Does our health system really need doctors?

A dark wind is beginning to blow through the tortured landscape of health care in America. At the confluence of the corporate cold front with the warm front of technology innovation, a storm is brewing. A storm that may grow into gentle and much needed rain showers, or the grandest tornado ever experienced by mankind, and unlike the wondrous works of nature, the path taken here is completely within our control. The US government and all its federal, state and local branches spent over 1 trillion dollars of our tax money on health care for the poor, elderly and disabled last year and we spent well over 1.5 trillion dollars of our own on health care for everybody else. Most of these monies are going to medical service delivery systems, some is going to financial management intermediaries and a fraction is going to companies providing services to these corporate entities.

Obviously, this level of expenditure is unsustainable, and when we look at other developed countries, we realize that we could be spending a lot less for similar results. However, this is America, and while we must find a way to reduce the number of dollars spent on health care, we must do so without adversely affecting our health care corporate citizens.  This leaves us with two options. One is to simply not provide care to some of us some of the time, i.e. lower the volume and increase profit margins, and the other is to find cheaper ways to provide health care at higher volumes with lower margins. As long as the sum total of corporate profit remains unchanged (or happily improves), any combination of the above should work well for our purpose. Since we are a monetary democracy, we will have to carefully combine strategies so that moneyed citizens continue to enjoy the same levels of service, while the less savvy voting masses do not perceive significant rationing or cheapening of their health services. The non-voting folks are obviously free to perceive whatever they want.

The first thing to do is to change the discourse from all antiquated and touchy feely definitions of health care to a more modern conversation about consumer goods and services, which in a free society implies well understood variations in quality, availability and ability to purchase, based on one’s socio-economic status, closely mirroring our three groups of citizens described above.

The second thing to do is engage the fiery wave of information technology sweeping the planet. In the realm of consumer goods, information technology is accomplishing nothing short of magic by transforming traditional goods, like books, into electronic services, and by orchestrating the manufacturing and distribution of everything else. Many service industries, such as banking and travel, have also been transformed from labor intensive enterprises to largely computerized electronic transaction hubs, with very little human intervention needed, and mostly insensitive to geographic location. These transformations resulted in lower prices, lower expectations, increased availability and convenience for paying consumers, paired with record profits for corporations. Seems like the perfect solution for our health care puzzle.

So we begin by transitioning medical record keeping from paper to electronic format, and by standardizing medical transactions so they can be eventually captured by predictive algorithms that will accept standard inputs from consumers and industry knowledge bases, resulting in the dispensation of standard medical advice pretty much on demand. Very much like using Travelocity to book a vacation. If you are a physician, you are probably growing a bit uncomfortable at this point, because this is precisely the type of work you do now.

But wait, we are not as ignorant as you think. We completely understand that some medical transactions require human touch and that even the best medical algorithms still need some form of supervision, but do we really need an overeducated doctor for every routine medical encounter? For very simple things, the autonomous algorithms should be just fine, for medium complexity a trained technician oversight should do the trick, and for complex stuff, or for people with lots of money, a doctor can be added to the mix. This model of operations kills two birds with one stone. It immediately solves the artificially induced shortage of educated physicians, making more of them available for the wealthy, and it drastically reduces the cost of medical care for the masses because technicians don’t need formal education and uneducated workers can be both cheap and plentiful. We just need to secure a good supply of people without any formal education, by convincing everybody that absence of education is now the ticket to a good job and middle class status. And here is where our ominous meteorological event is now unfolding.

In a JAMA article almost a year ago, Drs. Emanuel and Fuchs began by defining the “obsolete” physician, “an incisive diagnostician and empathetic clinician, a productive researcher, and a scintillating teacher”, as a “triple threat” and terrified us all at the mere thought of encountering such a dangerous creature in real life. They then propose a new model based on the assumption that people are incapable of excellence, and “no physician can be a competent triple threat”, therefore why bother trying. Instead, we should apprentice most medical students to be practitioners of a narrow trade, and leave scientific research activities and critical thinking (a.k.a. autonomy) to a select few. This should shorten training periods, lower costs of training, and obviously we wouldn’t have to pay these guys as much, once the “threat” is eliminated.

In a more recent article in the Atlantic, Jonathan Cohn is advancing the thesis one step further. After exploring the emerging wonders of algorithm driven medicine, and drawing from the expertise of medical quality beacons, such as Tanzania, India and Brazil, Cohn is suggesting that health care will prove to be the salvation of the “middle class”, because “[i]f technological aids allow us to push more care down to people with less training and fewer skills, more middle-class jobs will be created along the way”.  Middle class jobs, according to Mr. Cohn, are those that “don’t require college or a bachelor’s degree, just a technical program”. So our uniquely American solution to the health care problem is two pronged: eliminate as much expensive education from medicine as possible, and simultaneously ensure that the vast majority of citizens are devoid of enough education to know the difference.

This pioneering stance in health care is reverberating through other realms as well, and reinforcing the notion that technology has freed us from the need to educate ourselves and our children. The Economist for example is taking on the legal profession, which may not be as education intensive as medicine, but it still commands large consumer prices. Instead of educated attorneys, why not use computerized algorithms provided by ZumbaLaw.com at a fraction of the price? And most importantly we should allow investors to buy legal firms and employ (uneducated) lawyers so they can create a more efficient legal system for consumers. Sort of like the miracle solution now applied to health care, where professional people are forced to surrender their autonomy, and now their education, to shareholders and managers. The term efficient here, as in health care, means that ethics and obligations to put clients/patients first are superseded by financial needs of the few, and cheapness needs of the impoverished many. Having professionals stripped of their education and economic power is only half the job to be done. If we are to be successful in reducing prices of everything down to the new “middle class” levels of affordability, without significant civil unrest, we have to make sure that we maintain the ratios of educational attainment, between our new professionals and the typical consumer, constant. To that end, we must convince everybody that we are in an education “bubble” and sending our kids to college is detrimental to the realization of the American Dream in this technology era. Or as Mr. Charles Murray gently puts it in a CATO institute Quarterly Message on Liberty “the BA is the work of the devil”.

In a letter to Charles Yancey dating from 1816, Thomas Jefferson stated that “If a nation expects to be ignorant and free, in a state of civilization, it expects what never was and never will be.” The education Thomas Jefferson thought was necessary in his times had very little to do with picking cotton and making nails. Similarly, in our current “state of civilization” the prerequisite education to freedom has nothing to do with learning a technical trade to better serve the corporate masters of computer algorithms, which seems to be the preferred prescription of the educated elite, liberal and conservative alike, for everybody else. The only question remaining, before we swallow the pill of voluntary ignorance, which has been shown to work for the benevolent tyrants ruling the United Republic of Tanzania, is whether the long term side effects of this treatment are congruent with our expectations, or what’s left of Thomas Jefferson’s hopes for the nation.

Margalit Gur-Arie is founder of BizMed. She blogs at On Healthcare Technology

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  • http://twitter.com/DavidGelberMD David Gelber MD

    The age of health care technicians is upon us. Diagnosis will be made by total body CT/MRI/PET scans, treatment plans idetermined by computer algorithms and surgery done by technicians seated at a console while the robot does the surgery. Doctors are unnecessary, outdated dinosaurs on the path to extinction.

    • Guest

      Those patients who never knew anything different will accept this model. Those of us that knew a better time, where a doctor used critical thinking and clinical skills (does anyone know how to do a physical exam anymore?) to manage our illness, will weep and live in fear of getting sick.

  • http://twitter.com/garysweetenblog Gary Sweeten

    Let us not forget that health care/wellness is largely a matter of the patient getting involved in his/her own self care. Doctors are needed even more but not for routine mundane interventions. But the key is how to keep patients involved in self care and mutual care.

    • T H

      Let’s not get all crazy about things. Expecting patients to take responsibility for their own health care is asking a lot in this age of entitlement mentality.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        I have to agree 100% about the expecting patients to take responsibility for their own healthcare is asking a lot in this age of entitlement. The majority of people are not interested in taking responsibility for their own health and paying the consequences of whatever actions they choose.

      • David Skinner

        In spite of entitlement mentalities, people have never been so engaged in their own health. It’s not about what we expect the patient to do, they are already doing it. Institutional inertia that still denies the ability of patients to look after their own health is the biggest barrier to empowerment.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      “Doctors are needed even more but not for routine, mundane interventions.”
      Interesting statement. Unfortunately for those that have chronic illnesses those routine and mundane interventions that doctors are not needed for anymore there is nothing routine about it. Their status with their conditions could change very rapidly at any second. Sometimes that condition being very dangerous, so a doctor will still be needed for those patients.

      • http://www.facebook.com/shirie.leng Shirie Leng

        That’s not what she’s saying. In anesthesia, my field, routine means standard care with healthy patients. You don’t need doctors for them. You DO need doctors for complicated or chronically ill patients. That’s the point. Doctors can use their lengthy education on the hard stuff. Let your extenders help with the rest.

        • Guest

          You have acknowledged that you have quit medicine. Yet you are arrogant enough to feel qualified to allocate x practices to midlevels and x practices to physicians. Why would you advocate against your fellow physicians this way?

    • David Skinner

      Absolutely. integrating the patient through self care is essential to health care sustainability. Research has demonstrated that up to 40% of MD time is taken up with minor ailments like mild acne, seasonal allergy etc. All of which have simple self care options that are effective. The movement of pharmacists to take over this workload of “minor ailments” is a signal that there is credibility to these facts. However, I’m pretty sure that just paying a different health care professional to do things that the patient can do themselves doesn’t solve the issue of payers having to spend money without significant outcome improvements. Money would be better spent on educating consumers. Pharmacy studies show how many millions (hundreds of millions; if not billions) can be saved if doctors did not have to treat minor conditions. Why not spend even 20% of those savings on quality information and self care algorithms and getting HCPs to help patients help themselves?

  • buzzkillerjsmith

    Dark, very dark. I like it. The article, not the picture it paints.

    I agree that outpt primary care is in deep, deep trouble. PAs and NPs can handle much of it, at least enough of it. Management of complex problems is hard for them, but corporate profits might outweigh that consideration.

    Proceduralists are in a better spot. It’s hard to see midlevels taking the lead on mesenteric ischemia cases, at least in the near future. Especially for 100k a year or so.

    Robots=rubbish. It’s a personal service profession. Enough said on that.

    Emanuel and Fuchs could very well be right. Medicine might become quite unattractive to academically accomplished college students.

    I suspect CorpMed will continue to do well for a while. Profits to be made. Not as powerful as the gun lobby but definitely in the same ballpark.

    Other than that, the future is pretty cloudy. Trifurcation of medical care could very well continue to evolve, with the wealthy in concierge, the middle class slogging in out in the offices of the unhappy docs that are still in primary care or the offices of soon-to-be unhappy midlevels, and the rest cooling their heels in community health centers staffed by midlevels.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      You’re probably right about that trifurcation… Do you think hospitals care will “trifurcate” as well?

      • buzzkillerjsmith

        Well, as you know, we already have poor-person hospitals. I think we won’t see concierge and middle-class hospitals soon, mainly because the huge capital investments are so high that targeting only a specific type of pt is risky. It might happen in certain areas. When I did my residency at UCLA in the mid 80s they had 2 special floors, one medical and one surgical, for Hollywood stars, the wealthy, and politicians. That kind of think is more workable maybe.

        Sadly, when the stars went to the ICU to die they were unable to avoid the hoi polloi dying next to them. Maybe UCLA has fixed this with its new hospital.

        • azmd

          You’re not allowed to have special floors in a hospital for private pay patients any more. Mt. Sinai in NY got into huge trouble in the 1990′s for having such an arrangement on its post-partum wards. It’s also unlikely that we’ll see the sort of entrepreneurial activity that would result in physicians grouping together to open up their own more-efficient hospitals that would cater to private pay patients, since there’s legislation making it illegal for physicians to own hospitals.

          • buzzkillerjsmith

            I stand corrected. I agree that special hospitals, physician-owned or otherwise, are in the cards soon.

          • buzzkillerjsmith

            should be not in the cards

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            it’s cards…so you never know :-)

          • Guest

            Really? I did my residency in the early 2000s and my hospital (a highly recognizable name) had 2 special floors on the top of the hospital. With wood paneling and views to die for, celebs and Arab sheiks would be catered to away from the stinking commoners. What was most amusing is that the least competent nurses worked the special top floors and the patients up there received some of the poorest nursing care in the hospital!

  • azmd

    Bravo. Should have been entitled “A Modest Proposal.”

  • w_km

    Yes. Let’s all swallow that pill of “voluntary ignorance” along with some fudge to drown our sorrows. Let’s continue on the path to becoming stupid and fat, and hope the algorithms, robots, and magical medications solve everything.

    • T H

      The fact of the matter is that algorithms DO help in patient care when the problems are routine and predictable, even very serious ones, like CVA, MI, and similar situations. They do NOT help when they become overly complex (more than three treatment loops) or when the patient’s medical situation is complex, which is happening more and more these days as once deadly medical conditions are becoming chronic medical diagnoses to be ‘managed.’ (ex: cardiomyopathies, HIV/AIDS, several types of neoplasia, renal failure, etc.).

      Reactive medicine has advanced quite a bit. Preventative medicine, which was once all we had, has fallen by the wayside and attempts at a renaissance have been quashed time and time again by various interests because it would seriously impact their bottom line.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        And that’s the problem, chronic illnesses and serious conditions like CVA, MI, and other similar conditions are not always predictable because the way it affects the person is going to be different from one person to the next. And unfortunately these examples are already very complex on its own when it comes to trying to manage them so that the person doesn’t get sicker.
        As for preventive medicine going by the wayside, and the attempts to revive it being quashed time and time seriously impacting the bottom line of the various interest groups interesting. However, here’s the problem. If preventive medicine was supposed to be such a good thing why are there just as many articles about studies saying that annual physicals and wellness visits aren’t that important? Why are they saying that they aren’t cost-effective?
        The reason that I ask this is because even though preventive screenings are covered at 100% the exams that may be necessary afterward if a problem is found is not covered at 100% by insurance. Also, the issue of annual physicals and wellness visits has become a concern to some because of the fact that incidental findings may show up on these tests worrying people more than is necessary in a number cases.
        The reason that I ask this

        • T H

          First, let me say… Cost-effective and good medicine are not always synonymous.

          You’ve touched on part of the problem: preventive medical exams DO find problems. Screening exams are meant to find problems so they can be fixed; however, they also find things that may be abnormal but actually are not – called ‘False Positives.’ Docs don’t know that these are not problems until they get the same workup that the True Positives have. Same cost for no actual benefit – and risk to the patient because sometimes the follow-on testing is not benign.

          Another part of the problem is that preventive medicine doesn’t get a lot of research dollars because there is little profit motive in it. Where there is profit motive – vaccines, for example – they are sufficiently expensive that many insurance companies don’t cover the entire cost to the physician – so doctors’ offices don’t offer them anymore.

          Yet another issue: if we get better/good at preventive medicine, specialists will have less work. Less work = less $$. Sure, they say that they’d love to work less, but if it affects their bottom line, they complain.

          And these are just a sample of the issues: of course there are more.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Interesting. So, that means that if there were more research dollars going in to preventive medicine that might then cause medical students to take more of an interest in Primary Care? I would be interested to hear a bit more about some of the other issues that are involved.

          • T H

            No. Medical students follow #1 the money and #2 things that are interesting to them (the order may be flipped depending on the person). We don’t live in China: the gov’t does not dictate to us what we can/cannot do as a profession.

            Where research dollars are allocated would have little effect on which medical student goes into which specialty.

            I’m saying that Pharma (big or little) has no vested interest in Preventative Medicine unless there is money in it. Insurance providers like the idea of preventive medicine, but they want someone else to pay for it (gov’t). Gov’t loves the idea, but is spread too thin and there is no effective way for them to get Pharma and Insurance to get excited about it because there isn’t much money in it.

            Other issues:
            >Recognizing that the workers in the trenches have little to do with the cost of health care. If you take into account insurance companies, there are 2-3 admin people per practitioner (MD/PA/NP). Why?
            >I’d like to just have a single billing format among all the insurance companies.
            >EHR: garbage in, garbage out.
            >Too much emphasis on ‘proper credentials’ and not enough emphasis on ‘we’re doctors.’
            >> A BC FP: why CAN’T they go into any of the medical subspecialties, like Rheum, GI or Cards? No good reason.
            >>Why don’t surgeons do interventional endoscopies? Why is it almost exclusively the GI’s?

            The main answer to most of these questions is ‘Because that’s how we’ve let the medical establishment grow up and now entrenched interests don’t want to let go of their piece of the shrinking pie.

            Personally, I work ER. Judging by the news of what’s coming, I’ll be able to work for the next 200 years taking care of patients who can’t find primary care.

  • Guest

    ‘To that end, we must convince everybody that we are in an education
    “bubble” and sending our kids to college is detrimental to the
    realization of the American Dream in this technology era. Or as Mr.
    Charles Murray gently puts it in a CATO institute Quarterly Message on Liberty “the BA is the work of the devil”.’

    If the average American kid with an Arts degree actually any smarter or better prepared for life than an Aussie kid with a trades apprenticeship or a Certificate I–IV under his belt, though? Less than 25% of Aussies have Uni degrees, yet they have a more robust economy, low unemployment, good healthcare for all, a more generous social welfare safety net, and they live longer too.

    Churning out hoards of 21-year-olds with 4-year degrees in Women’s Studies and Art History (and tens of thousands of dollars in school loan debt) DOESN’T seem to be doing America much good. Murray may have a point.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      This is a very good question. I don’t know about “smarter.”, but “better prepared for life” is a loaded description. The US took upon itself a different role in global society than Australia did, and with a military arsenal larger than all other countries combined, it seems intent to continue in that role. Perhaps our kids need to be prepared for different lives. Of course, we could abdicate our role as a nation, revise our aspirations, and throw another shrimp on the barbie, but I am not sure that considering everything, this is a viable option for our “shining city on a hill”.

    • buzzkillerjsmith

      If you get a degree in Art History and do not already have a job set up with the family company, you’re in a world of hurt. But engineering and computer science majors, at least around these parts, are getting good jobs. That was not the case a few years ago when the financial crisis was really biting, but things have gotten better, at least in Washington state.

      • Quill

        Are Engineering and Computer Science “Arts” programs in the States? (Referring back to the comment about BAs)

        • trinu

          BA vs BS doesn’t have to do with choice of major. You can get a BA in biotech or a BS in Art History. BS is usually more rigorous in that it requires taking more courses in fields related to one’s major (for example a BS in chemistry might require more physics than a BA in chemistry).

        • buzzkillerjsmith

          Engineering is both science and profession, like medicine.

  • JPedersenB

    Rather than make doctors obsolete, why not take the profit motive out of the medical industry? One thing is for sure, change will and has to come as the current system is unsustainable!

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Profit motive has been such a big part of the healthcare industry for as long as I can remember. So what suggestions do you have that could take that motivation out? I do agree though that the system as we have it now is unsustainable and is at the breaking point.

  • http://twitter.com/Listen2theOm Jeffrey Brinkmeister

    This message has been brought you and paid for by the founder of BizMed, a purveyor of HIT services. Perhaps this explains this individual’s extraordinary bias. This is written by someone trained as an aeronautical space engineer who has never CARED for a patient in her life, nor does she envisage CARING as part of healthCARE. Like so many, she refers to the “magic” of IT and in her magical thinking and naivitee she thinks that technology is going to save the very human enterprise of CARING for patients. Medicine is only in part a cognitive process, and at its heart it involves CARE and CARING.

    Healthcare providers should boycott MedScape and leave MedScape to the algorithms, bots and HIT providers.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      You may want to reread the post…. slowly. Looks like you misunderstood it by about 180 degrees.

  • http://twitter.com/Listen2theOm Jeffrey Brinkmeister

    I have data and time stamped screenshots of the disappearing upvotes MedScape. Is it your policy to censor upvotes that you do not approve of?

  • ninguem

    All these healthcare systems elsewhere in the developed world. Systems you say do the job better and cheaper.

    Do they have doctors? More than us?

    What is their use of nonphysician midlevels, compared to the USA?

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Yes, they have doctors. Lots of them. Certainly more than we have (per capita). And most are in private practice and are paid fee for service. I pulled together a little primary care review here: http://onhealthtech.blogspot.com/2013/03/around-primary-care-world-in-80-seconds.html

      • ninguem

        Well, then why is there a question about “needing doctors”?

        Are the Brits questioning their need for doctors? The Canadians? The French, Germans, Aussies? If they are, in any serious manner, I’m missing it.

        With all due respect to the NP’s on this site, I don’t see the growth of nonphysician providers fixing any problems with American healthcare……..if that’s your point with all this.

        I remain with the null hypothesis; whatever cost and access problems we have now, we will continue to have, regardless of the letters after the “provider’s” name.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          There shouldn’t be. The original title of this post was “The Destructive Recreation of Medicine”. That was my point…. obviously not very well made :-)

          • Guest

            I got the tone and I enjoyed your article :)

  • http://euonymous.wordpress.com euonymous

    I just hope Watson has some really good programmers. Our lives may depend on it.

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