Lord, grant that from hence I may learn to withdraw thoughts, affections, desires, and expectations entirely from the world, and may fix them upon the heavenly state, where there is fullness of joy; where reigns heavenly, sweet, calm, and delightful love without alloy; where there are continually the dearest expressions of this love; where there is the enjoyment of this love without ever parting; and where those persons, who appear so lovely in this world, will be inexpressibly more lovely, and full of love to us. How sweetly will those, who thus mutually love, join together in singing the praises of God and the Lamb. How full will it fill us with joy, to think that this enjoyment, these sweet exercises, will never cease or come to an end, but will last to all eternity.
Jonathan Edwards

Medicine Is In Big Trouble

Medicine Is In Big Trouble

Medicine is in big trouble.

In not too many more years the medical industry will be radically different from what it is today. There will be widespread rationing of medical services, decreased access to physicians, particularly in rural areas, and generally a lower quality of care, except for those who can afford to pay cash. Here are the reasons why:

  1. Although a small dip in medical malpractice rates has occurred in some places this year, the expectation is that they will continue to rise. Physicians in certain specialties in some states now pay up to $300,000 per year for malpractice insurance. Many physicians in these areas are changing their practices (for example, obstetriciangynecologists dropping obstetrics), moving to other states, or retiring early.
  2. Medicare and Medicaid reimbursement is falling. Legislation is being introduced to cut it back even further, as medical care costs continue to rise. In our area, Medicaid pays only $4 for an hour of psychotherapy. Many physicians therefore no longer see Medicaid patients. We accept Medicare assignment (meaning we’ll agree to take only what Medicare pays, perhaps half of our usual fee) on a case by case basis. We don’t feel the need to extend charity to someone driving up in a chauffered Rolls, for example. Even if we don’t accept assignment and the patient has to pay the balance, we are still prevented by law from charging the full amount we would charge someone with, say, Blue Cross Blue Shield. For this reason, some doctors are also refusing to see patients with Medicare even if they have coinsurance or are willing to pay that balance out of pocket.
  3. Medical school enrollment is plummeting. Not being able to find enough qualified applicants, the Universities of Wisconsin and Minnesota and Northwestern University, all top quality medical schools, had to contract their freshman class sizes last year. The biggest decline in applications has been from children of physicians, normally making up about half of medical school enrollees. Their parents are telling them that its not a good way to make a living anymore. Scores on standardized tests in medical school (notably the three part Medical Boards) are dropping, suggesting that the quality of those coming out of medical school now is not what it once was. I’m told that college advisors frequently try to dissuade their charges from a career in medicine, pointing out that salaries are not keeping up with inflation. A noted medical futurist has predicted that the average doctor will be making $30,000 per year in ten years (in today’s dollars).
  4. It’s not just physicians who are in trouble. Even if by some miracle physician’s incomes remain essentially unchanged, the rest of the health care industry is likely to go through some serious convulsions. It is predicted that one third of all general hospitals open today will close within ten years. There is currently a serious shortage of nurses, physical therapists and other health care professionals, and little likelihood of this being temporary. The pharmaceutical industry is getting clobbered by rising product liability insurance premiums just as we physicians are by rising malpractice premiums. Some very useful medications have been taken off the market because sales didn’t pay the insurance. Many will never be brought to market. The average price of a new medication today is much higher than a few years ago.

If malpractice rates keep rising, I don’t see any way out of national health care coverage (Medicare and Medicaid extended to everyone), agreed to by physicians in exchange for the government taking over our malpractice premiums. We’ll become government employees. If you sue me then, you’ll have to get it out of Uncle Sam. I predict this will cause some rapid and dramatic changes in the tort laws. In fact, such changes may not even be necessary. When lawyers see how much time and effort it takes to press a successful suit they may think twice about taking such cases. But as a government employee making $30,000 per year or whatever, you’ll have a MUCH harder time getting me out of bed at night to come into the emergency room. There will also be many fewer of us willing to be doctors. There will still be some, the cream of the crop, who can make a living serving the rich on a cash-only basis. This is about the way things are in England right now, with the projected salaries at about the same level. If you need your gall bladder out or your hernia fixed there, you get put on a waiting list for six months. If you develop kidney failure and you’re over a certain age (60, I think) then you are ineligible for either a kidney transplant or dialysis. On the positive side, everyone will have access to this care, even those who presently have no insurance and are not getting adequate medical care because of it.

Who should we blame for the decline and fall of American medicine? Greedy physicians? Perhaps some specialties are ovepaid, and there are certainly a few physicians who try to milk the system, but I submit that the large majority are getting paid what they are worth, particularly when you factor in the fact that many don’t get out of training until they are in their thirties and may have hundreds of thousands in tuition debts. As a believer in a free market economy, I’d say it looks like physicians are now underpaid, since there are not enough students interested in going into medicine to maintain our current numbers.

Are the lawyers to blame? Not really, although it doesn’t help when they have a seminar at one of their recent national meetings entitled “Dentistry — A Great Untapped Reserve” or somthing to that effect (my dentist told me about this one this morning). As long as there are patients coming to their offices wanting to sue somebody, we can’t really expect them to nobly refuse the business. The insurance companies? If they were all charging too much, some upstart would come in charging less and clean up. Saved again by the free market economy.

I think the real problem is that medicine has gotten too good. The better we get at prolonging life and relieving suffering, the more it will cost, even if we manage to trim off all the fat (unnecessary tests, futile or marginally effective treatment, etc). We can no longer afford to do everything we know how to do. Years ago we heard patient’s families say, “We know you did the best you could”. When we could do little, we were thanked for whatever help we could give. Now that we can treat almost everything (with varying degrees of efficacy), patients are instead angry and even litigious when our treatment doesn’t work. It is thus paradoxically the increasing quality of medicine that fuels the upward spiral of malpractice insurance fees. Patients somehow feel that everything should be fixable, so if an individual physician can’t fix them up, he must be incompetent. And if you think patients are mad now, wait until rationing strikes and we start trying to tell them that, yes we have a treatment, but they can’t have it! I’m sure they could have dealt much better with being told there is no treatment.

What can be done to maintain the quality of health care in the face of declining health resources and personnel? I predict that computers, particularly expert systems, will become increasingly important in health care. There are lots of things that non-surgeons handle that could be done just as well by an expert system running on a PC. Well, maybe not just as well but well enough for what we as a nation may be willing to pay. For example, diagnosis and treatment of most headaches or management of high blood pressure (perhaps with an automated blood pressure cuff plugged into the serial port). Expert systems could monitor for dangerous side effects of medications, one of the main reasons we like to keep seeing patients back in the office whose ilnesses are otherwise well controlled. If the FDA could be convinced that the expert systems are working well enough, many prescription drugs might be made available over the counter. Of course, the software and drugs would have to be sold by the government, again to get around the medicolegal liability problems. Socialized medicine in a big way.

I can envision a medical clinic of the future with many certified medical assistants, each leading a patient through a computerized medical history, then doing a physical examination, perhaps being told specifically what to look for by the computer. A computer generated history and exam summary followed by a list of possible diagnoses with further test or treatment recommendations appears in the office of the lone physician, who light-pens the recommendations with which he agrees. The lab orders or prescriptions are electronically transmitted to the selected lab or pharmacy, and a page or two of information about the patient’s diagnosis and his medications is printed out at the desk. Only if he had some questions left unanswered by the computer would the physician see the patient. Believe it or not, the technology to do this is all available today, although not yet being sold commercially. It would be a simple matter to set up such an office, run some patients through it, and compare the quality of diagnosis and treatment against an all-physician, noncomputer -assisted clinic seeing the same patients. Perhaps computers will allow us to continue to deliver quality health care at a cost we can afford.

David Nye MD