Some Definitions (And Maybe Even Some Practical Examples)

In case it isn't obvious, I've had a little bit more time to post lately. As I wind down my medical education, my responsibility is approaching zero. I don't start residency orientation until June, so I've really encountered an unprecedented amount of time off. With some of the responses to my posts in the past, I realize that there is some distinct confusion as to the meaning of words related to politics and economics. Consider this post a bit of a dictionary for economics, government, and healthcare. I've got the time to clear it all up, so why not.

Economic Schools and Political Terms-

Capitalsim- Private individuals own the ways and means of production. Property is all or largely private, with the individual owners having sovereignty over the use of what they own. There is zero central directing of production or the use of resources. Free individuals trade without any central interference with the rules or prices, with all of these things being set up on a cases by case basis based on uncoerced agreed upon contracts by individuals. There is a lot of capitalism in the US system, and it is not dependent on large corporations or well connected business entities. Every time you walk into a store and buy something that the owner decided to sell without being coerced, you are engaged in capitalism. There are no good examples of capitalism in modern healthcare.

Fascism- Individuals own the ways and means of production, but the government controls what they can and cannot do. Usually, companies are directed to engage in activities for the "socal good." If a factory owner is ordered by the government to build tanks, but the government then reimburses him and lets him keep the money, that would be fascist. In medicine, the best example of a system that is defacto fascist is the Canadian healthcare system. Individuals (private physicians) own the ways and means of production, but the government controls what they must produce and how much they get paid based on the "social good."

Socialism/Communism- Socialism and Communism are really two peas in a pod, with one simply being further along the spectrum than the other. In a socialist system, the government owns some of the ways and means of production, where in a communist system, the government usually owns all of the ways and means of production (though it supposedly does so on behalf of the workers). The British healthcare system is a form of socialism, in which the government owns the healthcare system, but private competition is allowed. The Cuban healthcare system is a communist system, in which the government owns the healthcare system and private competition is not allowed. These systems often rely on strong unions as representatives for the workers' collective interest.

Austrian School- The Austrian School of Economics is a purely libertarian school of economic thought. Though there have been a number of famous economists that subscribe to this school, the most famous is Ludwig Von Mises, who was an Austrian Jew who fled Hitler to the US during WWII. This is the only school that supports complete unhampered free market capitalism. Austrian economists tolerate zero government involvement in the economy. This school subscribes to the theory that peaceful trade between willing participants with no coercion from the outside is the way to prosperity. Austrian economists tend to be extremely fond of open borders, no tarrifs, and private production of everything. They vehemently oppose the existance of a central bank. The Austrian School blames the Federal Reserve for the business cycle and would like to see the bank dismantled and replaced with a gold standard.

Chicago School- The Chicago School has a lot in common with the Austrian School. It was named after the group of economists that founded it, who were largely based out of Chicago's Universities in the mid-20th century. The Chicago school supports an economy mostly based on capitalism and free trade. They do differ in the sense that they are much more tolerant of a central bank, and there is no striking desire to return to a gold standard. The chicago school tends to be more tolerant of collectivisation in both bargaining and production. You could still probably call the Chicago School capitalist, but it isn't as pure in that respect as the Austrian School. Probably the most notable Chicago economist is Milton Friedman.

Keynesian School- This school is based on the writings of John Maynard Keynes. Keynes was a somewhat flamboyant academic economist who lost a significant amount of money in the stock market crash of 1929. Keynes believed that the business cycle (boom-bust cycle) was caused by an inappropriate supply of money. The Keynesian system is completely dependent on a central bank. Keynesian economists believe that a recession is caused by too little money in the economy, often due to hording of capital. It is then the central bank's responsibility to increase the money supply during a recession (lower interest rates, print money, etc...). On the flip side, inflation is caused by too much money supply according to Keynesians, so the bank must decrease the money supply during a period of inflation. This is the general system by which most modern economies operate, though there is some pressure to change it. This is NOT a capitalist system, though it clearly relies on some elements of capitalism to function. It is sort of like capitalism blanketed on top of central control. Individuals own the ways and means of production, but all trade goes through the filter of very strictly controlled money supply. When everyone keeps talking about how capitalism has failed, this is really the system that is in place.

Marxian School (Communist Theory)- This economic school is based on the writings of Karl Marx. Marx believed that the ways and means of production had been co-opted by a few wealthy individuals who were taking advantage of everyone else. He believed that the way to economic prosperity (and the natural course of man's evolution) was to a world where everything was collectivised and owned by the workers who worked within it. There is no real free trade under Marxian theory. Prices are set at the "appropriate" price. All businesses are owned by the collective of the workers who work within the business. There are no entrepeneurs, and there is no private ownership of property or business. There is no real reason from a purely economic perspective that a strong governmnent would have to be involved in Marx' theory, though all attempts at creating it on a national scale have provided exactly that.

The US Healthcare System

The US healthcare system is a strange hybrid of a number of different systems. It is NOT a capitalist system, though it does incorporate some capitalist elements. It is capitalist in the sense that people can pay cash for services, and that a lot of contracting with insurance companies is private and uncoerced. However, all of these entities are heavily regulated. Insurance companies are private but heavily regulated and directed by the government. This makes the insurance system fascist. Medicare/Medicaid is really a socialist system. These are owned by the government. The fact that they contract with outside firms for both the distribution and occasionally the regulation of healthcare place them a bit in the fascist category as well. The government owns Medicare, funds it with tax dollars, provides it as a regulated benefit for whom it sees fit, but then uses the money as a way to force providers who take those funds to adhere to a plethora of government regulations. The government also directs, controls, and largely funds medical training. I will repeat, it is NOT a capitalist system.

Medical Training Terms

The Path to Becoming a licensed physician- In the US, to practice medicine, the most common path after high school is as follows:

College (4 yrs)-->Medical School (4 yrs)-->Residency/Fellowship(3 to 10 yrs)

There are some variations on this path, with some people completing differing numbers of years in college or medical school (though all medical school is ATLEAST 4 years).

College- There is no requirement as to what someone must major in to become a physician. As a general rule, applicants to medical school must have completed one year of general chemistry, one year of organic chemistry, one year of biology, and one year of physics. Common extra requirements that vary between accepting medical schools are a course in biochemistry, calculus, or some amount of english or literature. Students at the completion of college have no medical training, but they should have the scientific background that allows medical training to make sense. Those that wish to apply to medical school must complete and exam called the MCAT. In general, the applicant pool is reasonably self selecting, and from year to year, 1/3 to 2/3 of self-selected applicants will fail to get into medical school.

Medical School- To be accredited, a medical school must offer 2 years of basic and medical science and 2 years of clinical training. Some schools offer or require additional years of research. The first two years is largely classroom based. Different schools will also teach clinical skills in a variety of different ways during this time. The curriculum may be based on broad concepts (ex: courses in anatomy, physiology, pathophysiology, etc...),on specific organ systems (ex: cardiac system, renal system, etc...), or as a hybrid of the two. All of the same material must be covered, however it is presented. After the first two years, a medical student must take, and pass, the first step of a three part licensing exam called the USMLE. In the second two years, students must work at the hospital. While curriculums vary, ALL schools require some amount of medicine, pediatrics, surgery, psychiatry, obstetrics and gynecology, and general primary care or family medicine. Electives are also usually available to tailor the education to the needs of the student. Students then apply to residency through a process called the match. When a medical student graduates from medical school, he is given the title of Medical Doctor (or Doctor of Osteopathy at a limited number of institutions). This, along with the completion of the second step of the USMLE gives him the right to practice medicine only under the supervision of a residency program.

Residency- All residents are physicians. Post graduate training used to require an internship, but this internship has largely been incorporated into residency. The rules vary by state, but as a general rule, physicians may complete one to three years of residency and drop out to practice independently as a general practicioner (assuming that they pass the third part of the USMLE). No one ever does this anymore for practical reasons. Upon completion of a residency (which is 3-7 years depending on the residency), physicians become board eligible or board qualified in a specialty. At this point, the physician may practice independently as a specialist, though physicians increasingly need to complete a seperate specialty board to qualify for compensation as a specialist. Residents work in hospitals and practice medicine under supervision. Depending on the program, they can prescribe medication, perform surgery, and complete documentation.

Fellowship- For those who want further training as a sub-specialist, fellowship training is also available. This generally takes 1-3 more years. For example, if a general surgeon wants to become a cardiothoracic surgeon, he may train for 2 more years in a fellowship dedicated to teaching this type of surgery. The same would apply to an internist who wanted to become a nephrologist or a cardiologist.

USMLE- Each state licenses its own physicians, but all states now accept a single licensing exam called the USMLE. The USMLE is broken down into three parts (or steps), with the second part having 2 sub-parts:

Step I- This is an ~300 question exam taken at a computer center that covers all basic science as it pertains to medicine. The minimum passing score is changed every so often, but at this point in time, a score of 185 is required. This does NOT mean answering 185 questions right. The test is on a scale that no one really knows or understands. As of now, a score below 200 is acceptable but poor, a score of around 215-220 is average, and a score over 240 is really good. Residencies rely heavily on Step I to screen applicants. It is taken between the second and third year of medical school.

Step II- This test is broken down into two individual parts, a CK (clinical knowledge) and CS (clinical skills). The CK portion is similar to Step I, though it requires ~350 questions, and those questions are more clinical. CS is administered at one of 5 testing centers in the entire country. Students have to interact with 12 different standardized patient actors, treat them in a manner deemed appropriate, come up with a differential diagnosis, and write a coherent note on each actor. This portion of the test is a bit subjective and is generally abhorred by students required to take it. It was originally started as an exam for foreign medical graduates coming to the US to prove that they could speak english. These tests are completed some time in the fourth year of medical school.

Step III- This test is also similar to Steps I and IICK per my understanding (I'm not quite at this one yet). It tests patient management, and completion is the last testing step towards medical licensure. If you've completed all of the steps and completed your states residency requirements, you can be licensed as a doctor.


I hope all of that helped. Feel free to ask any questions if you still have 'em.