Our medical system, our largest industry, is seriously dysfunctional. Perhaps its most egregious defect is its cost which when placed in the context with the cost of the medical systems of the rest of the Western world is outrageous. It submits a bill in the amount of $8,000 per person per year for all of us. It is out of control, with no slackening in sight.
A major contributor to this cost is the doctor bill. This cost starts the first day in medical school, and the cash register keeps accruing every minute thereafter. The average debt that accompanies going to medical school is $185,000. And this all at the tender time of life when students start to have a family. A baby or a bigger loan?
The much quoted faculty member of the Harvard Business School, Clayton Christensen, suggests a "Disruptive Prescription." (1) He tackles the multiple excesses of our way of delivering medicine. Among his most prominent complaints is the overtraining of our medical work force, physicians and everybody else. In effect he asks is it necessary that everybody involved in the system needs to be a super-specialist with umpteen years of postdoctoral training just to qualify for the opportunity to practice medicine?
Similarly, in an essay entitled, "Shortening Medical Trading by 30 Percent," Zeke Emanuel and Victor Fuchs estimate that the average length of time in medical training can be reduced by 30 percent without compromising competency or quality of care. (2) The six-year college/medical school programs now in effect show equal results on standardized medical exams and quality of medical practice. Emanuel and Fuchs indicate that every portion of the predominant model of the subspecialty programs is susceptible to substantial shortening. The effect of this of course would be a major reduction in cost of all.
These comments are particularly appropriate to me. I graduated from college at age 21 and medical school at age 25, by which time, irresponsibly, we already had two children. For the subsequent eight years, including two years as a regimental surgeon, I was trained and trained, polished to a high gloss. Finally at the age of 33, now with four children, my GP physician father-in-law asked, "When are you going to get a job?" This was totally relevant to my over-training. Eventually at age 33 I settled down to be what I intended to be, like my father, a real doctor, a general internist, as general a specialist as possible.
I was far over-trained to perform 98 percent of the tasks that I eventually did. All of this was an orgy of self-gratification. I loved being super trained, super smart, 150 percent more competent than I needed to be. The tragedy was that I did not see my children grow up.
Finally, I began medical practice at age 33. In retrospect I recognize that my practice pattern could have easily been filled by a person with much less training, a physician's assistant or nurse practitioner. These job categories did not even exist when I was in medical school. But they are now happily finding their way to the fore, and if Christensen's prescription is filled they will play an even larger role in the future care system.
My primary care provider is Steve Johnson. I hired him 30 years ago directly from his experience as a paramedic. After this he had undergone extra training that qualified him to be a physician's assistant. He played his role to a superior degree in supporting my geriatric practice. He is now 61 years old and still practices his trade to such a wonderful degree that I have identified him as my primary caregiver. He is smart, kind, careful, respectful, cheaper. We need to clone him times a hundred thousand.
Last week I clumsily skidded in the kitchen and busted by eight rib. With no hesitance I called Steve and was immediately tended, no fuss, but great skill. I now observe that the medical system would be immediately improved as most medical and surgical subspecialists are traded in for a physician's assistant or nurse practitioner. Many studies have shown equivalent or even better quality of care by such persons that is much cheaper and less distracted by the other expectations of sub specialty practice. More time spent per visit means fewer tests, fewer prescriptions.
If this is what Christensen talks about as a disruptive prescription, I welcome it.
References:
1)Christensen, C.H. et al The Innovator's Prescription; A Disruptive Solution for Health Care 2008, McGraw Hill , NY.
2)Emanuel Z , Fuchs V. Shortening Medical Training by 30% Essay in New Papers on Health, 2013. Fuchs V. Stanford Institute for Economic Policy Research