few decades now have become so information-dense and the growth of new knowledge (and procedural skills) so rapid that it is extremely difficult to be good - or possibly even competent according to community standards - without being a specialist.

The health care "system" and market understand this and therefore reward specialists much better than generalists because it is specialists who more less produce the results we want. In a larger urban area, such as Portland, it is standard of care for someone to see a specialist if they have complex organ-specific pathology. My primary care preceptor last year refered virtually every "difficult" patient to a specialist. Those who remained were patients with chronic diseases, aches and pains, psychosocial issues, common infectious diseases, and other non-acute, non-serious problems. For me this was all pretty boring from a medical point of view (although the patients as people were always interesting). It struck me as a waste of resources for an internal medicine physician to treat these kind of patients as his bread and butter (it requires 7 years of training for internal medicine). I think many young doctors-to-be feel the same way. A specialist career track will allow them to earn money that is more commensurate with their extensive training, and provide them with a job that is challenging and that lets them work on the leading edge of medicine.

So the question remains: wherefore primary care? My personal feeling is that the progress of medicine will require more specialists to deliver competent care, and these can only be MDs. So we are going to have to look towards lesser trained health care providered to fill the primary care vacuum: nurse practioners and physician assistants. For much of the ailments I saw in my primary care preceptorship, I am pretty confident that a NP or PA working under an MD could provide just as good of care. In fact, for low grade complaints - the majority of primary care visits - the quality of care is often determined by factors irrelevant to technical training, such as so-called bedside manner and listening skills. That said, there will still be chronic disease patients who should be managed by an MD, such individuals with diabetes or hypertension.