Medicine and Economics

Movin' on Up

2009-06-11T16:16:00.001-05:00

I'm just letting everyone know that I haven't stopped blogging. I am in the process of completing a move across the country, so I'm a little slow. Check back in a week or two at the latest for more.

New Blog Link

2009-05-06T15:50:00.002-05:00

As some of you may have noticed, I am a little bit stingy with handing out links on my blog. After recently speaking with a blog author however, I think that I've found a good one to add to the list. The blog is entitled, "Are You A Doctor?" It is written by a physician's assistant who works in the ED at the Mayo Clinic in Rochester, MN. We agree on a number of things, though healthcare policy unfortunately seems to not be one of them. Yet, I respect his perspective. He is intimately familiar with some of the recent developments in US healthcare policy, and his position at the Mayo Clinic gives him first-hand knowledge as to how some the ideas are being handled by the country's healthcare big-whigs. Plus, it's always good to have a spy at the mother ship.

All joking aside, I hope you check him out. You can find the link to his blog in my sidebar with the others.

OH MY GOD!!!!! IT'S THE SWINE FLU!!!!!!!

2009-04-30T12:35:00.002-05:00

I have been reading so much media hype over the swine flu, that my head is beginning to hurt. For my readers that have been living under a rock, there is apparently a horrible flu in Mexico that has killed a few people while simultaneously sending the entire world into a frenzy. Infectious disease is certainly not my forte, but I can explain a little bit about influenza. I can also explain a little bit about my personal opinion on this disease.

What lay people consider the flu is actually a variety of similar ailments. The most common causes are from a couple of different types of influenza virus. Similar symptoms may come from the parainfluenze virus, as well as a couple of other outliers. The only "flu" that is actually the flu comes from influenza virus. This particular virus that is causing the swine flu is of the Influenza A type of influenza virus. This type of virus may express a variety of different antigens. The antigens to which antibodies are commonly made are generally knows as H and N antigens. The variation within these antigens is why there are so many different strains of flu and why unlike say the chicken pox, you can get infected with the flu virus repeatedly. Different influenza viruses can exchange DNA with each other to produce genetically distinct daughter strains and promote variation.

Humans are not the only species that can be infected by the flu. Strains of the flu can affect other animals, including species of birds and pigs. Generally, bird flu and pig or swine flu are not infectious to humans. However, a flu that can afflict these species may exchange some DNA with human flu. Occasionally, a flu that is infectious to another species may, either by spontaneous mutation or by exchange of DNA with a human virus, become infectious to humans. Most of the time, this infection is isolated to a specific person or group of people that have contact with the infected animal or animals. However, there are cases where this new infection will further mutate to allow transmission from human to human. This introduces a bunch of new DNA into the human influenza genome.

Humans usually walk around with some immunity to the flu. We have a part of our immune system that fights viruses in general, but most humans have been exposed to flu before, and thus most people walk around with additional immunity. The different strains of influenza are distinct enough, that they can re-infect the same host. However, they are similar enough that a previously exposed host can usually mount a partial response to the infection. We could think of this as damage control. You're sick with the flu, but your immune system can hold it at bay with relative ease due to its similarity to other strains that you have been exposed to. You are also part of the way towards developing immunity to the new flu, so the response is quicker.

In cases where there is exchange of DNA from an animal to a human flu (or worse yet when an entirely new flu virus crosses over from animal to human), people will lack this immunity. This gives the infected person fewer resources to hold the disease at bay up front, and it takes longer to develope a specific response to the virus. The VAST majority of the time, this makes for a bad long lasting flu. It is usually NOT fatal. However, occasionally an extremely virulent strain will cross over, and the previously unexposed human population will have very few big guns to stop it up front. Major flu pandemics (such as the flu of 1918) can be the worst-case scenario result of this sort of event.

There are a few more facts to keep in mind about the flu. Common everyday influenza is already the bane of the very young and old, the immunocompromised, and the sickly. Every year, 30,000 people will die in the US from the common everyday flu. Most of these people will fall into one of the above categories, though there will be some who will end up susceptible in the not obviously sick adult population. To put it into perspective, the flu kills as many people every year as 6 world trade center bombings.

The fear and panic over the swine flu seems to come in large part from the fact that a number of young people have died in Mexico, and the strain seems to be a swine strain of the flu that has crossed over to humans and mutated so as to be transmissable from human to human. I agree that this little set up is exactly how most pandemic flu starts. However, there are some things which make me seriously doubt the current degree of crisis, and more importantly, make me doubt whether this will really turn into a global pandemic spreading death in its wake.

The official number of deaths in Mexico currently sits at ~7 per the WHO, with estimates up to 200 of actual victims. There are over 27 known cases of flu in the country, but we all know that the majority of cases probably never sought medical attention or made an official statistic. This 27 number is only laboratory confirmed cases. These are people who made it to the doctor, had signficiant symptoms, were suspected, were tested, and came back positive. We have no way to assess these numbers. Were these really healthy people? Is the number really 7 or 200? Is it possible that there is a group of immunocompromised patients that got hit with the flu?

The flu has currently spread, per the WHO website yesterday, to 9 different countries. The CDC this morning has confirmed 109 cases of swine flu in the US, with one solitary death. This death, though unfortunate, was in a toddler in Texas at the age where children may be susceptible to death from any flu. No one outside of the US and Mexico has died of this flu. The fact that no is dying of this flu outside of Mexico alone makes it suspect. Are we dealing with two different strains of swine flu? Is there some other contributing public health disaster in Mexico to which we are not privy? Are the official deaths all immunocompetent hosts?

Lastly, this whole thing is essentially starting after flu season. The flu just doesn't generally reach peak virulence when it starts this late.

Here's what we should do (this is if someone were to ask me of course). We should work on a vaccine for this particular strain to offer to individuals who are likely to be susceptable before next flu season. This flu very well may attack at the beginning of the next flu season. We should also make sure that there are sufficient stockpiles of anti-viral drugs to address the possibility of a bigger problem. We should really only use these when people are very sick or start dying in real numbers. The last thing we want to do is breed resistance in a virus that seems to be doing minimal damage in our country now, only to have it develop resistance if it becomes more virulent. We should also watch the virus and its spread. A sudden rise in flu related death should necessitate further investigation.

Here's what we should NOT do. There is zero reason to panic at this point. We should not be stockpiling Tamiflu and N95 masks. We should not be cancelling events. We should not be living in fear. Every few years, we panic over a new strain of flu (remember the whole avian flu debacle). These sorts of things happen all the time, and it would really be ridiculous if we all shut down ever couple of years over the small possibility that a flu could become a pandemic. Most flu pandemics come from the crossing over of flu from species to species, but most crossing over doesn't result in a pandemic.

As I have always maintained on this blog, one of the few legitimate roles of government in healthcare is the control of infectious disease. It is appropriate for them to watch this. Remember however, that the vast majority of infected people have probably never been tested or even sought medical attention. The death rate amongst known cases (which are probably the worst cases) is still less than 1%. Let's keep this in perspective. Right now, the rate of death from this swine flu in the US really isn't any higher than the rate from regular flu (something we do not panic about).

It is smart to stay vigilant, but we cannot panic over every potential problem, because the possibilities are endless. If I see one more person walking around in a surgical mask (a mask that probably doesn't protect the person) here in my state where we have no cases of the swine flu, I may lose it. The panic is ridiculous. Could a swine flu pandemic occur? Sure. So could a nuclear war with China. At this point, I don't see a reason to panic about either of them.

Some Definitions (And Maybe Even Some Practical Examples)

2009-04-23T05:44:00.004-05:00

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.

It's Hard to Stop a Moving Train: A Primer on Inertia in Modern Medicine

2009-04-21T06:45:00.004-05:00

As a senior medical student, I recently went through the match. The match is the process within which senior medical students (or anyone else seeking a residency) are accepted to residency positions. Most schools release a match list after the process is over. This allows everyone to see who is going where and which specialties are being pursued. A match list is more than just a list. It is largely a reflection of the interests, philosophies, priorities, and successes of a medical school class. It is also interesting to see how these things change over time. Specialties come in and out of vogue, priorities change, and what was once the pinnacle of achievement becomes a dumping ground for those that couldn't get in to some specialty that was itself a dumping ground not too many years before.

While these things wax and wane, it is clear within my own institution (and really amongst medical school graduates at large) that the last decade has ushered in a paradigm shift. The traditional medical school class is full of extreme type-A overachievers who have been at the top of everything forever. The traditional rank order list of the years of yore reflected a desire amongst the top applicants to continue this type of function. Once upon a time, and this was before any work hour restrictions or attention to resident health, students fought over the right to work 120 hour weeks in surgery pyramid programs or gruelling schedules at large academic medical centers as internists. Those days are clearly gone. In those same years of yore there were a cadre of specialties which brought a more friendly lifestyle, sometimes without a significant pay cut. Specialties like Dermatology or Radiology were a way out for those who were done with the intense pace that categorizes life in the hospital. From the medical community at large, these jobs have often been considered secondary. I know an old internist who referred to essentially all radiology as "scut." No one speaks like that anymore. In fact, the current shift has made these specialties the most attractive to the creme de la creme.

The classic lifestyle specialties are known as the ROAD specialties (Radiology, Opthamlmology, Anesthesiology, and Dermatology). My class, which is graduating around 170 people, had over 20 people apply to radiology in the match. 5 More matched (with several not matching) into Dermatology. We had 15 match into anesthesia (which is also become more attractive to the lifestyle conscious). We had 9 match into Opthalmology, with atleast 2 more taking time off for research to apply more competitively next year. If you add it up, this puts 49 people (or nearly 30% of the class) in the four most most lifestyle friendly specialties. We have more people in all but one of the ROAD specialties than in General Surgery. We have more people going into these specialties than internal medicine.

The other divergence of members of the top of the class is to direct surgical specialties. It seems like in many cases, the broad training of general surgery is no longer required or desired. It really does make some sense. You can cut a year or more off of your training or enter a field which requires the same number of years it takes to train to be a generalist to be a specialist. Applications to Neurosurgery, Orthopedics, ENT, and Urology are stable to way up. Direct Plastic Surgery and Direct Vascular Surgery are insanely competitive, with the former being the most difficult to attain residency in all of medicine.

So why the paradigm shift? We could blame it all on our lazy generation, but I think that there's much more to it. This is still the extreme Type-A hardworking group at the top of the academic curve that it was in generations past, and I'm not sure that the true underlying ethic is extraordinarily different in this group.

I've heard different explanations:

1.There are more women in medical school today, which tend towards more lifestyle friendly specialties. This is however nowhere remotely true in a universal sense (In fact, the fields with the fastest growing percentages of women residents are the difficult surgical fields, and the field with the highest percentage of women is OB/GYN, which is hardly lifestyle friendly). This also doesn't explain why a higher percentage of men are going after lifestyle friendly or direct specialty fields.

2. Medical School isn't as hard as it once was. This is probably true in the sense that the total number of hours required of a student is probably less than it once was. On the flip side, the amount of standardized testing and the overall knowledge requirement has probably increased. This is certainly not a slam dunk.

3. Medical Students aren't socially conscious anymore. This one is almost hilarious. Students today flippantly bounce from one cause to the next, with what has to be record enrollment in every social justice group in existance. Medical missions and the "underserved" are the thing du jour. Students are so busy being socially conscious, that it is sometimes hard to figure out when they have time to study medicine. Students in the 70s were probably far less likely to intentionally pursue something in order to fall on the grenade.

So you've probably guessed that I've got a theory. You're right. You may have also guessed that it boils down to simple economics. You're also right. Atleast, it boils down to a combination of respect and simple economics.

Physicians (nearly all physicians) used to tower above their communities in a financial sense. From the ushering in off Medicare until the HMOs of the 90s, physicians were usually amongst the wealthiest in town. This was true of all specialties. Student loans were relatively low, and training time was MUCH less in many specialties than it is today. Money, while important, was really much less of an issue. Everyone could do well. Today, through a combination of declining physician reimbursement and everyone else getting richer, the relative wealth of medicine is much less. It makes the financial factor more important in specialty selection. Students are often sitting on a student loan mortgage or two. My personal student loan payments will be approximately 5 times my mortgage payment, and still 3 times my mortgage payment if paid off over the same 30 years.

Additionally, specialty physicians (while often of questionable added value compared to their generalist counterparts) are virtually always better compensated. Lifestyle specialties are usually much better compensated on an hour to hour basis.

Today, there is an inverse relationship between pay and value. The most critical jobs, or atleast the most logistically complicated important jobs (middle of the night emergencies and such) pay much less than most of their elective outpatient counterparts and come with the added sucker punches of higher rates of being sued and an inability to select your patients.

In the past, the difficult specialties like primary care or general medicine were respected. They are clearly not in the same way today, and they are clearly not respected above their counterparts in more friendly specialties at all. To be a generalist today is to be hit with a mountain of paperwork (no reimbursement for completion), lower reimbursement, higher rates of lawsuits, and generally poor public opinion. No wonder people are running from it. Reading CT scans from home at 10:00 AM is a heck of a lot less demanding than poring through dead bowel at 2:00 AM, and you get paid a lot more to read the scans.

There will always be people who find some sort of inherint satisfaction outside of direct specialization or lifestyle friendly specialties. I for one chose general surgery because the I am personally satisfied with the idea of being able to handle everything, having a broad scope, and being the last line of defense. There is a growing number who agree with me, but that number is dwarfed by those running for the hills away from all that really matters.

Here's the problem. You can't run a medical system in which everyone is a Radiologist. You cannot operate a system in which everyone wants to perform cool new endovascular or robotic surgical procedures, but no one is willing to do the midnight appy. People really need a PCP to be the first line of evaluation in many cases. I am in no way denigrating specialists or radiologists, but we need all types. The problem is that the train has left the station and is moving. The medical system will continue to move people away from where they are needed most. Our skewed payment system in concert with a confused legal system and laws limiting physician's ability to be compensated in a relatively appropriate manner have taken the medical train on a one way track towards a cliff, and we all know its hard to stop a moving train.

Spam Blog

2009-04-15T06:53:00.000-05:00

I have apparently been identified as a spam blog. I can't begin to speculate as to why this is (I have no links to commercial sites, I post consistently but rarely, etc...). If you are receiving a message that this is a spam blog, please disregard it. I have no idea how what I write could be identified as this, but I've contested the label. I sincerely hope that Blogger corrects whatever flaw is in its software that would identify my blog as spam.

Winding Down

2009-04-15T05:50:00.004-05:00

I saw my last patient as a medical student on Wednesday last week. I'm going out on a two week rotation in pathology (so I'm not quite finished yet), but I have seen my last live patient as a medical student. As I approach graduation, I have some time to reflect on the experiences that have defined the last four years of my life. If I had to guess how all of this would end four years ago, the only thing I know is that I would have been off the mark, possibly about 180 degrees.

Four years isn't that long, and it seems that every four year cycle in my life takes just a little bit less time than the one before. Yet, the changes in my own life are profound. I've more than doubled the size of my family, changed career trajectory, watched people die, been exposed to tuberculosis (fortunately never became positive myself), and I'm ending the whole thing off with a move from a hot steamy flat metropolis to a small cold mountain town. I would have never guessed it, but I couldn't be happier in the end with how it all worked out.

It's strange how a few years in medicine changes your perspective. I suspect that this was uniquely exacerbated in my case by my near omnipresence in a large county hospital and level I trauma center. There was once a point in my life where being cursed at in spanish by a drunk guy who showed up at my door via helicopter with numerous pieces of long bone protruding through the skin would have been a bit odd. Now it really feels far too normal. In fact, I started this journey by dissecting apart a decaying corpse. I watched my wife lie in the same beds on the same wings of the hospital where I rounded on some of the nameless, nearly faceless, morass and prayed to God that someone who knew more than me was watching. I watched my son go into full respiratory arrest and drop his O2 saturation to 19% after extubating himself in the ICU. The second time I saw it, it seemed eerily normal. As those close to me suffered, I was still bombarded by strokes, gunshots, heart attacks, cancers, and more. I feel as though I ought to be suffering from some sort of post-traumatic stress syndrome. Yet, it all feels quite normal. It's as though it was meant to be the way it was, and I've made peace with the whole thing in a way in which I'm starting to forget how disturbing it all once was.

It's not that I'm jaded. I'm not. I appreciate the gravity of what I'm seeing and what I saw. Some of my patients still tug on my heartstrings in a way that makes me reflect on the meaning of it all. It's just that I'm used to it. I guess that this is one of the successes of my training.

I have also learned such an incredible amount, that I can no longer remember what it's like to not know some of it. I've picked up some amazing skills. I can safely pull fluid out of a swollen belly or out of an infected spinal cord. I am comfortable closing relatively complex lacerations and stab wounds. I feel comfortable assisting a surgeon in those which are even more complex. I actually know what all of those weird numbers written between strangely constructed lines mean, and I can identify whether they signify a problem. I've had to hold the hands of patients when I was in the unfortunate position of telling them that the problem those numbers signified was severe. I've also picked up and distributed this data in English and Spanish. I've also done so with written notes, through interpreters, impromptu sign language, and sometimes I've had nothing to go by but old notes on an indigent comatose patient with no family to be found.

Different people come out of this experience with extremely different perspectives. People enter medicine for a variety of reasons (save the world, make money, love science, etc...). People's expectations for medical school are all over the place and rarely on the mark. There is no consensus on the quality or value of this education. I have classmates that would take any offer of student loan repayment and take a job at Starbucks over another day in the hospital.

I am one of the people who would absolutely do it all over again. If I knew what I know before medical school, I would still absolutely sign up and do it all over again. The experience is incredible. The extraordinary becomes ordinary. Even with all of the paperwork, beauracracy, physical strain, and student debt, there are still very few other fields where everyday is part of an epic struggle between life and death. It's not all exciting, not all of your patients are good people, and it seems like all of the problems of society have been dumped down upon the decaying structure where you spend 80+ hours a week, but the upside is incredible. Every encounter brings a true window into someone's life. People trust you, often because they have no choice. Whether that patients are sitting in a clinic for some medication adjustment or flailing, screaming, naked and bleeding, in the trauma bay, they have at that moment put some portion of their lives into your hands. It is an awesome responsibility. I do not regret taking it.

I'm looking forward to the next step. While the location is quite different, much of the struggle will be the same. I will continue to compete in this epic struggle as long as the patients continue to bring me something worth fighting for. When I speak with my next patient, it won't be as a med student (or student doctor, or trainee, or whatever). I will introduce myself as Dr. Miami, and the title will be appropriate. I've earned it, and I never intend to lose it.

If Only it Were a Joke

2009-04-10T12:12:00.003-05:00

The following quote is directly from an MSNBC article:

"France and Germany especially have suggested that the better response is not more government spending but tighter regulation.
The Obama administration has urged European nations to do more to restart their economies through financial stimulus. Mr. Obama is hoping that by showing a serious commitment to tighter regulation he can more easily persuade other countries to increase government spending and stimulate demand by consumers and businesses that would help pull the global economy out of a serious decline."

This would almost be hilarious if it weren't true. This argument is sort of like this:

Obama:You all should print a bunch of fake money.
Europe:We would much rather strangle the economy to make sure it never totally recovers
Obama:If I strangle the economy too, will you print a bunch of fake money?

A Quick Run Down of Why the Economy is Performing So Terribly

2009-03-12T07:26:00.004-05:00

OK, OK, so I said that I wouldn't write about any of this. I won't get too specific. Yet, I really couldn't write on much of anything if I didn't address some current issues, so I'm going to write a primer on why booms and busts occur.

How Money Works

There is no such thing in this world anymore as sound money. I would define sound money as a tool of trade available in a relatively stagnant quantity that retains similar value amongst all participants in the economy that allows for the determination of relative valuation of goods and services while they are traded. Sound money is usually tied to a resource in relatively static supply (often gold) to maintain this stagnant quantity. The actual numbers are irrelevant in a sound money system. If Paul and John each have one dollar, and it costs one dollar to buy a loaf of bread, each of them can afford a loaf of bread. If they each have ten dollars, and a loaf of bread is ten dollars, then they can each afford a loaf of bread. In this case, ten times the amount of currency in the system didn't impact the relative value of each man's wealth. The trade for bread could be carried out just as easily in a one dollar world or a ten dollar world. If the value of the money is unchanging, the bread's value may fluctuate over time due to changes in supply and demand, but the specific digits don't matter. Similarly, If the US suddenly stated that every dollar is now ten dollars and in real time multiplied everyone's savings by exactly 10x, and multiplied everyone's debts, obligations, salaries, etc... simultaneously, the result would be inflation to 10x current value with no real change in the economy, as everyone would have 10x as much money.

When we think about it logically, there is no reason to ever multiply everyone's money by 10x. The simple act of creating more digits does absolutely nothing to improve the economy. In the above scenario, the printing of 10x the money supply will simply cause goods and services to increase in cost by 10X. It doesn't make everyone 10x richer.

Let's take what happens in the US. There is no sound money. The US dollar is not attached to a gold, or silver, or platinum, or anything standard. The money supply can change on a whim (and the quick turning on of the printing press by Ben Bernanke at the Federal Reserve). If all of the money that they printed hit the market at the same time equally in relative proportion to current wealth and all current obligations were changed accordingly, the only impact on the economy would be the excessive waste of paper. However, this doesn't resemble the current situation. Currently, money enters the system at certain points. It goes to banks in the system of fractional reserve banking, and it goes to the government. This gives both banks and the government (along with those well connected to the government) a real time financial advantage. To use the previous example, the banks and the government see their 10x increase before the cost of the bread goes up 10x, giving them greater relative purchasing power. Eventually, the money will even out in the economy, and the bread will rise by whatever percentage increase has occurred, but not before the banks and government have had the opportunity to purchase bread at the lower price with the new money. This allows them to accumulate resources with greater ease than other players in the economy.

The other thing that does not change in the current system is debt obligation. If I make a loan, and I charge a 10% interest rate, the balance of the loan isn't impacted by relative inflation. In other words, if I lend you $100, and the money supply goes up by 2x, you still only have to pay back $100, which is now only half as much money in a relative sense. Lenders cannot automatically determine exactly how the government will mess with the money supply, but an adjustment for inflation must be built into any banks lending portfolio if they want to stay in business. In other words, if I determine that with all risk and cost, that I can profitably lend at 5%, and I assume 3% inflation, I must actually lend at 8%.

Another point is that the relative change in wealth due to the entry points for a non-sound money supply cause distortions in the value of different goods. Things for which the banks lend money, or the government supports, will increase in relative cost to other goods. This can cause all sorts of confusion in the economy. As the money makes its way into the economy at large, inflation will occur in some sectors, while deflation occurs in sectors where the money first hit. In other words, lets say that the government prints an extra 10% of the money supply, which goes primarily to banks through the Federal Reserve. Banks use this to invest in abandoned mines. The relative increase in money initially going towards abandoned mines will be much greater than 10%, as all 10% increase in the money supply is going towards something that was much less than 100% of the economy. This may triple, quadruple, quintuple the cost of an abandoned mine. However, assuming no further distortions, that 10% will eventually work its way into the economy, and the value of all other goods and services should increase in relative proportion by 10% while severe deflation hits the abandoned mine industry and knocks prices down to only about 10% above the original price (and possibly even lower for a time, as its hard to tell exactly where this bottom price is.)

How Does This Apply to the US?

Ever since the creation of the Federal Reserve, the lack of sound money has caused ebbs and flows in economic distortion. As I've already pointed out, increasing the money supply eventually leads to inflation of cost by a similar amount with distortions brought about along the way as the money balances out in the economy. The concept that the government could in some way increase productivity and wealth by printing lots of money is based on the writings of the economist Keynes. It has never worked in action ever, but it is the basis for everything that we've done to bring us to this point. The economic distortions, followed by their corrections, are the likely cause of the business cycle, and the current situation is nothing but an overblown business cycle.

After 9/11, the economy went into a recession. It was not severe, and it made sense. Total economic activity declined in the environment. A sound money economic theory would tell you that the recession was due to a real decline in national productivity and that the solution would be to wait for productivity to pick up again. Instead, Alan Greenspan (chairman of the Federal Reserve at the time) implemented a loose monetary policy. This means that he essentially flooded the market with new money to "jump start" the economy. The tools that he used were primarily aimed at banks. Banks make loans, and the increase in economic activity went towards large capital investments that banks make loans for. This caused a relative expansion in business (one for which there may not have been demand to justify), an increase in cost for higher education, and more conspicuously began to drive up the price of real estate.

This policy became a runaway disaster. At one point, 8% of the entire money supply was being printed annually. As with my example of the abandoned mines, the relative increase in cost in certain industries that are primarily financed by lending was MUCH greater as the relative distortion hit those industries first. In other words, instead of everyone getting 8% more money and paying 8% more for goods, we saw huge increases in wealth amongst a few people and hyperinflation in real estate (and to a lesser extent higher education and large scale business investment products).

People well connected to the government or close to the banks made HUGE amounts of money. Meanwhile, regular individuals became priced out of many housing markets, because they were now trying to purchase the more expensive houses without any increase in personal wealth from the original dollar. The only way to access these things became to borrow money. Real estate debt skyrocketed. Student debt skyrocketed. The relatively loose lending standards that came to exist due to the excess of money at the banks led to easy loans and this brought the distortion into other luxury industries, as people were able to borrow against their hyperinflating real estate values in the form of HELOCs (home equity lines of credit). Labor was also misallocated, as jobs in real estate, construction, lending, etc... took workers that might have worked in other industries.

Then it all ended. As the money has made its way into the economy at large, we are seeing inflation in some goods with a severe deflation in real estate. This is just like the example of the abandoned mines. In many ways this is GOOD. Houses will no longer be out of reach for normal people without exotic bank loans. People will be able to work in industries where they will produce things for which the demand is not artificial.

The problem is that there is a period in which these distortions have to work themselves out. These distortions were severe, and thus the correction is also severe. All of the people who were employed in real estate, construction, lending, etc.. are now unemployed. They are now not producing anything, which causes a real loss of productivity and growth. This reduces demand, which causes other industries to suffer, and the whole thing ripples like a wave through the economy. This doesn't even take into account the simultaneous correction of distortions in business investment and the loss of the luxury distortions due to the HELOC falling out of favor with declining real estate prices. The point really is, that the economy was severely distorted due to the departure from sound monetary practices and now the correction is severe

The end result of all of this should eventually be the new money working its way through the economy and a return to normal relative valuations with the natural fluctuations due to changes in supply and demand. The recession is not permanent. The loss of productivity is not permanent. People will eventually find work again, and the recessionary cycle will unwind.

Except....

The Wrong Solution

The current philosophy of the US government is to attempt to print more money to "jump start" the economy again. Bail-out, stimulus, TARP, whatever, it all means the same thing. These pork-laden bills funded again with fake printed money will only cause distortions in favor of whatever is in them, which will lead to future recessions. Instead of a real estate bubble, we could have a green jobs bubble, or an infrastructure bubble, or a health IT bubble. It's all the same concept. Attempts to save the artificially inflated housing market will only distort the market further and delay a recovery to natural prices.

One only needs to look at what other nations have already done. Japan spent trillions trying to save itself from its own real estate bubble in the 80s, and parts of the economy still haven't recovered. In many European nations, with France being my favorite example, bad monetary policy coupled with severe restrictions on business, wages, hiring, and firing creates a distorted environment in which the economy isn't even allowed to adapt. This leads to perpetually high unemployment, as cycles and corrections lay one on top of the other, and nothing resembling a steady state is ever reached.

We should be looking in the exact opposite direction for an effective public policy. STOP DISTORTING THE MARKETS. STOP PRINTING NEW MONEY. Let the economy correct.

That's what's happening in the US, and that is why the economy is performing so terribly.

Stimulus for the Soul

2009-03-07T18:38:00.003-05:00

I've been busy lately. Really busy. Home is chaos, the match (the date on which I'll figure out where I'm going to move for the next few years) is less than two weeks away, and I've been pretty busy on my rotations. This has of course occurred just as everything that I've been predicting on this blog for a couple of years has started to happen.

I could write 100 posts on what has occurred in the last six months. We've essentially nationalized the banking industry. The president's forum on healthcare was nothing more than a room full of yes-men parroting back to him the same tired garbage. Things are changing. The inevitable recession is starting to heat up, and we've got atleast 3 different stimulus or bailout packages, aimed at doing everything from bailing out autoworkers to developing Healthcare IT mandates, encompassing trillions of dollars of non-existant money.

I could write about these things, but I won't. It's frankly overwhelming. I couldn't explain it all in any reasonable period of time, and I really don't want to throw up a bunch of rushed half thought out posts on really complex material. Instead, this is going to be a little bit personal and very non-scientific.

As a man, I've always wanted to control my own destiny. You could say that I respond poorly to authority as well. I want to live in the real world. This is a world of consequences and rewards. It is a world in which one has the capacity to reach the peaks of the highest mountains as well as fall into the depths of despair. It is a world in which some people are great, not everyone is created the same, and in which a purpose drives the action of people.

The maddening descent into socialism, that has been slowly gripping this country with an ebb and flow for a century, is disturbing to me on multiple levels. It is a failed system by every objective and nearly every subjective standard imaginable. Yet, this sort of logic becomes circular in a way. It's like saying that the only thing wrong with socialism is that it's bad for society. That sort of argument leaves the door open for new attempt after new attempt to create a more perfect society. No. The reason that socialism bothers me is because it takes away my independence and creates a strain on all of my personal autonomy. My work in both action and reward is never really my own in such a system. It is dehuminizing.

The real world isn't pretty and perfect. No amount of central planning, "hope," or "change" can begin to make it so. The real world is dirty. It is a place where people lie, steal, and cheat. It is a place in which mothers get cancer, people become dependent on drugs, and storms rip away homes and communities. The real world is a world in which people face hardships, struggle, and sometimes fail.

Yet, the real world is also wonderful. Greatness is born out of overcoming hardship and adversity. Generosity and charity are endemic to the human condition. We create new technologies to fight cancers and disasters. We can treat the sick. We can rebuild what is lost. Humans, individual humans, can take this initiative. People fight to better their condition, and they fight to better the condition of their fellow man. I love living in this horrible, twisted, beautiful world.

What disturbs me so much about the events of the last few months is not that I don't know what is going to happen, but that I know exactly what is going to happen. History is riddled with the corpses of attempts to create more perfect societies. We may persistently redefine what it is to be perfect, but outcasting and extermination inevitably follow any attempts at perfection. Many people will inevitably be outside the mold. The USSR, under the premise of trying to create perfect equality, destroyed wealth, killed a few million people, and then became a nation of haves (the politically well connected) and have nots (the not so well connected). The Nazis tried to create the perfect race. A drive for equality inevitably begins to attempt to create sameness, and because no one is the same, chaos inevitably follows. Individuals can never rise to that level of terror, in all of their zeal, without the backing of a coercive state.

In my personal life, I have always strived to do well. I seek excellence. It's not that I'm perfect, but I want to be better. I want to make my situation better, and I want to improve both my personal lot, and that of my family, in this world. I would say that the party line of any socialist government is exactly what I want, but the actions speak differently. Higher earnings become something that needs to be redistributed for equity. Any desire to accumulate wealth or luxury is seen as evil. It's as though the failure of someone to achieve what I have achieved somehow makes me indebted to him. In this world, the only person who is truly free is the one who has nothing. In fact, he is much more free than nature would let him be, because he is fed from the labor of others. Only in this world is the man who works for what he is given judged a villain, an outsider, the one who needs to be cleansed, in favor of every glamorized dreg of society that has wasted his life. Socialism IS wealth redistribution on all levels, monetary and personal. It is throwing success down on the rocks in favor elevating the bottom of the barrel. In this system, I have been a hero while I have been poor, receiving bounties and gifts for my struggles, all the while knowing that I will soon be the villain if all of my struggles allow me to succeed.

Likewise, I have found a passion in medicine, which has become the center of EVERYTHING that is wrong with the way things are done in this country. The only person who is not allowed to make decisions in the current healthcare system is the one who trained appropriately to be able to make them. Autonomy in both training and practice is disappearing at an alarming rate. Physicians have become so worried about their incomes, that they've lost their souls. This was once a profession in which greatness was expected. It was not flawless by any means, and it suffered from all of the problems that training and practice monopolies create, but greatness was expected. Arrogance was common, but it was also often deserved. In a few generations, we went from giving people arsenic for malaise to being able to successfully sew in synthetic pieces of an aorta. I will defend my desire to earn a good income, and I agree with most of my colleagues that this is a problem. Yet, we cower on the steps of the capitol lawn every year begging for a pittance. Our masters usually give, usually with an attached condition that further erodes the profession. Our training now teaches us to pass along responsibility, and we've taken on the mentality of employees. No longer the masters of the hospital domain, we will soon be employees of a government beauracracy led by a nurse or some beauracrat who will dictate exactly what we do in order to continue to collect that ever shrinking pittance.

I want a stimulus. I don't want money beyond what I deserve. The only thing that I want from the government is to stop interfering and let me do my job. If I must be robbed, make it predictable. Take some consistent percentage of my income. Atleast stop trying to make me an outcast for working hard enough to earn enough to have something worth taking. I am a charitable person, but let me decide where to be charitable, and stop creating a situation where generous people cannot afford to be generous because their extras are being confiscated for the "public good." Let me pursue my passion. Let me work towards higher levels of success, discipline, ability, and function without telling me how it must be done. I want to impose nothing on anyone. I'm sick of being a slave to student loans and government payments. I simply want to be able to contract with my patients and engage in mutually beneficial agreements. That would be American. That would be antithetical to socialism. That would truly be a stimulus for my soul.

And So it Begins......

2009-02-14T18:07:00.003-05:00

I realize that this is an opinion piece, but it gets the point across quite nicely:

http://www.bloomberg.com/apps/news?pid=20601039&refer=columnist_mccaughey&sid=aLzfDxfbwhzs

To summarize, written into the new "stimulus" package is money to create what is essentially a big government electronic medical tracking system. Now your doctor (as well as any court, politician, computer hacker, etc...) will have access to all medical records on all Americans at any hospital. There will be significant penalties for not adopting this electronic system within a limited time span. In addition, there is the creation of a new position, some sort of Director of Health Information Technology. This individual will eventually oversee a large beauracracy that oversees all healthcare administration and has the right to impose financial penalties on physicians who dare to stray (regardless of patient preference).

In addition to how scary a centralized database of everyone's personal information is, there are also a lot of unforseen consequences of this setup. I was speaking with an attorney that, I know quite well, who mentioned that there may be serious implications to the "standard of care." Prepare for lawsuits whenever anything goes wrong with medical care that doesn't have access to these electronic systems. What, grandma had a drug reaction in your makeshift clinic inside the hurricane disaster zone. Had you read through all of the data in her electronic medical record at some place with electricity, you might have noticed the same reaction ten years ago in a physician's note from another state. Lawsuit!

The director with his minions overseeing all clinical decision making is self explanatory. I don't have a lot of time to write today, but I thought that this needed to be exposed further. This is scary stuff.

Politics and Human Nature: Sometimes It Doesn't Pay to Take Over Completely

2009-01-28T06:36:00.002-05:00

While this post may be peripherally related to some of the content on this blog, I'm going to admit that this is me just taking some liberty and putting down some sleep deprived thoughts. It's my blog. I'll do what I want.

Before I entered the hallowed halls of what has become the modern hospital, I lived another life. After some youthful impetuousness (and a lack of capacity to get rich quick in my late teens), I decided to go to college. I was a pretty big screw up in my earlier years, and I had to spend a couple of years at a community college to develop the credentials necessary to attend any sort of quality university. Going into medicine was not something that I really thought about, and I would have questioned whether such an undertaking was even possible considering my background.

In those early years of college, I studied some programming, some music, and some other hard disciplines. In the end however, I pursued a degree in anthropology. My wife earned a degree with a double major in anthropology and classical studies. This made for interesting dinner conversation, absurdly intellectual with very limited life experience to back up anything that we talked about. I will now, dear reader, impose some more of that esoteric armchair theory on you. At least I've now got some genuine experience to back it up.

The Giants of History

Leadership is really a very treacherous thing. If you think about it, the rate of assassination amongst kings, presidents, etc... is so high that one wonders why anyone would want that sort of job. These individuals are often in very complex political positions. They have to promise things to attain their positions that they have limited capacity to deliver. They become figureheads for blame when things go wrong. Leadership styles and the power in the hands of an individual leader vary, from the dictators to the "presidents" of countries largely in anarchy.

The thing about being a dictator is that you get to have what is essentially absolute power. This isn't just economic. Dictators largely attempt to alter the very fiber of the culture over which they rule. Most first generation dictators encounter a people with some measure of independence interwoven into the common fabric of society, and this is the sort of thing that an iron fisted ruler would want to eliminate. If not, these people might very well take it upon themselves to form a revolution, and that sort of thing is looked down upon by the type of person that wants absolute power. This is of course the downside to being a dictator, because you're the only guy with enough power to blame when things go wrong.

This can easily be contrasted to the modern democracy, where who gets the blame is not so clear. Every errant happening results in a chorus of "it's not my fault," followed by a game of circular finger pointing. Who actually did what becomes secondary. People take the fall for things that they had no capacity to control, and people who can be directly connected to a crisis often walk free. There's always a way out, but no one is safe.

Staying in power is usually a struggle, even for one individual. When a similar line of rulers keep in power for an extended period of time (or when a single kingdom maintains dominance over other kingdoms for an extended period of time), it usually comes about as the result of some unique circumstances. There are some common threads that unite these sorts of rulers. We'll call them the giants of history.

The Romans

The Romans (of the famed Roman Empire) started as little mini-kingdoms dominated by hovel dwelling farmers in an earthquake prone peninsula. The degree of dominance exerted by the Romans was so profound and longstanding, that one might argue that we still haven't really outlived it. The Romans eventually came to develop this international power with the convergence of a couple of unique philosophies and the right circumstances.

Roman prestige was largely tied to military success. There was also a dominant sense of the local culture. The Romans, like all great conquering empires, were extreme xenophobes. This success however did not drive a huge amount of micromanagement. Content to simply be the dominant culture, the Romans never really attempted to make all of their conquered territories Roman. Conquered states became sources of revenue and sometimes slaves. Romans often set up local figureheads who shared a common culture with the local population (think King Herod of Israel). Over time, Roman influences worked their way into some of the farthest reaches of the empire, but this was a natural acculturation developed due to the relative ease and free flowing of ideas through the relatively safe avenues behind the Roman front line. In this respect, the empire made everyone more Roman precisely by not trying to make them so.

Future conquerors were successful for a time using variations of this technique. Genghis Khan used to present an ultimatum to cities as he would pass. Submit to me and pay some taxes or die. Those that agreed would live life the same as they did before, accepting the mild hardship of a foreign imposed tax. Those that disagreed usually found themselves decapitated with a large pile of skulls set at the front of their respective villages. After each scenario played out a few times, people decided that they preferred the former and the empire exploded. The relatively short life span of the Mongol Empire was largely due to the inability to pass on leadership. The nomadic pastoralist ideals of what makes a good leader and succession were simply not in keeping with controlling a vast stable empire.

The British

The British Empire took control of vast lands through military conquest in the same manner as the Romans. These lands were even more spread out and vast, owing to advances in technology between the two time periods. The primary difference between these two empires was in what happened after the conquest. While the Romans were relatively hands off, the British were very hands on. As was said, the goal was to, "make the world England." While the Romans taxed remote regions to bring wealth back to Rome, the British would largely use pilfered resources to continue campaigns to make more of the world British. In keeping with the general social shake-ups of the early industrial revolution, London became full of sick people, living in filth. As the capital got sicker, Britain got bigger. As the saying went, "The sun never sets on the British Empire, but it never rises over the streets of London."

Unlike the Romans, who could often maintain amazing degrees of social harmony between conquered groups behind the battle lines for centuries, the British were constantly dealing with uprisings. As illustrated by the American Revolution, the British social policy was stifling enough to turn colonists of British descent against England. Thus, the very large British Empire really didn't last all that long by historical standards. Remnants of British culture are unmistakeable in countries from the US, to South Africa, to India, but these places did not remain England.

The Leaders Themselves

Living in South Florida, I have spent the majority of my life very close to one of the most enigmatic dictators in recent history. Fidel Castro led an internal revolution, consistent with values (right or wrong being irrelevant) that were found within portions of the local population. In this case, Fidel attempted to internally change pieces of the Cuban culture, but there was no attempt to impose an outside view on the people. In a funny way, his leadership remained so dominant because the aggressive sorts who might have challenged him escaped here to Miami. As he has become frail recently and passed off some of his power to his brother (also old and not too far from becoming frail as well) it will be interesting to see how it all plays out. I suspect that change is brewing, though only time will tell.

One can come up with a veritable laundry list of ruling parties or dictators that came to power, attempted to control the dominant culture, and fell as a result. Sometimes they never really took power completely, other times it took 50 years, but the result was the same. The USSR, the taliban, etc...

The United States

There is one final approach that we haven't mentioned. At its inception, the US began to grow rapidly. The US largely didn't conquer. They displaced. Early American conquest had less to do with subjugating people and more to do with killing them or moving them out of the way. Good or bad, this is a relatively effective approach if you have a population with enough size (or growing at a rapid enough rate) to control the lands you've taken. It is very clear that much of the US in the future will never return to being Seminole land or part of the Iriquois Nation.

The modern US approach to conquest (both internally and externally) is very different. The export of American ideals (democracy by force) and the internal conflict between similar (though not so similar) sub-cultures within the US have created a very different America in the last 60 years than the one that existed before. We implement policy from Washington DC where we attempt to tell people on the other side of the world when they can walk outside. We implement policy from Washington where we tell people in Spokane, Washington how much water they can use when they flush the toilet. The degree to which we attempt to centrally micromanage every facet of daily existance is frankly unheard of in human history. Historically, most dictators just didn't care enough about these little nuances of daily living.

The Conclusion to the Ramble

Just remember that the Romans had wild success with economic subjugation utilizing military force. The British on the other hand (and the Russians) couldn't hold social subjugation together. While people will complain about, but tolerate, virtually every tax or economic burden that is imposed which does not impair their ability to attain a reasonable standard of living, people defend their culture vehemently. The rambling point is that the unless the US intends to anhialate everyone both internally and externally who disagrees with the prevailing politically correct point of view, history tells us that our current policy might not bring us down the road of ongoing leadership.

When Morality Meets Scarcity in Medicine

2009-01-21T07:52:00.006-05:00

The only thing universal about individual morality is that it is in fact individual. Regardless of whether you believe in absolute truth, a religious code, the golden rule, etc, the fact of the matter remains that everyone interprets these things differently. What is or is not truth is secondary in the scheme of what actually happens. This becomes even more complex when considering that certain codes diametrically oppose each other, and some codes clearly sacrifice other people who do not subscribe to the code. There's an interesting conversation about abortion for example over at http://studentdoctor.net in the topics in healthcare forum debating this very topic. One side essentially claims that failure to perform abortion or refer for it is in some way a direct violation of medical ethics. The other side claims that doing these exact same things is a violation of the will of God. Often, neither side believes in an allowance for a differing opinion.

There is one thing however, that holds universally true, and no amount of denying it changes it. Resources are scarce and limited. They may be used ever more efficiently and/or prudently, but there is only so much matter in the universe. This example can be applied to medicine. In its current state, medicine in its attempt to be all things to all people is rapidly becoming nothing to anybody. It's becoming a sort of service black hole and an expensive black hole at that. Rising from ~5-6% of GDP in the days before Medicare, healthcare costs are now estimated at about 16% of GDP. Sure there have been some technological advances, but there are clearly some changes in our approach to healthcare distribution that perpetuate these deficits. Let's consider some of the paradox into which we are plunging ourselves:

Many people advocate doing everything that people need. This is all well and good, except that defining "need," is not all that easy, and there are many times that the "needs," of two individuals conflict. Let's look at the following example:

Two middle aged men walk into a community emergency room. One has terrible crushing chest pain, radiating to the left arm. He has specific V2-V5 ST-segment EKG changes consistent with an anterior wall MI (heart attack) and his cardiac enzymes are through the roof. The other man has a non-compound humeral fracture (a broken arm) and is in considerable pain. The ER is currently full of other patients. What to do? In this case, the usual response is that we have to triage. Even with the full ER, we will make room for the man having the heart attack. We'll start treatment. The man with the broken arm will have to wait. In fact, some of the patients who were already brought back will have to wait.

In this example, it is clear that the man with the heart attack is receiving a benefit at the expense of the man with a broken arm. In this particular example, we've sort of attempted to minimize "badness." The long term outcome for a delay in treatment for the fracture of a few hours is probably nothing, while a similar delay in the treatment of the heart attack is potentially fatal.

Triage is sort of the original approach to the collision of scarcity and morality. If we can't do right by everyone, we'll attempt to get the most right out of the situation. The original concept was that we would go after the sickest who could be saved first and then in order of decreasing severity so as to maximize the chances of the most good outcomes.

In modern day medicine, we have no real triage outside of the emergency room. We attempt to just give everyone everything, the cost be damned. It's the equivalent of building another room onto the ER and hiring another doc every time another broken arm comes in the door. It's incredibly expensive, and it doesn't necessarily improve anyone's long term outcome. We also tend to ignore the most important rule of triage, in which we do not waste scarce resources on individuals beyond repair. Every severely demented nursing home resident who takes a two week vacation in the ICU costs the system tens of thousands of dollars in order to "save" a person who is beyond repair. This is partly why healthcare is 16% of GDP.

Another question is how far do we go to ensure 100% accuracy. In other words, how much money are we spending over progressively smaller benefits in diagnosis and treatment? This is the question that comes about in the current predatory legal environment. The added cost of testing in an environment in which every individual miss imposes a nearly insurmountable burden on the system creates a system in which every low yield test in the system is ordered in order to avoid error. Is it right to tax a large segment of the population solely to fund CT scans of the brain for low risk falls in alcoholics? We surely pay for them now.

It's very simple. In any type of collectivist system, the "morality' of what is being provided will eventually bump into scarcity. There has to be some sort of rationing. There has to be some sort of triage. Someone's rights will have to take a back seat to the more critical or those with better long term potential. Period. If not, any system goes bankrupt and no one benefits.

The alternative is a non-collectivist system. In this system, individual choices determine what happens. Individual morality may factor in, but there is no "morality of the system." This is where competition comes into play. In our above example, the man with the broken arm may go to a different hospital. He may have to pay more. Perhaps the number of people waiting for treatment with broken arms leads a group of entrepaneurial orthopods to open a special orthopedic ER that caters to broken arms and doesn't treat heart attacks. Then there's no conflict at all. If someone felt morally compelled to treat heart attacks, they could go around treating all heart attacks, regardless of ability to pay. This is rationing in a way, but the rationing is done by individual preference and morality. In this particular approach, no one individual can impose a specific morality on everyone else within the system.

Regardless of how you approach it, no code or philosophy on whom is entitled to treatment can overturn the laws of nature. Matter can neither be created or destroyed. Resources have to be rationed. The only question is whether that rationing occurs by an imposed centralized system or the individual codes of the individuals involved.

Mandated Health Insurance Isn't a Capitalist Solution (Or a Solution At All for That Matter)

2008-12-30T16:08:00.005-05:00

Everyone from my classmates to some of my family members has recently been talking to me about universal mandated health insurance as the solution to our healthcare woes. Apparently, we can solve our healthcare crisis by making everyone give money to insurance companies. The two things that I find most amazing about this argument are:

1)It is almost universally proposed by individuals with socialist leanings
2)The argument as to why it should work is usually that it is a capitalist or free market solution.

I think we need to get a couple of things straight. There is no such thing as a federal free market mandate. By being a federal mandate, it automatically ceases to be free market, which is essentially defined as being devoid of government interference. You cannot mold capitalism to your personal whims. Capitalism is why some people don't buy health insurance now. Forcing everyone to buy it is a strangely crossed socialism/fascism hybrid in which we force everyone to subsidize each other while simultaneously creating a profit for a private financer that is controlled by public regulatory bodies. This system cannot work effectively. I'll explain why:

As a precursor, let me point out a couple of universal points that are argued to achieve the mandated health coverage utopia:

1)People who can "afford to pay," are required to buy health insurance or face stiff tax penalties
2)People who cannot "afford to pay" are subsidized to some degree in the purchasing of insurance, with some groups inevitably being fully funded.
3)Insurance must cover pre-existing conditions
4)There is some control on insurance rates
5)Your insurance can't "drop" you
6)There is some continuing tie to employer funded insurance

Here's why these things don't work:

1)It doesn't address the overall cost at all
2)By forcing those who can "afford to pay" to also pay the taxes that subsidize those that can't "afford to pay" you are creating socialized medicine with two middle men. You have the government AND the insurance company. Far from being a free market solution, you get a government beauracracy and a company that largely generates profits by lobbying the government beauracracy and denying payment for things that the government gives it money to pay for.
3)If insurance covers pre-existing conditions, rates have to go up.
4)If rates are controlled, they cannot go up to cover pre-existing conditions. Companies will have to lobby for a rate hike that no one can afford, receive subsidies (a second knock against those who can "afford to pay") , or operate in the red.
5)By requiring insurance companies to keep patients for life, you require them to charge everyone more up front to deal with the inevitable risk factors that will appear later
6)You continue to rely on the employer based insurance model which is itself a relic of the New Deal Era as an attempt to avoid wage control policies.
7)The new system does NOTHING to address malpractice problems
8)The new system does NOTHING to ration expensive care
9)The new system becomes a hindrance to a new system, because it is now a mandate.

If people had to pay for their own care, there would be no medical cost crisis, because contrary to popular belief, the cost of medicine would over time come down to the price that people could pay. If you eliminate some of the malpractice incentives to over test, people will simply not want to pay for low yield testing. Insurance companies couldn't sell insurance unless it was cost effective. In a system without EMTALA, the cost effectiveness of the insurance system would be better assessed, as people would actually have an incentive to buy it.

Something doesn't become capitalism because a corporate entity is making a profit from it. Something is capitalism when it is the product of the natural adaptations of the free market based on the individual preferences of the people within the system.

I am actually going to take a stance here that most people will be shocked by. I believe in a two-tiered system. I believe in a locally funded county system that adapts to the local needs of its area and provides safety net care to prevent the spread of infection and control disease. I believe that the proper role of a lot of residency training is in these institutions as it was originally designed to be. I want the feds out of 99% of medicine beyond the prevention of nationwide disease epidemics and bioterrorism. I want the local governments out of the private medical system. A private system with a small safety net is better than than the hybrid mess we have created, and seem to want to perpetuate, any day of the week. That would be a true capitalist solution to healthcare. Entitlements at the public institution would be limited by budget considerations, and private healthcare would function like all capitalist systems, providing what it can based on the preferences of the people with the most cost effective solution that meets those demands outshining the others and taking market share.

Only in a dream.

Duty Hours/Regulation/The IOM/The Cost/The Logic/AHHHHHHHH?

2008-12-07T12:34:00.002-05:00

So it appears that the IOM has released its recommendations to congress regarding duty hour restrictions for medical residents at programs receiving federal funding (AKA every program). I'd like to take a minute to go over some of these recommendations, discuss the potential impact, and then explain why this is a bad idea. I do not have a comprehensive list. All of my information is second hand, as the report itself is rather expensive to access. If I write anything inaccurate, or anyone else finds something in the report worth mentioning, please let me know.

1. Maintain 80-hour workweek. There is no recommendation in the report as some program directors feared limiting resident work hours to 56 hours a week. The cap is however limited to 80 hours a week, which would eliminate averaging. I guess the big change here is that a congressional mandate would be accompanied by stiffer penalties than the RRC can possibly impose. It would also make some efforts to balance rotations a bit more complex, as the strict 80 hour max is currently not the norm at many surgical programs that have residents cover >80 hours some weeks and make up for it during others.

2. Maintain 30 hour shift max. There is no change here, except for the fact that they now want to require a 5-hour mandatory sleep break within the shift if it supercedes 16-hours. This would be the first required nap at any adult job in the history of working in the United States. It also makes it virtually impossible to cover a night call with only one resident.

3. 1-full Day off per week with NO AVERAGING. For those that suddenly found that weekends could exist again as part of the 80 hour work-week, no more. There are no more golden weekends under this report without extra days off (Something hard to give in a system in which there are multiple residents required for each call and residents can't alternate going above and below 80 hours each week. Whereas now some programs have residents alternate weekend call, this system will soon be a thing of the past if the recommendations are implemented.

4. Call no more often than q3. There will be no more q2 call even for a small stretch. This means that you cannot alternate q2 call to cover vacations. You also cannot do a Friday-Sunday call to give another resident a weekend off.

5. No more than 4 night shifts in a row. Of all the recommendations, this really makes the least sense. The obvious adaptation to all of the above call requirements is to establish a night float. This would only be possible under the recommendations by having people switch onto and off of the night float every few days, making establishing a circadian rhythm impossible.

6. Interns can't be the only MD in-house. This is really ridiculous, as many hospitals currently have no physician in house. In other words, it is legal to have the intern go home, leaving no one in-house, but it would be illegal for him to stay alone. It also makes the call schedule even harder, as junior call interns couldn't cover a potential nap break for the senior residents in a junior-senior joint call system to adapt to the required nap under the new recommendations.

There are some more, but they're escaping me at the moment. Feel free to post them.

Why are we here?

For those of us in the trenches, this really makes no sense on so many levels. I am going to be the resident who should theoretically be receiving the benefit of these work-hour restrictions. By continuing to have 80 hours weeks with a bunch of crazy rules implemented on top of them, compliance costs will go through the roof, AND it will do nothing to solve resident fatigue. There is no evidence base for any of these changes. Why would we even consider implementing these changes as a requirement for every program with no reason to believe that they will work? Again, this smells an awful lot like what happens when we start to dismantle the free market.

Medical licensing is a hot-button issue to bring up in some groups, so I will not go all the way back to that point in terms of market intervention. If we assume that the government should require some minimal level of proficiency in order to practice medicine, then we have to question how that level should be obtained. In other professions with similar requirements, the usual course of action is to have a some degree of professional schooling as a primary requirement. This is the case in every profession from law to architecture. After these different types of schooling, there is usually a state sponsored exam. The bar exam might be an example of this. There is some variability between states and professions, but the concept is the same. This is also true in medicine with the USMLEs, which every state has now simply adopted as its state licensing exam.

After this, certain professions require different things. Most people agree that hanging a shingle immediately after school is complex. In law, this is legal but relatively rare. Most people will go work for a firm, where they will get real world experience. The firm can be a solo attorney or a Devil's Advocate styled enterprise. Nevertheless, it is not formalized. The formal background is found in the schooling itself, and everything thereafter is variable, creating a vibrant heterogenous market. Pay ranges are wide, with some new associates demanding >$100k/year and some receiving $25k. People migrate towards positions that meet their needs for work, pay, hours, training, environment, location, etc... Everyone is a potential employer and a potential trainer.

In medicine of course, we have a formalized residency requirement. Without belaboring the entire history of residency training, some of the following things are true:
1. Every physician who wants a license has to complete somewhere between 1-3 years of formal residency depending on the state.
2. Every physician who wants to specialize must for the most part fit his interests into a series of predefined specialties that require anywhere from 3-10 years of formal training depending on the specialty
3. The government funds almost all of these positions through Medicare
4. Residents receive a surprisingly similar percentage of this money at most programs, with almost all salaries falling between $40k and $60k depending on location, specialty, and post-graduate year.

This set-up is why we are currently dealing with the IOM report. The government funds these positions, which gives them excessive amounts of power in regulating them. Work hour restrictions get tricky on a constitutional level when the government isn't funding things. When they are, it's very simple. They can simply take the money away.

It is also very clear that different people want different things from their post-graduate training. Some people like to work hard and often. Others have different priorities. Different people have different tolerances for stress, labor, sleep-deprivation, etc... Yet every program is regulated to be similar.

As an attorney looking for a niche, let's say tax law, there are a million different ways to fall into the niche. You could get a masters in tax law, you could go work for a big tax firm. You could work for the tax division of a big firm. You could enter a small firm looking to expand into tax law and become the specialist by doing the job. You could hang a shingle. It's all possible. In many ways, the only difference between one of the big firm jobs and a medical residency is that the big firm usually pays better up front with less remote guarantee. However, all of these entities are possible. They are regulated by their ability to get people willing to work in the way that they require, and they are limited by the ability to provide for their clients. A few botched cases, and a big firm doesn't remain as big.

In residency, the only way to change things is to lobby congress. You can't quit easily. You can't find a different training model for your specialty. You can't just go out and work with someone who performs your specialty until you start to feel proficient. One might say that this isn't so bad. I mean, at least we'll set a floor on quality. Close reflection (and the recent IOM report) show what the problem is.

There is no natural adaptation. Residencies functioned until the original RRC changes in nearly the same manner in which they worked 50 years before, with the only major changes being the progressive addition of more years in order to be qualified to do the same thing. The 80-hour work week was the first real new step in 50 years. Normal markets, including those in training programs adapt slowly over time. These changes were abrupt, and rather than being based on mutual preferences, they were imposed from the outside. There was an extremely hetergenous response. Many couldn't or wouldn't adapt at first. Many residents loved it. Many hated it. Many ignored the rules. Many programs made them ignore the rules. Some of the biggest programs in the country went on probation.

Eventually, people mostly adapted to the new rules, but there is no evidence that they've done anything to improve outcomes. Many residents are happy with the changes, but some are certainly not. One must question the decision to force people to work less who want to be more productive. The new restrictions are not based on anything. There is no logic, no evidence, and no real objective standard behind them. However, we are a federally regulated and funded enterprise. Arbitrary rules and compliance are the lot in life of such an entity.

Medicine has evolved over so many years within the system of federal funding and control, that it is hard to see how it would work without it. This doesn't however, mean that it couldn't, Residency would probably have to continue to exist in some form. No one is ready to be a surgeon at the end of medical school, but the rules would have to be different. That may not be so bad. We might eliminate some the conflicts that we have now, where a PA straight out of school can bill as a first-assist on an operation where a chief resident with over 1000 cases cannot. We might change the system in which it costs more money to hire a secretary to do scut work than an intern. Many programs are dedicated to training, but the natural evolution of a training system would slowly lead to a proper balance between training, service, and the reimbursement that is proper to achieve those balances. Service could be exchanged for teaching, and resident reimbursement could be based on what they actually produce. Some could forego residency, though hospital credentialing for all but the most simple practice would require some demonstrated competency, setting a natural floor on the system.

That was probably a long incoherent ramble. Whatever the case, I am scared. As a new trainee, I know that the system is flawed, but it does produce competent physicians in large part. If implemented, these new rules will hit hard. Because we've let ourselves become beggars at the foot of congress, we are essentially powerless to stop them.

A Note From the Interview Trail

2008-11-27T14:25:00.002-05:00

I do sincerely apologize for being absent for so long. After completing some difficult clerkships, I've basically been living out of town. You see, I'm currently on the interview trail. I'm looking for a surgical residency. The current system is a bizarre one, in which I pay huge sums of money to fly around the country and try to impress people. In return, they usually put together a pretty nice looking package with which to impress me. A typical interview goes something like this.

1. Night before event- All but one of my interviews has been associated with a night before event, at which applicants meet the residents and possibly some of the program leadership. These events are highly variable. They range from being told to show up at a bar and buy your own drink to a formal reception complete with Chardonnay and Filet Mignon.

2. The Interview day- You usually come to the hospital where there will be some sort of introduction to the program. You will then attend some sort of academic conference (a way for the program to show off its academic credentials). After this usually comes some combination of talks, one-on-one interviews, and hospital tours. Then there is usually a lunch. Residents are usually invited to the lunch for one last chance to ask questions. Some programs also spice lunch up a bit. One program gave lunch against the backdrop of a talk from an eminent trauma surgeon. One program broadcast a live gastric bypass during lunch (probably the most amusing). There may or may not be an afternoon activity.

There are some variations on this, but it really is pretty consistent.

In keeping with the major theme of this blog, I'll tie a little bit of practical economics into the discussion:

This process is expensive, especially if you are applying to a competitive specialty. More competitive specialties require more interviews and are less likely to help you financially. In other words, some of the less competitive programs will partially fund flights or pay for a hotel. This is often not the case in the more competitive programs. Thus, a plan is paramount in figuring out a way to go where you need to go.

If you are applying to a less competitive specialty, a few interviews at dream programs, a couple of programs of even qualifications, and perhaps a safety school is all that is really necessary. I would recommend no less than 10 if you are applying to surgery or Emergency medicine (15 is better). For Plastics, Ortho, Derm, etc... I would take every invitation that I received.

There are two major expenses in the process. The first is the cost of travel. With gas down to under $2/gallon, driving is often a very viable option. If you've got a bit off time off and friends in multiple places with a couch, driving can easily make your trip cheaper. If you are staying in state, it really makes no sense to do anything else. I pulled off one interview in which I drove across the state and stayed at a friend's house for under $100.

If you absolutely must fly, comparing flights is very important. Orbitz is sort of my favorite site, because it is pretty convenient to book flights and car reservations at the same time. I also find it to be a little more user friendly than Priceline or Travelocity, though these are also viable options. If possible, non-traditional carriers such as Southwest or JetBlue can be an amazing alternative. Southwest has the best service of any airline in the country. It is not close. Southwest also sometimes has some amazing flight deals online at Southwest.com known as "wanna get away" fares. I've actually flown across the country for $70 including fees this way. It may or may not be more expensive to link your rental car reservation to your flight, so you should check both ways. It may also be cheaper to fly into a regional center and drive to a close by program than to fly to a local airport. As an example, flying into Detriot and renting a car in order to drive to Lansing or Ann Arbor is a lot cheaper than flying direct and finding local transportation.

The second major expense is lodging. As previously alluded to, staying with friends or family can really cut down on costs. If this doesn't work, cheap hotels are a must. Many programs will recommend a hotel. With a couple of exceptions, this is usually NOT the best place to stay. Including taxes and fees, most cities outside of the biggest will have numerous hotels in the $50/night range with fees and taxes included. I made the mistake of staying at the recommended hotel once. Then I found the hotels.com deals to be excellent and I never looked back.

Other price saving tips might include using only carry-on bags. Many airlines will charge fees to check baggage. If you are willing to sacrifice a bit of comfort, a suit can often be worn onto the plane, freeing up storage space. I took week long trips with multiple one-way flights while doing no laundry out of a carry on roller bag using this method. Airport food is also expensive. That being said, you may find yourself stuck in a terminal for 3 hours waiting on a delayed flight. An overpriced hamburger or drink may not be too much of an expense at this point.

For those in the early stages of medical school, I would recommend that you start putting money away early. I managed to underspend by a couple of thousand dollars each year, and that has basically funded my residency travel. Even though you'll be paying some extra interest, these loans are often deferrable, often qualify for a forebearance, and will definitely be included in any calculations of income based repayment. This makes them VERY friendly compared to conventional loans. There is an interview and relocation loan available for up to $25k. This is a private loan that requires good credit on the part of the borrower. It also comes with variable interest rates and no promise of future deferment. In other words, it is not the best loan. It's also not easy to obtain in today's credit market. All in all, it is better than not doing enough interviews to match.

It's about time for Thanksgiving dinner, so I'll be going. If anyone has any questions, feel free to post them and I'll do my best to answer them.

Happy Thanksgiving.

It Passed

2008-10-03T17:45:00.003-05:00

It's official. The US Congress passed a $700 billion dollar bailout package today, and it was later signed into law by president Bush. In one of the most interesting moves by government that I've ever seen, this thing actually failed earlier this week. I was a little shocked, though a little bit cynical. I suspected that it would lie dormant until after the election, after which it would be shuttled through in pieces with little fanfare. Instead, greater than thirty congressmen changed their votes in less than a week with the only changes being some random tax cuts and changes to the FDIC limits on accounts that will barely impact anyone (who the heck with >$100k in liquid cash keeps most of his money in a savings account?). Apparently two more days of talking about "greedy" people and a couple of woe is me's on the stock market is enough to convince more than half of the representatives of the people to do something that is both stupid AND clearly against the will of most of the people. This isn't even a case of the people being stupid.

In other news, Wachovia is attempting to ditch its still incomplete deal with CitiGroup in favor of a deal with Wells-Fargo of San Francisco. The CitiGroup deal required a large influx of capital from the FDIC (aka the taxpayer). The Wells-Fargo deal gives Wachovia and its shareholders more money, more autonomy, saves everyon's deposits, AND requires ZERO government intervention. Wells-Fargo, which is an entity that didn't invest heavily in sub-prime mortgages and is not going under, is currently in a market position to gain market share, largely due to more intelligent financial decision making. The FDIC is challenging the change, apparently ever eager to waste taxpayer money. First we blame the market for central bank failures, then we prevent the market from fixing the problems that we blame on it. Brilliant. I'm still not optimistic.

A Little Bit More on the State of the Financial System

2008-09-25T08:57:00.003-05:00

I'm sorry for the last couple of posts, which have very little to do with medicine. We're in the midst of one of the most crazy reform periods in modern business, and I feel compelled to document what is wrong, what will go wrong, and why it will happen.

As of right now, the republican (supposedly conservative) plan to deal with the economic "crisis" is a 700 billion dollar bailout package. This package in perspective, is greater than $2,000 for every man, woman, and child in the US. It is more money than the entire cost of the war in Iraq. One might say that this would be a logical point for the democrats to crack down on corporate welfare, which is one of the few places that I tend to agree with democrat economic philosophy. Forget it. The democratic plan seems to be, "OK, we'll give $700 billion to corporations that we don't have, but only if we make even more fake money and give it to people who took out stupid loans over the last 5 years to buy houses that they couldn't afford." As I said at the end of my last post, I'm not optimistic.

There are three highly irresponsible parties in this mess. Number one is the government, who created that housing bubble with fake money and cheap credit from the federal reserve. Number two is the individual running the companies on Wall Street that used the fake money to make bad loans. Number three is the individuals who took the bad loans and used them to overpay for housing. Everyone agrees that this failure is largely secondary to the housing market failures. The solution seems to be to bail out parties #2 and #3 with party number one, using money from people who are not responsible. Brilliant.

However, this is becoming far more sinister. Rather than letting companies fail, the government is instead buying them with taxpayer money. At first, Fannie Mae and Freddie Mac were nationalized. Because they started as nationalized institutions that were later privatized, I wasn't sure what the effect would be. However, we have now effectively nationalized AIG, and as part of the bailout plan, we may look at a significant amount of nationalization on Wall Street, primarily in the insurance and financial sectors. This puts the government in charge of the majority of home mortgages and the largest insurer in the country. As opposed to allowing for a short term shake-up in the market, with some firms going under, we are going to insure that the government will compete within the private sector, using taxpayer money to prop itself up. In other words, this is the end of anything resembling true free market capitalism in the financial markets.

For those of you who think that this is a good thing. I will point out that the two periods with the greatest amount of new government intrusion into the market were the Great Depression and the Stagflation Seventies. To rescue the market the first time took a world war. The second time took deregulation.

What we are witnessing is an Atlas Shrugged style takeover of the financial markets, with Henry Paulson playing the role of Wesley Mouch (a reference to my objectavist readers). As the inevitable slide continues, we will continue to do things to "fix it" that will infact promote future slides. The right thing to do is let the insolvent firms fail. This will lead to short term chaos but long term stability. It will also make people much less likely to engage in this sort of behavior in the future, because every who does it now expects a bailout (we seem to never disappoint). It will also prevent the government from destroying the future of the financial system by nationalizing companies and then competing with an unfair advantage against private firms (causing greater distortions in the market). As I said before, I'm not optimistic, and nothing in the last week has done anything to change my feelings on the matter.

You know, as much as I really detest both major political parties, I never thought that the first steps towards true nationalization of the economy would be undertaken by the republicans.

An Economy in Crisis

2008-09-16T05:25:00.006-05:00

Ok, Ok, so I haven't published in a long time. Between the kids, and a surgical Sub-internship, I've been a little bit preoccupied. However, I think that it's time for another post. This will lean a little more towards economics than healthcare, but I think that it's crucial at the current juncture to understand what is happening in the economy.

Yesterday, the Dow Jones Industrial Average (DJIA) crashed down over 500 points, the worst loss since trading resumed after 9/11. Financial giants Lehman Bros. and Merril1-Lynch essentially fell apart, with one going into bankruptcy and the other being bought out. AIG and Wachovia are still looking a little shaky. The government has actually seized control of Fannie Mae and Freddie Mac, the largest government takeover of companies ever. Gas spiked again in the face of plummeting commodity prices, especially oil. What's the deal?

The History

I think that many people fail to grasp the significance of what has just happened. If you put all of the above problems in with the current real estate crisis, you've got a recipe for financial disaster not seen since the late 1920s. I'm not saying that I think that we're in for another great depression, though I don't think that anyone thought we were in for a great depression until the great depression occurred either. It is clear that something is terribly wrong. That something is a little bit complex, but I will do my best to elaborate on the problem.

In the early part of the 1990s, as Bill Clinton was taking office, and the DJIA lived below the 3000 mark, a couple of interesting things were happening. It was the beginning of a revolution in the way everyone did everything. Computers were becoming integrated into the fabric of day to day business. The internet was becoming available to private individuals, and communications were becoming cheaper than ever thought possible. We were also in a small recession. The Fed reacted to this small recession by pumping liquidity into the financial markets (fancy jargon for lowering the rate at which banks can borrow money or allowing banks to keep a smaller percentage of their total portfolios on hand so that more money can be lent out). This coincided with a progressive explosion communications and then the rise of the dot-com boom (anyone remember Silicone Valley?).

It was the beginning of a recipe for an economic boom. There was cheap money, new technology hitting the business world, and after the failure of the democratic party to keep congress after the first two years of Clinton's leadership, government gridlock with minimal regulation on the booming economy. Oil went down to close to $10/barrel. The DJIA soared over the decade, jumping from less than 3000 to well into the five-digit range. Small booms rippled through many industries. There were small spikes in real estate. Some of the biggest transformations however, occurring outside of the technology sector, occurred in the financial sector. Banks, which had been de-regulated in the 1980s, were now able to fuel the growing demand for start-up capital. They were aided by cheap money from the Federal Reserve, which allowed them to operate outside of the normal boundaries that contain risky practices in a true free market economy. That being said, a great part of the boom was the result of natural market forces reacting to unprecedented changes in efficiency afforded by changes in technology.

Around the turn of the century, this boom hit its peak, and a small recession took place afterwards. This was nothing catastrophic. Central bank liquidity always fuels a boom-bust cycle in business, as markets have to adjust from the distortions on the market imposed by newly printed money interjected into a market with no economic foundation to support it. Then it happened, 9/11. A couple of big explosions at the financial center of the US caused a number of big Wall Street players to become very concerned about the economic future of the US. When trading eventually resumed, there was a quick and fast drop in virtually all indicators of the health of the US stock market. What to do?

If you ask me, this is the turning point where things went bad. All damage done to the economy before this was correctable in a relatively painless manner. The market wasn't more distorted than the usual state of affairs. The average person was able to afford virtually everything he needed. However, Americans are not very patient people. We may have set up an economy in a hurricane zone before this point, but the next maneuver was when we finally started building on the sand.

Alan Greenspan, as head of the Federal Reserve, announced drastic rate cuts, allowing banks to borrow money at incredibly cheap rates. This essentially meant that banks could get money at far below market rates and lend it out at a profit. The Fed also began to print money the like the printing presses were gonna go out of style, reaching a rate of printing 8% of the entire US currency in circulation per year. This had two drastic effects on the market, and it was the sentinel time for setting up the current conundrum.

Effect number one was to distort the relative location of money within the economy. Financial institutions were receiving this money first, giving them greater relative wealth than other businesses (and individuals). The extra cash caused inflation, but not until it was spent by the big financial institutions and infused into the market. Contrary to popular belief, this phenomenon is what caused the "rich get richer while the poor get poorer," or the "squeezing the middle class," conflict. The big guy gets money for cheap or free and spends it at pre-inflation prices. By the time that money gets to the middle class, it has to be spent at post-inflation prices and the value of the assets owned by the middle class has been devalued by inflation. Thus, effect number one caused a mal-distribution of overall capital into the financial sector while squeezing the average person.

Effect number two was to put a huge amount of money into the market with zero justification. There was simply no logical place for the money to go. Interest rates were low however (a side effect of two much money), so the borrowing commenced. People bought SUVs, personal watercraft, fancy vacations, etc... However, the more unpredictable effect was that on the real estate markets across the country. The cheap money went into housing. At first, prices rose at a level that was proportional to the cheaper cost of borrowing, but it soon turned into a spiral. As prices rose, more money was pumped into the market to allow people to buy more houses. Speculative fervor took over, based solely on the back of fake money. At the end of 2005, most people couldn't afford to buy housing in the major metros of the US, and some of the speculators were left holding a financial hot potato. Prices couldn't rise forever.

In response, the fed dropped interest rates again (yes, again). Inflation started to become a huge problem. Food was up, healthcare was way up, education was up, housing was up. However, as most Americans were now deeply in debt, the new fake money failed to have the same economic impact as previous infusions. The new money did find its way into the economy though. In concert with irresponsible printing across the world, new money chased commodity prices. Oil and foodstuffs went through the roof. However, the beleaguered economy didn't have the strength to support that boom long term, and we're already seeing it fizzle out.

One more impact of rising real estate prices. The government originally created Fannie Mae to provide mortgages to those who could get them on the private market. This of course has had the obvious effect of rising real estate prices (increased demand) and more irresponsible lending. When the government decided to privatize Fannie, they decided that competition was good, so they created a fake company out of thin air to compete in the bad loan business. This company is called Freddie Mac. As the fake money piled on, and loans got more exotic, Fannie and Freddie went from being involved in ~20% of real estate in the US to the majority.

Whew.... That was long winded.

What Happens Now

The government takeover of Fannie Mae and Freddie Mac has now had the unintended (or perhaps intended) consequence of making the majority of mortgaged real estate holdings in the US indebted to the US government. It has also exposed the US taxpayer to losses sustained by these companies as they attempt to discharge all of the bad debts that they accumulated over the 3-5 years of real estate boom. This exposes every responsible investor to the excesses of the last 5 years. It also gives the Feds a huge amount of control over the private real estate market.

Many of the crashing financial giants were also well exposed to sub-prime real estate. If you ask me, we should let them crash. The market is a mess, and they are at least in part responsible. However, we have seen a strange combination of letting them fail, industry bail out, and private bail out by the Feds.

The crashing of oil is simply a correction of the short lived commodities bubble.

We are really at a crossroads. The economy is distorted, but there is a lot of fundamental goodness in the US economy. We really do create and produce. There is a foundation to recover. However, we have five years of the distortion of capital towards financial companies and real estate holdings. Jobs have to be lost. Companies have to disband, and the economy as a whole needs to rearrange itself. Over a few years, in a good capitalist system, that should happen. Let the recession occur, let unemployment go up for a couple of years, and let business slowly adapt to the reality of non-distorted market demands. It really is better in the long run. We don't need to waste manpower that could be driving the economy forward building unnecessary houses in the Arizona desert. Removing the market distortions (by removing the infusions of fake money) will accomplish that.

All of that being said, I'm not optimistic. The feds are already talking about lowering interest rates again to "stimulate the economy." The average American seems to want a short term bail out a whole lot more than a correction to a sound economy. The fake money might was well be green cocaine, and we are seriously addicted. It felt good at first, but now we just can't let it go. Neither of the current major party candidates for US president opposed the takeover of Fannie or Freddie, and I suspect that both will promote economic policies that continue to let the Federal Government and the Federal Reserve meddle in the US economy.

Many economists have looked back at the great depression, and even many of the more liberal members of this group have conceded that the policies of FDR did wonders to expand the length and breadth of the depression. The New Deal took real money out of the economy and put fake money to work on projects that really did nothing to solve any problems that faced the country. The US economy has a firm foundation, but it is what we do next that will determine how this plays out. Will we have a bumpy ride for a couple of years or will we bear hug the economy with such restrictive rules to fix it that we love it right down into another depression. As they say, hope for the best, but prepare for the worst.

Elaborating

2008-07-14T09:28:00.004-05:00

OK. I realized after some lengthy comments on my last post that I wan't exactly clear in getting my point across. There were definitely some holes in my statements as I read them again. So this is the advanced version of why centralized healthcare in the US will fail:

1. Cost shifting- As was rightly pointed out to me, cost shifting doesn't bankrupt the economy in and of itself. It really is always less efficient, but there is much cost shifting in the modern US, and its mere existance hasn't destroyed the economy. However, what it doesn't do is lower the cost. People occasionally bring up administrative costs or duplicate tests. Compared to a government system (which largely shifts the costs to physicians as opposed to eliminating them), there is no reason to believe that these will change that dramatically. The problem with healthcare is simply that it costs too much. As healthcare approaches 20% of all US dollars, shifting the cost to "the rich" or subsidizing "the poor" will do little to stop it from running the rest of the economy over like a bulldozer. Giving the government the money first will simply mean that the money will spend more time out of the economy and then inefficiently be spent.

2. The US is not Europe. Europe is actually a conglomeration of numerous different types of universal healthcare systems. Here is the truth. Most European countries ration care. Some services aren't provided, they don't have enough equipment, or people who meet certain criteria are excluded. This is how their systems stay afloat. This rationing is somehow seen as more moral because it is more "equitable," but I doubt that people who can't get lifesaving cancer drugs or wait long periods for imaging agree. More importantly, Americans wouldn't stand for it. We can't let 95 year old ventilator dependent with advanced dementia granny die after she becomes septic from one of a million bedsores. We're a long way from rationing.

3. Without rationing, prices escalate. That's already what happens now. If we could spend $1 billion dollars to keep someone alive for 1 extra minute, is it worth it? Most would say no. The use of finite resources involves the constant weighing of cost and benefit. Our current system doesn't do that. We essentially expect everyone to be entitled to everything. Using other people's money, everyone wants everything done. This is actually bad for society. Using the example from number 2, a family that wants everything done for granny may have second thougths if they were presented with the $5000/day bill. As an example, many people in my area are being priced out of housing by the cost of property taxes. This is the equivalent of taking all of those taxes for an entire year from a family each day to keep granny on the ventilator. Without rationing, prices will continue to climb. If someone else is always buying dinner, everyone's always at the steakhouse. This puts Subway out of business, and the low cost options disappear in a sea of ever rising steak prices, due to the unlimited demand driven by people who's personal stake in the rising prices is trying to get as much steak as possible until the system collapses. Every double read film or "just in case" CT scan that comes along to avoid a lawsuit adds to this misery.

4. Americans will not accept government rationing, and it will not be feasable for the government to ration as a political point. Americans only can't afford healthcare now, because they expect everything. They will still expect it in any kind of universal system. We will thus see a system in which the government will cut payments, trying to spread out the money over an ever increasing sea of people. With cut payments, will come a reduced supply of hospitals, doctors, technology, etc... There will be no "rationing," but the waits will grow. Physicians, who will be largely the vicitims in this system, will be blamed for caring about money (ie keeping the business open and making an actual profit). The government will point the finger. Meanwhile, costs will continue to rise as everyone tries to become more (not less) expensive in order to claim that they deserve a larger percentage of the money. This is sort of the same concept that always drives beauracracies to grow.

5. If we are going to ration anyway, we might as well use the market, as the market atleast promotes efficient resource utilization. May some people be excluded? Yes. Will some people also be excluded in the universal system? Yes. People who's treatments are not covered exist all over the place. The government simply adds inefficiency. They will either ration less efficiently than the market or go bankrupt for lack of rationing.

Our resources are finite. We can't give everyone everything. It doesn't matter whether we have a single payer, a socialized system, a subsidized system, a mixed system, etc... Without changing the entitelements and spending less money, we will go bankrupt. Centralizing the system will not fix the problem.

Every Centralized Idea to Fix the Healthcare Will Fail, and Here's Why.

2008-06-17T12:24:00.002-05:00

This sounds like it should be a long topic, but in fact, it's very short. Every central system will fail because any sort of involuntary insurance is effectively a forced redistribution of wealth. Without eliminating the entitlements, it doesn't matter if there is government insurance, a choice of private plans, a hybrid system, a system that involves the easter bunny, etc... The system will eventually bankrupt itself because it will progressively demand more and more money from the most productive members of society in order to pay for things that are largely the result of either poor life choices or inevitable old age. Insurance only works if everyone takes the risk voluntarily. Throwing oneself into a risk pool with people who are much higher risk than you is stupid. Forcing this stupid decision is the only purpose of central insurance.

Medical Malpractice is a Symptom: And We All Know That You Can't Cure a Disease By Treating It's Symptoms

2008-04-26T10:55:00.004-05:00

"Malpractice Reform!"
"Malpractice Reform!"

If you listened to the AMA (something that I do my best not to do), you'd think that this was the holy grail of physician protection. As though all we had to do implement this reform (along with shoring up those Medicare payments that they've supposedly been fixing for the last decade or so) and this country would become a medical utopia. We could practice without fear, pay for our malpractice protection at a reasonable price, and provide medical care to the patient at a reasonable price.

Here's the facts. In states that have enacted this reform, there has been anywhere from a flatlining in insurance prices to real, but small, drops in price. While these reforms, which are primarily aimed at non-economic damage caps, have some impact, they certainly do not change anything significantly. They don't stop defensive medicine or let physicians sleep at night. Part of the reason is that an extra $250k to $500k on top of already calculated economic damages is still a heck of a lot of money. Part of it is that it doesn't change the underlying culture that produced the mess. You see, medical malpractice is part of a larger concept, which is professional malpractice. Professional malpractice is part of an even larger concept, which is consumer protection.

You see, the concept of consumer protection, which is certainly a hot topic now, barely existed a century ago. It is new. While it's earliest implementations were of a relatively benign nature, it has become the beast that is poised to destroy the modern world. It was once assumed that the use of products or services came with risks. Many of these risks were inherint, no one really questioned them, and it was common sense that the choice to use a product or service was to take on the obvious risks. If I bought a horse in 1890, it was poorly behaved, and I proceeded to fall off and break my neck, my family had no concept they should sue the previous horse owner for its behavior. Falling off of the horse is an inherint risk in riding a horse. No amount of protection, skill, equipment, etc... will ever make riding a horse 100% fall proof.

Early implementation of consumer protection occurred when licensing went from being a pure tax to being a tax AND qualifying process. In the early part of the 20th century, a medical license could be had in a number of states for the price of $5, there was no real required or standardized training necessary to get one, and the purpose of the license was really for the state to collect $5. Licensing was one of the earliest implements of consumer protection. Early licensure rarely had anything to do with the state telling people how to do things. Early changes in medicine, law, architecture, engineering, etc... were really supposed to show that the people performing these tasks had actually studied their respective professions, not to tell them how to practice.

This really goes back to the concept of a contract in common law and all throughout history. Free and competent adults could make determinations of risk and benefit and agree to essentially anything, as long as neither was coerced. In the past, to end up in court, one would have had to violate the agreement. Period. There were very few rules governing what the agreement could be. The same was largely true within licensed professions. The medical license implied that the doctor had studied medicine, but the contract for treatment thereafter was between the doctor and the patient. If there was an adverse outcome, very few people thought that it was the doctor's fault if he honored the contract.

Early malpractice concepts were largely contract disputes. These might include removing a mass that the patient had never agreed to have removed or giving a therapy never agreed upon. The concept of a standard of care came later.

As the century progressed, the concept of consumer protection moved forward to include things that didn't work, then things that had unintended side effects, then things that did work but produced negative outcomes. All the while, the government got more and more involved in the business of telling people how to do things and violating rules of the government became a secondary source of liability exposure on top of violating the actual contract.

Here's a rough scale broken down into 20 year increments (with some variation from region to region) on how liability impacted physicians over time. This is how one avoided liability implemented for consumer protection:

1900: Physician is a person who enters an agreement to provide medical treatment and must provide the treatment within the agreement

1920: Physician is a person who graduated from Hopkins style medical school in order to get license and then enters an agreement to provide medical treatment and must provide the treatment within the agreement

1940: Physician is a person who graduated from Hopkins style medical school and completes atleast a year of medical internship and then enters an agreement to provide medical treatment and must provide the treatment within the agreement.

1960: Essentially the same as 1940, though early concepts of negligence due to failure to follow standards of care periodically impacting physicians

Late 1960s- MEDICARE

1980: Physician is aperson who graduated from Hopkins style medical school, completes medical internship, probably completes a residency, might complete a fellowship, and is then obligated to provide care both in keeping with an agreement with the patient AND in concordance with the concept of "standard of care," which is not explicitly stated anywhere, varies between region and specialty, and is oftened proposed by someone making a lot of money from the side that brought the suit. Non-economic damages are in full swing, so courts and lay juries attempt to attach dollar amounts to the value of having tea on the porch with one's now deceased grandmother or pain and suffering at the loss.

2000: Same as 1980 PLUS consumer protection now ALSO applies to government and third party payers. Improper coding, documentation, use of procedureal etiquette, etc... can result in civil liability as well as possible criminal liability.

One might say that this has run up the price a bit. It has, but it really mirrors what happened in other industries. Why do you think there are all of the ridiculous warnings on products. If one spilled coffee on himself in 1900, he was a klutz. Today, he is a millionaire. In 1900, no one though that they needed a "hot when heated" warning. One can apply this concept similarly to the use of sleds as weapons, placing small objects in the mouths of infants, etc... The other major change is that in the past, the consumer would have been largely responsible for anything that did happen. Today, it's the producer. It goes something like this:

1900: Consumer buys product after inspecting. It doesn't work. Oh well

1950: Consumer buys product after insecting. It doesn't work. He may recover the money he spent plus possble attorneys fees (if malicious intent is found). If it does work though, and he breaks it or uses it improperly, he may not recover.

2000: Consumer buys product after inspecting. It doesn't work. He may recover money spent plus possible non-economic damages, plus attorney's fees. He may also recover if it does work and he uses it improperly if not warned. If I use my sled as a weapon and hurt someone, I may argue that I didn't know that the sled being used as a weapon instead of a sled might hurt someone. If I use the product correctly, and it works, but someone gets hurt, I may still win. An example is firearm manufacturer that produced a perfectly functioning pistol that worked exactly as it was supposed to losing a suit when a victim that was shot by the pistol sued the manufacturer, as opposed to the guy who SHOT HIM.

With examples like this, it's no wonder that everything is out of control. You can't protect yourself when you are responsible for products and services that are made or done correctly but still produce poor outcomes. You can't agree anymore to have someone wave the right to sue for a poor outcome in a situation likely to produce one. This isn't just in medicine. It applies to anyone who produces anything. The current system ALWAYS punishes the producer over the consumer, wheras in the past, the concept was to put them on equal footing. It creates a system in which we progressively discourage production. There's no quicker way to eliminate all of the technilogical gains that are producing the very things that consumers are now "entitled" to in 100% perfect working order all the time with no errors or less than optimal endings. By punishing producers long enough, society will simply begin to implode. In this case, the physician is just another producer, and malpractice is simply another symptom of a culture in which the consumer expects perfect outcomes from every producer with every product and service 100% of the time. Change the culture and you fix malpractice. Reform does little.

A quick thought

2008-04-25T18:29:00.002-05:00

While completing an outpatient clerkship, I recently had a strange realization about all that was wrong with medicine at my preceptors office. A patient came in with a relatively simple abcess vs. cyst on the medial thigh. It was relatively superficial, not located near anything major, and my preceptor had extensive urgent care experience dealing with things just like this. In fact, I've done the I&D on similar lesions in medical school. So I asked, "are you going to drain that thing?" with of course the glimmer of hope that I might be able to do it.

He said no.

This patient's insurance wouldn't pay him to do it. As he put it, "I don't work for free." He instead spent 20 minutes on the phone referring to a general surgeon, getting approvals, etc... The patient's insurance was willing to pay a PCP bill, send the patient to a surgeon and pay that bill, and then have the patient return to both for more billing. What a bizarre system in which we send the patient to two extra appointments, pay for both, and waste the time of a highly qualified practicioner on the phone all for a simple procedure that the med student could have done and the doctor had done 1000 times before. You wonder why we spend so much money. There must be no real competition in the local insurance industry, because there is no way such a stupid system could survive any real competition.

Marginal Utility Becomes Mainstream (The Right and the Wrong Way to Do It)

2008-04-20T12:09:00.004-05:00

First of all, I aplogize for being absent for so long. Life has a way of keeping you busy, and I've learned first hand how busy a person can be. Anyway, enough about me.

It is absolutely clear that in modern medicine, a great deal of what we do is of marginal utility. We can look at this both in the sense of the utility of the treatment as to how it impacts whatever its endpoint may be AND the expense of a treatment versus how much value that endpoint actually provides. An example of the first might be the use of expensive MRI imaging on every nebulous back, knee, shoulder, neck, etc... pain. An example of the second might be $5000/day ICU care on a demented 90 year old with metastatic pancreatic cancer. In the first case, the cost is high, the yield is mostly low, and the data is often hard to interperet. In the second case, we can only hope to provide a limited number of days or weeks to the patient, with very little in the way of benefit in even the best case scenario. Being mainstream doesn't exclude something from being marginal.

History is full of many marginal items becoming mainstream. As they improve, the world adapts to them, and they often cease being marginal. Before Henry Ford, the car was an exclusive oddity for wealthy people. Poor people walked, took horses, etc... as they had for millenia. One day, Mr. Ford had a vision of mass automobile production at a price that the workers building the cars could afford. In comes the assembly line, the Model T Ford, and over the next couple of decades we went from a nation that walked and rode to a nation that drove. Newer cities sprang up around in a world in which people could travel long distances with ease, and all across the sun belt, it is now hard to call a car marginal. It's almost impossible to get ahead without one. A good way to enter the mainstream is to cease being of marginal relative value.

Television, the personal computer, and most recently the cell phone all fit into this category. They all have one thing in common. When they were of marginal utility, they were expensive. They became inexpensive first, and THEN they became the standard. The majority of people can afford these things, and that is why they entered the mainstream. Beforehand, the inaffordability prevented them from becoming common, and the people who sold them HAD to find a way to make them affordable in order to sell them. The incentive is to drive price DOWN.

This is in stark contrast to medical care. In the past, medicine followed this model. Pre-1970s (read medicare age) medicine saw numerous technologies from X-rays to Penicillin go from expensive oddities for the rich and well connected to common and affordable in a few short years, following the same model that ALL OTHER TECHNOLOGY uses to become cheaper. However, since the '70s, we've had an explosion of technologies of progressively more marginal utility at increasing expense. We went from X-rays to CTs to MRIs to PET scans and other nuclear scans. It seems quite clear that there is progression in which each step adds progressively less than the previous step added at an exponential increase in cost. Going from no imaging to having X-rays is far more important than going from CT to MRI.

When Medicare entered the market in the '70s, all incentive to drive down costs began to diminish. As government payment systems took over a progressively larger proportion of payments, incentives were turned on their heads. The incentive is to create MORE expense in order to claim a greater proportion of the pie. As is commonly understood, the incentive of a salesman is to claim he needs the least money for his product while the incentive of a beauracrat is to claim he needs to most.

By allowing access to the rich first for newer technologies, it allows them take hold. The existance of higher stores of wealth creates incentive for people to create marginal technologies. The natural progression is for these technologies to become progressively cheaper as people find a market in progressively poorer classes. Taking higher technology and expensive goods and making them affordable has been the success model for companies such as Walmart. Almost everything starts as the domain of the rich and in a couple of generations becomes a seen necessity for the poor.

We will use the CT and the personal computer as our example. Since the early 80s, CT have added some higher resolution and gotten quicker, but they generally do the same thing. Over that time, their price has gone up significantly. In fact, I cannot pay in inflation adjusted dollars the same amount for a 1980s CT scan than I could in the 1980s. The price is stagnant to significantly increased. The personal computer on the other hand was a dreadful box that required a long time to boot from a series of cards, could do little but word processing and simple calculations, and was hard to access. In the same period, it can now do what most supercomputers could do in earlier times and at a much lower price. The $300 Dell Cheapie is infinitely more powerful than the $5000 home PC of 1980.

Over that time, the government took over the bulk of healthcare costs, and various hospitals, Radiology groups, etc... argued for the need for MORE money for CTs. They lobbied and they won. Meanwhile, the computer was sold in near free market conditions. Newcomers such as Dell and Gateway entered the market and competed against the old time Compaqs and IBMs. Prices went down. Over that same period of time Microsoft and other software giants emerged and provided progressively cheaper options for software that did progressively more.

You see, now most people can get a computer and most people can get a CT scan. The computer is the right way to turn the marginal into the mainstream. A person goes, pays a price they can afford and takes one. There is no red tape, no roadblocks, no obstacles. The same person must beg for a CT from their insurance company or go to the very expensive ER. They must often wait for days. They must pay progressively MORE for insurance to cover the same CT, and the CT costs more than it did 20 years ago. The legal scenario of the modern world makes the CT mainstream, because we ALL have to order it, but it has gotten no more affordable. This is the way to take something mainstream that will simultaneously BANKRUPT the system for the sake of remaining mainstream, as the treatment is often still marginal. This is not an issue with the PC, which entered the mainstream by no longer having a marginal cost-benefit.

In summary, the MRI for nebulous pain symptoms is of marginal utility because of the cost. As costs go down, the cost-benefit improves, and its use becomes less marginal. The ICU stay is marginal because at $5000/day it provides little benefit. It is the same problem. At $100 an MRI would be of much greater relative utility than an MRI at $1000. However, no one will find a way to provide a $100 MRI as long as there is a non market payer providing $1000. There is NO incentive to drive the price down, and the mainstream imaging will have marginal value.

There. It was fast written, rambles a little, but atleast I'm posting again.

How This is Going to Happen

2008-01-06T17:18:00.000-05:00

As the presidential primaries come into full swing, I figure that it's about time that I relay a prediction. This isn't going to be about who is going to win or lose. It's all about what the winner, whomever he (or she) may be will do. This is really more of a long term prediction, as I doubt all but one or two candidates have any intention of doing it. This of course means that it will take time for it to happen.

There is right now a raging debate about how much physicians are worth and which jobs should be the purview solely of physicians. The issues of scope and reimbursement seem to have intensified in the midst of a very related debate taking place in the halls of Washington regarding the role of government in the provision of healthcare. These are currently seperate issues, but I predict that by the end of the next presidential term, they won't be. You see, when people debate these issues, the one thing that NEVER gets questioned is the fact that government has become ENTIRELY in charge of all of these points. Physicians, the market, patients, even the nursing unions and the hospitals that probably stand to gain the most from some sort of healthcare socialization still have no independent say in the way that things happen outside of their influence on Washington.

For the government to be able to take over healthcare, a number of things will need to happen. There is already a move (Kennedy bill to restrict compounding pharmacies, FDA attempting to standardize all supplements in N. America in conjunction with healthcare giants such as Mexico) to standardize medical care. Cookbook medicine is becoming a reality, and it doesn't take a genius to notice that critical thinking is already beginning to become more rare in a culture where every new idea is a potential lawsuit and strict reimbursement standards make it progressively more difficult to actually get paid for doing anything that Medicare deems unnecessary. This standardization will continue.

The next logical conclusion to jump to is that it doesn't require MD training to administer cookbook medicine. In fact, that training is almost a liability in the current environment. People in high places understand that there will come a point where reimbursement cuts will make becoming a physician financially unsound (though regardless of what many of us may think, this hasn't happened yet). The process is too arduous and expensvie to continue within the environment of declining reimbursement. As it is, physician training in this country is often akin to giving everyone a porcshe to drive through a school zone. Many of use are entirely over trained for what we do. The distinction of which training is necessary to what however, can't be decided by a committee.

Physicians have a nasty habit of going independent. They even opposed to the creation of Medicare and are one of the first groups who adamantly opposed free government money in the 20th century. None of us are naive enough at this point to believe that this remotely approaches majority opinion amongst physicians today. However, that independent streak occasionally pokes out. In the US today, there are a number of competing groups who are pushing for independent practice who have a history that is much more amenable to being told what to do. They have a lot to gain by giving in to any new initiative proposed (most of which they never really opposed at all). Enter the midlevel. The nursing unions already call any member who opposes ANY piece of legislation to extend healthcare entitlement immoral. That is a demographic that almost has to continually give power to the politicians in order to survive, thanks to a position that is held in large part by restricting training competition and keeping organized labor in an environment where physicians are not allowed to do so.

Now, I'm going to stop here and point out that I am NOT opposed to midlevels. I think that people should have the right to hire whoever they want to perform their services. If someone wants a midlevel PCP, that is their perogative. However, the one thing that seems to be true is that in this current climate, the patient will have NO say. While I generally support midlevels, I generally oppose misrepresentation. I believe that there is a definite attempt by some (not most) to overrepresent the training of midlevels, and I believe that this will be just a little too good to pass up on the part of officials in Washington looking to buy votes without devaluing the currency too much more than they already have.

You see, the current system is sort of like everyone being forced to buy a BMW or go without driving. The prices are high, and they are rising. The government wants to promise everyone a BMW, but the price is just a little too high. I think that the plan is to eventually buy a bunch of Fords covered with BMW symbols. No one is suggesting that we just have an open market in which some people have BMWs, some people have Fords, but almost everyone can afford to drive.

So this is my prediction. Obama, Clinton, Huckabee, Romney, or Guliani. Everyone has the same agenda, though that agenda is admittedly presented in a different way by each of them. Healthcare access for all will inevitably become healthcare provided for free either for all or for those who can't afford it (which is an ever growing piece of the population in the over-regulated healthcare environment) by the government. The hospital systems are becoming more monopolized and well connected. They will continue to get richer, because they don't really care about medicine itself. Physicians will either cave and become progressively more enslaved to the system, or they will be systematically removed from more and more of their responsibility regardless of what the patients want. The powerful nursing lobbies will continue to become more powerful, and the ARNP and the PA will take over a progressively larger role in healthcare. The ARNP will remain more powerful than the PA. The paycuts will continue, and the solution will be cheaper labor, not paying people what they're worth. It will continue to become more difficult to practice independently. It will all take time, but I suspect the agenda (which seems fragmented now) will become a lot more clear over the next 4 years.

Sorry for the negative vibes.

They're Here

2007-12-07T16:36:00.000-05:00

I apologize again for my delayed absence. Life has been a little crazy lately. My wife went into premature labor this last week with quadruplets. She was 26 weeks. 3 Boys. 1 Girl

They were big for their ages, 1'13", 1'13", 1'14", and 2'2."

They haven't had any true emergencies yet, but we are having a number of premie complications (PDAs, some lung issues, etc...).

Please keep us in your thoughts and prayers. We have already had many individuals donate their time and efforts in ways that most cannot even begin to comprehend how much we appreciate.

Magic Doesn't Make Things Happen

2007-11-12T06:47:00.000-05:00

This will be my last post that falls off topic from medicine and economics. It is highly relevant to both topics, but it is really more directly political. I think that it is an important thing to say though, and may clear up some misunderstandings as to where I am coming from. The following are some general rules that seem to be forgotten in the modern political debate.

#1: You cannot make things happen with a philosophy of government. If I have a philosophy that says that the government should take care of the poor, and I vote for people who espouse that philosophy, it doesn't make the government take care of the poor. What it does is generally give more power to the people in government to take money under the auspices of giving it to the poor. Whether this actually happens or not can be a matter of great debate. In other words, I cannot vote to make something happen, I can only vote to give the government the power to do something. This is a VERY IMPORTANT distinction.

#2: Getting things done is 10% inspiration and 90% perspiration. No matter how high and mighty my cause, somebody has to actually do the work to get it done. I usually fail to understand why we are progressively giving more functions of everyday life over to the same organization that we berate constantly for inefficiency. Around election time, everyone screams and moans about the lack of good choices and votes for "the lesser of two evils." They then proceed to turn progressively greater amounts of function over to "the lesser evil," who they all believe isn't actually that good. Considering that the work on the part of this individual is what gets things done, this is a recipe for progressively diminished efficiency.

#3: Giving the government power makes it more powerful. When it becomes more powerful, it is less likely to listen to you. As our good friend DeCartes said, "power corrupts, and absolute power corrupts absolutely." No matter how much you believe in the redistribution of wealth within society, you cannot do it yourself. You are actually voting for the government to do it. You are thus giving a central source of power a progressively greater say in the overall wealth in the nation. There is absolutely nothing that I have seen in my life that leads me to believe that anyone within this institution possesses some sort of superior moral or market insight.
Just remember, when you vote for a bill to save hurricane victims or provide healthcare to children, you are actually voting to give the government the power to take money from someone and use it to provide these services. This makes the government more powerful. It also means that any mistakes by the middle man prevent the actual implementation of the lofty goal (Katrina *cough* *cough*). It also makes it less likely that a progressively more powerful government will actually be held accountable for its failures. We might ask whether using the government to implement our desires is necessarily the best thing.

#4: The government is only force. The origins of government lie in defense. The only difference between the government and a private organization is that we let the government use force to accomplish its goals. What's the difference between the government providing health insurance to children and a private charity doing so? The government can use force to fund its program. Without the force, the government would be nothing more than an EXTREMELY inefficient form of charity in this instance. Voting for a bill to provide health insurance to children (as an example) DOES NOT provide health insurance to children. It gives the government the power to use force to take money from the taxpayers with orders to provide health insurance to children. This is an EXTREMELY important distinction.

Remember, magic doesn't make it happen. It's all about implementation. No matter how many warm fuzzies you get thinking about some political agenda, it doesn't change what the agenda actually means. We can want something until we are blue in the face, but nothing will actually happen unless we do it. Likewise, you cannot vote to make things magically happen in society. You can only vote to give power to the government to do things and hope for the best. Next time you hit the polling station for a proposition, ask yourselves whether whatever you are voting for is worth the cost of implementation. Ask yourself whether whatever you are voting for has any practical chance of happening at all. We could all vote by consensus that everyone gets a Mazzerati and a trip to Mars. Magic doesn't make it happen.

A Quick Note to Mr. Greenspan

2007-11-05T06:33:00.001-05:00

Dear Mr. Greenspan,

I would just like to write and thank you for some of what you managed to accomplish during your tenure at the head of the Federal Reserve. I've heard that a whole lot of people used to care what you had to say. Unfortunately, I'm pretty sure that most of them didn't really understand what you were doing. It's okay, all of my praise is sincere and related in the utmost to things that I really do understand.

1. Thank you for the housing bubble. Without the housing bubble, most of the people I know in Miami wouldn't have had the opportunity to borrow huge amounts of money against an aging structure and use it to take fancy trips and buy Hummers. This brief period allowed many people with lagging self esteems to delude themselves into thinking that they were rich. Some even believed that they possessed some kind of superior economic savvy due to their brilliant real estate investments. Yeah, so now foreclosures are at an all time high, and some of those buildings down by the beach are 50% empty, but it was all worth those 5 years of delusional glory.
Now, between the two of us, we both know that any time you drop the interest rate that banks borrow at to 1%, that there is going to be a run on money. We know that banks want to lend this money out to any takers and that it found its way into the housing market. We both know that this is fake money, and that it is all coming off of the printing press with absolutely no justification in the real economy. It's okay though, what could possibly be the harm in reproducing large amounts of the world's most powerful currency with no justification? Well, I guess that brings me to #2.

2. Thank you for the inflation. I was personally getting tired of being able to buy soda for under $1, a house for under $200,000, or a meal for $5. This made me feel poor. I feel much better now. We can all complain about the rising cost of EVERYTHING (This includes healthcare, oil, education, food, milk, travel, shelter, etc...). Between the two of us, I know that rising prices amongst all goods is probably a reflection of diminishing value of the currency, rather than mythical price hikes in every sector. The fact that we've been printing about 8% of our money supply in a year makes this more likely. It's okay, we'll keep it to ourselves.
One thing however. I'm as big a fan of Canada as anyone else. I've got good Canadian friends. I've visited and enjoyed my stay in the past. However, did you HAVE to devalue the US dollar below the Canadian dollar. I seem to recall buying Canadian dollars for about $0.70 10 years ago. My friends from the country haven't said anything about a great Canadian economic boom, so I suspect that the 40% increase the value of the Canadian dollar is really more of a 30% decrease in the value of the greenback.

3. Even though it's not really your fault, I'd also like to thank you for continuing the central banking-capitalism association. We both know that central banking and free market capitalism are antithetical to each other. However, you've kept the two so tied together in the minds of the average person, that they actually blame the free market for the failures of your central economic control schemes. They blame the market for your boom-bust cycles. They blame capitalism for you making the rich richer by giving them first access to the fake money you print, which gives them the option to purchase resources at lower prices before inflation takes hold. I've got to pat you on the back for this one. You've got them all fooled.
We'll add your association in with all modern oxymoron double speak. The free market is now central economic control by one bank. It fits in with how racism is now a failure to discriminate based on race or how charity is now being forced to give against one's will. It's not purely your victory Mr. Greenspan, but I'll give it to you.

4. You've got great timing. You gave the entire Federal reserve over to Mr. Bernanke right before the housing bubble that you helped create started to deflate. Now we'll all blame him. That sure is brilliant. I don't like getting blamed for things that are my fault either. I notice that he's cutting interest rates too. That's great. He'll continue all of the great policies that got us to where we are now in the first place. I don't really like leaving the country anyway, so I'll never need foreign currency. Besides, I'm sure the rest of the world will just take an ever devaluing dollar forever.

I have so much more to say, but I just have so little time. Feel free to write back.

All the best,

Miami_med

Humanitarianism and Destruction

2007-10-18T18:03:00.000-05:00

The following was found at the home website for the Mises Institute. They are a libertarian economic organization named after Ludwig Von Mises, an Austrian economist who revolutionized libertarian economic thinking.

This article is taken from a book called The God of the Machine, written by Isabel Paterson. It is called "The Humanitarian With the Guillotine:"

http://www.mises.org/story/2739

Changing the Rules: Making a Financial Deal With the Devil

2007-10-15T05:55:00.001-05:00

If you don't know by now, you've probably been living in a cave. The government has changed the rules for economic hardship deferment, effectively forcing most medical residents and fellows to begin paying back portions of enormous student loan burdens while still in residency. As with all changes in policy, we have to ask ourselves the question: "who benefits?"

In this particular case, the answer is simple. Lending companies love this. Yes, some of those loans may get paid off a little earlier, costing the company money. However, this is more than made up for by the fact that residents will effectively lose the ability to go after high interest loans first. Those Grad Plus loans just got a lot more profitable. Also, there's always some advantage to money up front.

However, none of this really gets the point across. All across America, students are writing their congressman and the lending companies are lobbying their respective representatives. The pendulum will swing back and forth, leaving many victims, many of which will probably be innocent taxpayers who do not have any outstanding student loans. All of this illustrates an important point: NO DEAL THAT YOU MAKE WITH THE GOVERNMENT IS SAFE, AS THE GOVERNMENT CAN SIMPLY CHANGE THE RULES. We're all just fighting to be the squeakiest wheel in this whole charade in order to be screwed over the least.

In the scheme of things, the new system isn't necessarily bad for all future medical residents. It is probably better for the average taxpayer, who might very well be subsidizing the interest on some Pediatric Cardiothoracic Surgery Fellow's student loan from his freshman year of college under the old system. The new system will force residents to make the difficult choice to cut back on their already meager lifestyles and atleast stop the financial bleeding. As most residents are not financially saavy and way overestimate their future incomes, this new system may make life a little bit more livable when the whole training process finally comes to an end, atleast diminishing the impact of the 6.8%-8.5% interest rates that have been plagueing the student since the last student loan change a couple of years ago. It may also have the benefit of stopping the ever expanding fellowship system from moving on into infinity, which may finally make it possible again to not spend 10 years in post graduate training to get a decent job on the other side. Funding super-subspecialization at taxpayer expense is frankly, a waste. It forces everyone to pay for a physician that becomes progressively less valuable to the majority of people.

The increasing supply of subspecialists is actually driving everyone's income DOWN. Each individual subspecialist is less valuable, and a generalist is progressively less valuable as his skills fall progressively farther behind some subspecialist in every aspect of his generalist work. God forbid anyone actually try to finish medical school, residency, and then start practicing anymore. Stopping this system with a little bit of repayment in residency and fellowship training may actually be GOOD for most physicians income in the long run.

However, for those of us who are already buried under significant debt, this should come as a reminder of how unfair the system is. Dealing with federal programs is risky. Regardless of whether the new rules make sense or not, the fact that they apply retroactively to all loans already taken is chilling. When I borrowed, I was under the impression that I could defer due to hardship while in residency. Right or wrong, that is the deal that I thought I made. Those that are pushing for a change back to old system are hardly going to get a lot of sympathy from the general public with demands that they shouldn't pay back 15% of income above 150% of the poverty line on money that they owe. This is not the inherint problem. The problem is the quicksand that is student loan repayment. Let people make informed decisions. If they want to start lending money with the new requirements for payback, let it apply to new loans given to new students, who understand what the rules are from the beginning.

Hoops Versus Learning: Why Does No One Want to Go to Morning Report?

2007-08-30T12:16:00.000-05:00

This is really just a rant. I'm annoyed this week.

Perhaps it's just some sort of personality flaw, but I've generally never been very good at jumping through hoops. I mean, I always did the bear minimum to get through any hurdle that I couldn't find a way to walk around, but I always grumbled and rarely did it with a smile. On the other hand, I've always been very good at doing what needed to be done. Like many people, I'm also very dedicated to things that I find interested and/or valuable.

I was a sub-par student at a sub-par high school. I learned nothing, and the thing was one giant hurdle. Did I graduate? Yes. I sure grumbled though, and my grades were a reflection of my commitment. When I got to college, everything changed. I studied things that I liked. I made very good grades (as all of us in medical school did), I published some abstracts, I was disciplined and motivated. As I worked myself through college, my weeks were generally of the 80 hour variety, but I never burned out. As time has gone along in medical school, I notice some of my high school habits coming back. I try to duck out of classes, I grumble a lot, I try to avoid responsibility.

I've put a lot of thought into it, and I realize that it's because I'm jumping through hoops. I will not pretend like some that I'm not learning anything. I'm learning a lot. I'm just learning it in a ridiculously inefficient way. I'm not afraid of hard work. I usually embrace it, but not when it's pointless. Is there some practical value to learning how to do a pap smear even though I find it personally revolting (you know you do too)? Yes, so I did it. Is there any value to anyone rounding four times on the same patient? No. It is highly inefficient, and I twiddle my thumbs most of the time. This is what qualifies as a hoop.

I think different people have different levels of hoop tolerance. As I said, mine is low. The problem is, that post-hoop threshold, your desire to engage in the rest of the activity is significantly impaired. Thus, if I'm on a rotation, and I feel like half of my time is wasted, It hurts the learning value of the rest of the time. I become disillusioned with the whole thing.

This brings me to morning report. On a certain rotation, morning report was a 15 minute to 1 hour get together with the entire department each and every morning. The value of this particular activity was highly variable. Sometimes an interesting patient would be presented, and there would be a lot to think about. Sometimes people would ramble for an hour. The problem was, I was spending about 80 hours a week at the hospital. MANY of these hours were spent sitting around waiting for admissions while on "call." This was a complete waste of time. By the second week, I was simply sick of sitting around the hospital, because half of the time I was there was useless in terms of educational value. I would have been happy to perform tasks with educational significance during this time, but it was not to be. Thus, when morning report came, I was sick of it. I wanted nothing to do with it. I though to myself, "I could have slept an extra hour without this," or, "I haven't seen my kid in two day because of this." The hoops overtook the value. I probably learned less that way.

The funny thing, is that the residents didn't usually look too pleased either. The post call residents had a longing in their eyes that screamed, "shut up and let me finish my floor work so that I can go to bed." They learned nothing. For them, it was a hoop. The attendings didn't get paid to be there. I couldn't figure it out.

Morning report isn't like some of the other hoops with obvious beneficiaries. It's obvious that certain interests are vested in maintaining training monopolies, long resident work hours, and a myriad of other hoops you have to jump through (ERAS *cough* *cough*). There is no such obvious interest for morning report. It's nothing but a culture of hoops and useless hurdles that keeps them going. Honestly, I hope I make it through medical school with enough interest intact to actually enjoy being useful as a physician. The hoops will remain, but I should atleast get paid for dealing with them. Money motivates me to jump. One can only hope.

There is no Direct Correlation Between Devoted Effort and Final Value

2007-08-12T20:11:00.000-05:00

As I make my way around the blogosphere and the internet medical community, I consistently hear an argument that is blatantly false. This is the argument that physicians should be well paid because they train for so long and pay a lot of money for the training. This argument is based on a fundamental lack of understanding of basic economics. It is also dangerous, because it detracts from a legitimate understanding within the medical community as to why we are worth a lot of money. In this blurb, I'm going to attempt to tease out the subtle, but extremely important, difference between a truly valuable good and service and a good or service that requires a significant amount of effort to produce.

I majored in Anthropology in college. I once had an advisor tell me that Anthropology had the longest average graduate school period, which is approximately 9 years between receiving ones BA and receiving ones PhD. Anthropology graduate school is a tedious process, one which I was frequently exposed to during my undergraduate training in the discipline. Many graduates would spend years in a laboratory, sorting microscopic pottery fragments that they had spent previous years tediously digging out of the ground in a variety of inhospitable places. This often included sleeping in the dirt, spending all day covered in mud, and exposing oneself to all sorts of vile insects and other not so pleasent creatures. This is the life of many anthropology graduate students. It will be followed by many months typing hundreds of pages explaining the above findings in details after which the graduate will have to defend those tedious notes to a group of people that will attempt to tear him apart.

The first thing that one might notice about this, is that the average time between college graduation and completion of training is the same for an anthropology graduate student and a general surgeon, nephrologist, and a whole host of other medical specialties and subspecialties. As a specialty that is reasonably attainable and representative of what we'll call the "average physician," I'll make most of my future comparisons with Internal Medicine. It is also close to the bottom of the salary scale, so most physicians should find internist income attainable. According to the Allied Physicians salary survey at: http://www.allied-physicians.com/salary_surveys/physician-salaries.htm , the average internist starts at $154,000/year. Since total graduate and post-graduate training in this specialty is only 7 years, this puts the internist $308,000 ahead of the anthropology student in income, more than enough to offset the differences in total debt (which are large, but not as large as many medical students would like to think).

So, what is the average salary of a starting professor of anthropology? In sociology (which is if anything higher paid), average salaries of an associate professor according to monster.com (and academic positions are highly competative) hover around $60,000/year. This is about 40% of the internist, whose position is relatively non-competative compared to those who he is competing against.

So, why is the internist paid more? In fact, why has he consistently been paid more over the course of an ever evolving healthcare system ever since the advent of medicine based on science? It's simple. His services are considered more valuable to more people. As I've said in previous posts, economic value is subjective. Anthropology is a fascinating field, but it's also an esoteric discipline, with very minimal value to the average person.

Physicians are valuable because their position on the supply and demand curve makes them so. In other words, the number of people with physician skills matches a level of demand at a high comparative salary. This isn't to say that the training period isn't important. In fact, the large training period, with all of its expense and effort, is the reason that physicians are less common. This relative scarcity in the face of high demand is what makes physicians valuable. The training period in anthropology training period is also long, and skilled practicioners are also scarce, but the demand isn't there on the other side. Thus, physicians are valuable because they are a scarce commodity in the face of high demand, not because the training period or hours are long.

As a final note, if hard work was the only thing that made workers valuable, we would all look up at mansions owned by farmers, migrant workers, and fisherman. I once worked over 60 hour weeks at a warehouse job in an unairconditioned warehouse here in South Florida. I can assure you that the physical assault on my body was significantly worse than anything that I have encountered in medicine. I was paid $6/hr for that. In fact, were hard work the top mechanism for determining payment, we'd probably all be servants of the Amish. If education were the mechanism, we'd all be watching the Anthropologists drive Ferraris down the street.

To the current or future physician:
The general public could really care less how much effort you've put into your training or the financial sacrifices that you've made. They care that you are a skilled practicioner who can solve whatever problem they present to you with. Complaining that you are underpaid for your time invested will earn you ZERO sympathy in the rest of the world. It should, because it's irrelevant. However, demanding to be well paid because you can provide a valuable skill that is hard to provide is perfectly within your right. In fact, that is the argument made by all professionals. Don't be afraid to demand to be paid for your hard work, but make sure that you're basing your demands on the reasons that they're valid.

Some Words from Our Friends at Yahoo

2007-08-12T12:02:00.000-05:00

http://health.yahoo.com/news/178301

I think that the conclusions are a little off, but it's interesting

U.S. life span shorter

August 11, 2007 05:08:02 PM PST

Americans are living longer than ever, but not as long as people in 41 other countries.

For decades, the United States has been slipping in international rankings of life expectancy, as other countries improve health care, nutrition and lifestyles.

Countries that surpass the U.S. include Japan and most of Europe, as well as Jordan, Guam and the Cayman Islands.

"Something's wrong here when one of the richest countries in the world, the one that spends the most on health care, is not able to keep up with other countries," said Dr. Christopher Murray, head of the Institute for Health Metrics and Evaluation at the University of Washington.

A baby born in the United States in 2004 will live an average of 77.9 years. That life expectancy ranks 42nd, down from 11th two decades earlier, according to international numbers provided by the Census Bureau and domestic numbers from the National Center for Health Statistics.

Andorra, a tiny country in the Pyrenees mountains between France and Spain, had the longest life expectancy, at 83.5 years, according to the Census Bureau. It was followed by Japan, Macau, San Marino and Singapore.

The shortest life expectancies were clustered in Sub-Saharan Africa, a region that has been hit hard by an epidemic of HIV and AIDS, as well as famine and civil strife. Swaziland has the shortest, at 34.1 years, followed by Zambia, Angola, Liberia and Zimbabwe.

Researchers said several factors have contributed to the United States falling behind other industrialized nations. A major one is that 45 million Americans lack health insurance, while Canada and many European countries have universal health care, they say.

But "it's not as simple as saying we don't have national health insurance," said Sam Harper, an epidemiologist at McGill University in Montreal. "It's not that easy."

Among the other factors:

• Adults in the United States have one of the highest obesity rates in the world. Nearly a third of U.S. adults 20 years and older are obese, while about two-thirds are overweight, according to the National Center for Health Statistics.

"The U.S. has the resources that allow people to get fat and lazy," said Paul Terry, an assistant professor of epidemiology at Emory University in Atlanta. "We have the luxury of choosing a bad lifestyle as opposed to having one imposed on us by hard times."

• Racial disparities. Black Americans have an average life expectancy of 73.3 years, five years shorter than white Americans.

Black American males have a life expectancy of 69.8 years, slightly longer than the averages for Iran and Syria and slightly shorter than in Nicaragua and Morocco.

• A relatively high percentage of babies born in the U.S. die before their first birthday, compared with other industrialized nations.

Forty countries, including Cuba, Taiwan and most of Europe had lower infant mortality rates than the U.S. in 2004. The U.S. rate was 6.8 deaths for every 1,000 live births. It was 13.7 for Black Americans, the same as Saudi Arabia.

"It really reflects the social conditions in which African American women grow up and have children," said Dr. Marie C. McCormick, professor of maternal and child health at the Harvard School of Public Health. "We haven't done anything to eliminate those disparities."

Another reason for the U.S. drop in the ranking is that the Census Bureau now tracks life expectancy for a lot more countries 222 in 2004 than it did in the 1980s. However, that does not explain why so many countries entered the rankings with longer life expectancies than the United States.

Murray, from the University of Washington, said improved access to health insurance could increase life expectancy. But, he predicted, the U.S. won't move up in the world rankings as long as the health care debate is limited to insurance.

Policymakers also should focus on ways to reduce cancer, heart disease and lung disease, said Murray. He advocates stepped-up efforts to reduce tobacco use, control blood pressure, reduce cholesterol and regulate blood sugar.

"Even if we focused only on those four things, we would go along way toward improving health care in the United States," Murray said. "The starting point is the recognition that the U.S. does not have the best health care system. There are still an awful lot of people who think it does."

On a Personal Note

2007-08-05T20:29:00.001-05:00

To those who read this blog with any regularity, I apologize for my recent absence. I have had a couple of major shakeups in my personal life recently, which have significantly detracted from my time to write and kept me distracted at that. Such is life.

At risk again of blowing my anonymity, I'll let you in on my situation. Sometime early next year, assuming that all goes well, I will be the father of 5. This is somewhat more complicated by the fact that I currently have only 1 child, and my wife is pregnant with quadruplets. As soon as I manage to bring some normalcy back into my own life, I will continue writing. Perhaps I'll let you in on the economics of bringing a family with a net income of $-35k/year to 7 people.

If anyone has any questions or suggestions regarding pregnancy or children in medical school, please feel free to talk to me. Different studies show average gestational age at birth to be somewhere between 29 and 32 for quadruplets, so I expect the magic moment to occur sometime in January (based on current estimates). I'll be on surgery then. On the bright side, my wife and children will probably get to live at the hospital with me. Wish me luck.

The Touch of the Master's Hand

2007-07-15T14:03:00.000-05:00

You'll have to forgive my recent absence, as I am going into the fourth week of my third year. I started on the OB/GYN rotation, and 70+ hour weeks elbow deep in you know what have prevented me from effectively getting anything of quality out. This article will stray from my usual reveries inspired by the blatant economic ignorance of the world in which we live and instead try to come to terms with the much smaller world in which I now find myself.

My school has an amazing hospital, and I mean that in both a good and a bad way. This is a place where medical students will scrub into cases that are still legends in the minds of many practicing surgeons. These are sometimes known as the quintesential "Jackson Specials." This is also a place where it can take over five hours to get a wheelchair for a patient who has been discharged or where it may take seven hours to get back a lab on a critical electrolyte. As one of my attendings says, "welcome to the Jack."

The University of Miami is unique in many ways, one of which is the fact that all medical students rotate through gynecologic oncology as part of the 3rd year OB/GYN clerkship. As someone whose interest in OB/GYN is mostly academic, I have been pleased that this is the case. Our "Gyn Oncs" carry the heads of surgeons, while maintaining maybe just a touch more humanity than those on the surgical service. I have to admit, I have largely enjoyed it (most of it). I will not pretend that I haven't been asked to complete some completely ridiculous tasks, some of which I have openly refused to do, or spent an occasional useless extra hour on rounds. By and large though, these things have been less than I feared. I have now scrubbed a number of cases, and I have yet to be yelled at by anyone but a scrub nurse, whose colleague actually apologized to me for her behavior. We even became friendly during that cases (Nothing else to do while watching 3 hours of laporoscipic surgery while your idle hands sit motionlessly on the patient's thigh).

What these weeks have done for me is pull everything into a frighteningly clear perspective. I understand the politics, the motivations of the physicians and other students, the thoughts of the patients, and who seems to be getting what out of what. It's odd.

Unlike many students, whose first unsuspecting marches into the lands of surgery or OB/GYN send them into a full retreat to the safe have of anesthesiology, I have actually been somewhat inspired. I wouldn't say that I am in awe, but I cannot help but feel a deep respect for some of the people with whom I have already had the pleasure of working. A particular attending of mine scared me to death with a particularly brutal form of humor at our first meeting. By the second time I met him, I realized that he cared more than most. He wasn't alone, but he was a striking example. For the first time since anatomy, I have questioned a commitment to Emergency Medicine and longed for scalpel.

This has really gotten me thinking about some of my friends who are pursuing "lifestyle" specialties (and I am not including EM as a lifestyle specialty as it is often defined). We could say it's all about the money, and it always is, but the mind numbing professional life that often defines a lifestyle specialty seems like it shouldn't always be the source of such glee from people who have spent their entire lives trying to stimulate their minds in a fashion that overwhelms all of their peers. Medicine has traditionally been safe, but I cannot believe that most of the people that enter the field do so only because it has been safer than other fields that also have a signficant up-side and a much smaller time investment.

With all of the problems in medicine today, I think that the most fundamental question has to be: what is going wrong with medical eduation? When I first went to medical school, the long hours of residency were actually a perverse attraction, an asset to the profession if you will. I imagined a world where people strove for excellence, often spending years trying to perfect their skills. I imagined doing what needed to be done. Medicine may have been a world of prima donas, but it was a world in which that arrogance was earned. Atleast that's what I thought.

As I stood watching my intern run around like a headless chicken the other day, I realized that residency and the long hours have very little to do with perfecting one's skills. Skill comes with experience, which happens by default in an 80+ hour work week, but the system is incredibly flawed. More than the usual banter about hospitals taking advantage of interns, it is as much what the resident fails to get than what the hospital gains that is the problem. Academically I understood this before, but I didn't really get it until now.

I frankly didn't enter medicine to learn how to be more empathetic, use the team approach, or any other politically correct method of medical training of today. It's not that empathy and team work aren't important. They just have nothing to do with why I went to medical school. I came to become a highly skilled practicioner, a master of my craft. I came to learn how to be a go to guy, a person who commanded respect because he earned it, and someone who has the skills to provide for himself autonomously. In modern medical training, I fear that these may be the very attributes that are most in jeapordy.

My wife's grandfather, who happens to be a former physician and one who trained in the early 60s, talks of medicine with a gleam in his eyes. He saw himself as a detective almost, personally charged with identifying an ailment that plagued his patient. He said very little about spending hours on discharge summaries or writing the 800th soap note on a patient in 2 days. I suspect that there used to be a lot less of that. Between these things and the dreaded "rounds," which were far less frequent in those days, the modern resident has to spend the bulk of his brain power fitting himself into a stereotypical behavioral mode and becomes as much an underpaid clerk as a physician. Yes, residents used to work longer hours, yes it was often bad, yes there was probably a better way, but atleast they spent many of those hours learning how to practice medicine, which is something notably missing from training today. In fact, the current policy wonks want nothing more than to turn all physicians into nothing but "members of the team," who will diligently and thoughtlessly pour out mesh terms over considering the uniqueness of a patient. Doing anything more would put them above "the team."

As I watched the hands of the attendings in one of my most recent surgeries, I began to question whether those hands will exist in another 50 years. It has nothing to do with 50, 80, or 100 hours a week. It has to do with the desire of the student and the willingness of the teacher. If these two actually care about each other, they will take care of each other, and the hours will be doled out in a way that is subjectively satisfying, rather that some arbitrary number of hours of scutwork. As the teachers become less willing, by choice or by mandate, the desires of the student will migrate elsewhere. Without a paradigm shift, my generation will be entirely educated in a sea of thoughtless conformity by a bunch of bitter old geezers who know that the whole thing is wrong. That can't go on forever. Then comes the next generation, and who will we teach?

The Wicked Truth: A Hypothetical Case Scenario as to Why Johnny Has No Health Insurance

2007-06-22T19:41:00.001-05:00

Johnny is 25 years old, and he is part of the largest, atleast as a percentage, group of uninsured Americans. That is, he is young, healthy, older than college age, younger than the age that most people get sick, and though this problem afflicts women as well, he is even more likely to be uninsured as a man. He has a two year vocational degree and is learning the real life ropes as an auto mechanic making about $26,000/year. He is white, his family was working class, but by no means poor, and he comes from a middle sized city in Middle America.

So what's the deal? Johnny's father gets insurance from his current job as an assembly line supervisor, and he covers Johnny's sister and mother. Johnny's mother gets no insurance from her position as a receptionist for a building that houses a few small private law firms. She has never really looked into it anyway, because his father has been fortunate enough to work for Widgets Inc., which has covered its employees since the 1930s. Johnny however, lost coverage through his father's employer when he finished trade school. He has been uninsured since, and it hasn't been a problem thus far. On the surface, Johnny appears to be the one in trouble. Looking deeper, a more severe crisis is about to unfold.

Only a handful of states allow insurance companies to band ages when determing risk. Johnny doesn't live in one. In his state, rather than being lumped in with other young healthy adults, he is lumped in with every 75 year old diabetic. In fact, it is illegal for companies to offer certain variations in treatment options or premiums. What they do of course is find an average where it is most profitable to sell insurance, deny people who are too sick, and sell insurance to young healthy people at a rate much higher than their personal risk justifies. In his state, Johnny would have to pay $150/month even for catastrophic insurance. He has a friend in a state that allows banding who pays only $70/month. He sees his offer as a ripoff, and he is right. He thinks about it and realizes that his odds of getting sick are very low, and insurance is more than 6% of his gross income. Besides, if he gets really sick, no one will let him die. It scares him, but he makes a choice that seems cunningly rational. He goes without. Atleast he doesn't live in a state that requires insurance to offer everyone treatments ranging from psychotherapy sessions to in vitro fertilization. Those things really run up the cost to the risk pool, and his premiums would have been even worse.

Johnny's father started working at Widgets Inc. at the age of 18. He was never a particularly bright person, but he was reasonably hard working. He is now 52, and he has been credited with 34 years of service. He has a pension that he will be able to access in old age and a company insurance guarantee that promises him benefits until death. He has considered opting for early retirement next year, which would lower his total monthly pension benefit, but would let him retire five years early.

Here's the problem. Widgets Inc. never really produced a cheap product. In fact, the product quality has probably declined since the companies inception, though there has been a recovery to a degree. The problem is that a new company formed in 1976, called Things Corp., has started producing the exact same product for 70% of the price. How? Simple, they had a better business model, a more efficient production line, and they don't have a load of pension obligations weighing them down. In effect, they are a better business. Once Things Corp. entered the market, Widgets Inc. started losing market share. They have only turned a profit in one of the last 8 years. The shareholders are getting restless. The company has considered filing for bankruptcy. Of course, one of the first things that they will be requesting in bankruptcy court is the right to reorganize (aka eliminate many of the benefits from) the pension fund. This really isn't because Widgets Inc. is evil or has some sort of conspiracyl; they simply cannot compete or fund future pension obligations with the current business model.

For Johnny's father however, it could be devastating. Bankruptcy might mean layoffs. Layoffs might mean he would become unemployed. Not only would this leave him with no job or pension (assuming restrucuring), but it also leaves him with no health insurance. If he loses his health insurance, the results could be disasterous for his wife and daughter.

Widgets Inc. never had any intention of offering health insurance when it formed in 1926. However, New Deal caps on wages forced the company to find another method of recruiting skilled labor. Like many companies, they started offering health insurance as an incentive. Before big companies like Widgets Inc. started offering health insurance, the entire insurance market was really a small niche industry, and almost no one actually carried insurance. Widgets Inc.'s attempt to get around government regulation in the 30s left them susceptable to future competition. The full impact of this is only being felt now

Health Insurance Inc. is a business that sells health insurance. Like all businesses, they want to make money. With a market of over 40 million uninsured in the US, the company president is seeking a way to tap into this untapped market in order to increase its profit. They now that many of these people are actually working, and they are seeking a low cost solution to offer basic services to these people at a price that they will buy at. People like Johnny are the perfect client. He is young, healthy, and low risk. The company keeps excellent records and determines at what price they can offer health insurance to people just like Johnny at an acceptable profit. They know that they can't try to make too much money, or Johnny won't buy it. For the rare accident or illness that does occur in this age range, they will offer coverage. For those that don't get sick, they will have been paying premiums that they can afford.

The president figures that he can do this by limiting the number of services that his company offers. He'll cover many of the common ailments that plague people in Johnny's age group, but he'll offer different plans at different prices that cover different things. As he attempts to move into Johnny's state, he is in for a rude awakening. He tries to offer insurance aimed at Johnny's age group. He finds out that this is illegal. He tries to eliminate services that while often desired, are not life or death, it is also illegal. He figures that he could offer insurance that covered the standard of care for 10 years ago, which still is the standard of care in many countries. He finds this either illegal or finds no hospitals willing to comply, as they will be liable for malpractice by not honoring the current standard of care. By the time that he complies with all of the regulations, he is shocked that he cannot beat the current market best price of $150/month for catastrophic. He is disappointed, but it makes no sense for his company to enter the market. Besides, it's nearly impossible to get passed the state regulatory board. Ironically, he offers insurance in the next state over, where the still significant, but less stringent regulations, allow him to offer the insurance to Johnny at $100/month. He figures that he might still turn a profit at this price, but he finds that it is illegal again. Johnny can't buy his health insurance from the next state.

The basic point is that health insurance for Johnny really is over-priced. I say this not because it is expensive, but because the only things stopping it from being cheaper are all sorts of rules and regulations that follow special interests, the well connected, the well intentioned, and some of the insurance companies within the state who themselves fear the competition. This isn't the true market price, and that is why it is overpriced. These regulations that help certain individuals have seriously hurt Johnny. Johnny is now a victim of regulations that protect others over him.

The rest of his family has also been victimized. The illogical process of offering health insurance through a job has made his father vulnerable to any market downturn that impacts a single company. His position is precarious. There is no reason why he should have purchased health insurance through a company. It is a fluke of history that failed to die based on a now defunked market control scheme instituted over 70 years ago. There is no reason that health insurance should be as all encomapassing as it is, leaving those that don't have it on the outside for basic treatment. There is no reason that group purchasing of insurance should go through jobs. It could operate through any sort of association, probably with a lot less variability and unpredictability than it does through a job. Regardless. the victim in this case is exactly the person that most of the rules have been instituted to protect.

Charity vs. Entitlement

2007-06-19T21:00:00.000-05:00

Alright, I'm going to take a quick breaks from the pure economic ideaology of the last couple of posts to clear up something about my personal ideaology. This is partially because I keep on having to explain this to people who I am debating and partially because those of you who are particularly disenchanted with my view on the world won't have to be bothered trying to determine what it is that I think.

I believe that charity is good. It is one of the things that makes us human, and care for your fellow man is both good for others and personally rewarding. I am personally quite charitable, and I have at times sacrificed time or money that I didn't really have in order to provide for others. The important note here is that I made sacrifices by choice. No one was hurt. No one did anything that they didn't want to do. There was good all around. Others received what they wanted or needed. I gave and found it personally satisfying.

I believe that entitlements are bad. Every entitlement has a victim, which makes them fundamentally different than charity. Entitlements are promised by the government, and they are promises of a product that the government neither has or produces. The only way for the government to get it is to take it from someone else. This can be in the form of money, time, or liability. Regardless of how it is done, the end result is one person being victimized in order to provide for someone else.

We'll take this one step farther. By and large, there are two people who are often exempted from much of the entitlement liability. These are the groups receiving the entitlements, meaning that the more you are given, the less that is expected of you, and the individuals who are powerful enough in government to avoid it. This largely leaves Middle America carrying the load, with the most productive members of society being most heavily punished in order to provide for the least productive members of society.

Charity is personally rewarding, while entitlements create a sense of loss. Everyone does their best to exempt themselves from as much of their tax burden as possible. In stark contrast, people overwhelmingly go out of their way to give by choice. Post-9/11, most accountants didn't go out of business, but the private giving was so profound, that it became difficult to find immediate uses for the money.

Individuals receiving charity have an incentive to better themselves. Quite simply, relying on charity is relying on good will. It is not usually permanent, and if you manage to make it so, a certain degree of appreciation towards the benefactor is usually observed. Contrast this to entitlements which have a tendency to create a dependent class that far from being appreciative, is usually militant in its desire to be given more. Also, charity respects the rights of the giver of the right of the receiver, while entitlements respect a right to property of the receiver that supercedes the right of the individual who actually owns the property.

That's where I stand. I have been accused of being impractical. I am not. I have been accused of being zealous. If the above is zealous, then I suppose I am. I have been accused of being uncompassionate. Anyone who knows me in real life would probably consider this absurd. I have a philosophy that finds giving to be very good. That same philosophy leads be to believe that giving is a choice that I make. Money taken from me isn't giving on my part, and it makes no one better in the end.

How to Make Good Healthcare Cheaper: STOP MAKING IT FREE

2007-06-15T13:49:00.000-05:00

Okay, so this post kind of sounds like an oxymoron. However, the above statement is true. We just need to define who it is getting cheaper for and who is currently getting it for free.

In the current healthcare system, there are 2 ways to get all of your healthcare for free and one more way that makes it kind of pseudo-free. The two ways are the following:

1: Qualify for and sign up for Medicaid
2: Go to an emergency department, shirk your bill, and don't keep enough assets to be worth suing.

What should be painfully obvious about the first two, is that the less productive you are, the more likely it is that you will qualify for free healthcare. The pseudo-free healthcare comes in the form of Medicare. I call it pseudo-free, because most of its recipients have been paying for it for their entire lives. However, it pays regardless of the level of investment on the part of its benificiary, and the citizens who utilize it generally stop paying for it around the time that they qualify to use it.

Generally, Medicaid doesn't pay well enough to cover the cost of seeing the patient. Obviously, someone is losing money when someone shirks the ER bill as well. What does all of this mean? For one, it means that healthcare providers generally lose money by seeing the people who currently receive free healthcare. Where does such a provider make up these losses? With paying patients of course.

I'm going to stick the obvious disclaimer on this post that seems to elude some people. Doctors cannot make money appear. If they are not profitable, they cannot stay in business. Regardless of how ludicrous it is to think that doctors should work for free all the time in the first place, it is even more ridiculous to think that even the most self-effacing physician could continue to treat people without breaking even. As they say in business, "no margin, no mission."

Now, let's take a look at an inner city ER, with a 20-30% collections rate. Consider this, the ER doesn't really care if it collects 20-30% of the bill from every person or 100% of the bill from 20-30% of the people. To them, the result is the same. Consider then, that in that same ER, each individual bill could be reduced to 20-30% of the individual bill if 100% of the people paid, without changing the overall cost structure. This same ideaology could be extrapolated, albeit a bit more complicatedly, to apply to every Primary care doctors office in the country, where they are forced to bill well paying patients against these losses from Medicaid or non-payers in order to stay solvent. These costs are then often pushed up through the insurance companies and come out on the other side as higher premiums.

I'm not advocating eliminating charity care, but it seems pretty obvious that the entrenched system that we have right now is what drives healthcare costs to the outrageous heights that they have achieved. When you have problems paying your own premiums, question whether your anger is well founded when aimed at your doctor or even the insurance executive. Perhaps we should all get a little bit more angry at the people who are abusing the nations ERs and the system that lets the least productive members of society leach the life out of its marginal income members. Many of these people are often forced to lose the very thing that they are being forced to pay for.

How Good Doctors Can Hurt Our Collective Health

2007-06-08T12:41:00.000-05:00

I promise that I'll eventually get back to my posts on economics and medical school, but my thoughts have been elsewhere lately.

INTRODUCTION

Even though we've had some bad press in the last couple of decades, those of us in the "caring professions" still enjoy a degree of respect that is often not afforded to those who pursue other careers. Doctors still have more knowledge and understanding about the human body than most people could ever dream of having, and an ever shrinking (but still large majority) of patients still understand that. In fact, physicians opinions have always been considered in many facets of social policy, even those in which a profound understanding of the human body isn't remotely helpful.

Doctors may collectively be the most ignorant group of professionals in the history of existance when it comes to money. On a personal level, the number of physicians who manage to pull in incomes that rival executives at large corporations and still end up broke is astonishing. Almost all of us who spend any time around doctors know of someone who managed to big house, exotic vacation, and expensive car his six figure income into bankruptcy. Much like the other group of people who consistently show financial incompetency (those in congress), physicians have historically been involved in numerous pushes for change in social policy. There is often a significant and ignored financial component to these things as well.

THE BENEFIT OF WEALTH

So you might ask, "how does financial ignorance hurt our collective health?" It's a fair question,and one which requires some explanation. I am the first to admit that most doctors who promote changes in social policy have done so with the best of intentions. This makes the damage all the more sinister, because those involved don't understand that it is being done.

Consistently, the number one indicator associated with health is wealth. Individuals with greater access to financial resources live longer. This has been demonstrated in so many studies, that I don't even know where to begin. Yes, some indicators in the form of race and gender play a role, but socioeconomic status is still consistently associated with better outcomes within these subgroups. Interestingly, this tends to hold true regardless of differences in insurance, neighborhood, or healthcare provider. In general, this may just be the benefit of consistently having good food, shelter, and the ability to go about one's business without constantly fearing bankruptcy. It may be because people with more money also tend to have a better education, which may translate into better decision making.

Regardless of the reason, it is hard to argue with those facts.

IGNORANCE AND ADVOCACY

So we've made two very important points:

#1: Health is strongly correlated with wealth
#2: Doctors know painfully little about wealth.

This brings us to another important point:

Doctors who fail to understand wealth may infact hurt health.

Ever since the end of the second world war, people got it into their heads that physicians should be politicians. Far from the sacred doctor-patient relationship of a one-on-one partnership espoused in the Hippocratic Oath (yeah, yeah, along with all of the garbage in the oath), we've graduated to the Code of Geneva, in which physicians who don't know anything about politics, money, or social policy are responsible for and expected to be involved in expensive social policy. In fact, it would be a bit unwise to even apply to medical school if you didn't think you could pretend that your actual job of being a doctor should come second to the "demands of society" or some other philosophy in which the physician becomes all knowing guru who can seemlessly weigh the cost and benefit of a treatment for his patient against the needs of society and bring the whole world into Nirvana.

The problem is that doctors, along with everyone else, don't actually know how to do this. On a large scale, economists and the "great leaders of state" have consistently failed to create effective controlled economies. There is really no reason to believe that physicians, who are among the most financially ignorant members of society, would do a better job of perfectly balancing everyone's needs than any of these entities.

SAVING A PATIENT AND LOSING A FAMILY

After it's initial opposition to the creation of Medicare and Medicaid, the AMA and the government organizations have become strange bedfellows, with many doctors becoming reliant on the entities for income. This kind of relationship exists in an even more convoluted fashion when it comes to physicians, local hospitals, and government funding for those hospitals. Regardless of the arrangement, it is clear that many physicians are deriving a good proportion of their income directly or indirectly through tax dollars. Thus, the treatment of a patient by a physician now often correlates to a direct financial loss on the part of an unrelated taxpayer. A loss that the majority of physicians providing the treatment fail to understand.

A simple example here in Miami goes as follows:

Many individuals are losing their homes in no small part because of rising local taxes, a not insignificant portion of which go to local hospital systems. Thus, the local healthcare system is actually hurting many of the individuals in the community. Physicians who are thorough with the treatment of local patients may actually drive up the number of individuals who are losing their personal wealth. This is even more profound when the government pays for something like an organ transplant. In this example, the $250,000+ correlates to the total taxes paid by ~25 families for the entire year.

CONCERNS FOR THE FUTURE

As the ever more predictable reality of a universal healthcare system comes to fruition, I can only see the above scenario multiplied over and over again. Physician advocates for universal access and other government intrusions may actually hurt the economic viability of other sectors of the economy. In doing so, it will diminish overall wealth, which is consistently one of the best indicators of health. Thus, good doctors will actually be bad for health. Remember that a good doctor isn't necessarily a good politician.

I'll probably come up with more on this later.

It's Finally Over (Atleast for Now)

2007-06-08T12:39:00.001-05:00

It's official. I am done with my boards. Thanks for your patience everyone, and I'll try to get everything back on line here soon.

Economic Value is Subjective

2007-05-20T15:30:00.000-05:00

I'm a little short on time this month, so I'm taking a break from your regularly scheduled series on medical school economics and instead writing on a key point in understanding capitalism. I'm going to use some healthcare examples, but this is mostly an economic point.

In a free market, value is subjective. An object, a service, or a piece of property has no particular intrinsic value. Value has to be ascribed by an individual. When people attempt to say that something is worth something, they are really saying that it is worth it them. Either that, or they are quoting a government official or real estate agent who doesn't understand what something being "worth" is in a free market economy.

I'll give you an example. The house I used to live in down in South Florida was originally purchased by my family for the price of $105,000. Over time, houses in the neighborhood went from selling for 90k-110k to 300k-500k. The only change to the houses was some age. Many of our friendly neighborhood real estate agents now claim that the house is worth $450k. This is simply not true in and of itself. The house is actually worth what someone is willing to pay for it. In today's market however, it is much more likely that someone will be willing to pay $450k for the house. Without the buyer however, as many people have discovered down here in the recent real estate downturn, the house isn't actually "worth" anything.

This may seem like semantics, but it is crucially important in understanding free market economics. One of the key principles given to us by the austro-libertarian economists is that the value of an object for sale or trade is what it is what it is worth the the person buying it. If the seller doesn't come down to the buyer's price, then the object has more value to the seller than the buyer is able or willing to trade for it. This is in contrast to previous economic theories which placed the value of an object at the investement required to make it. This is the principle that underlied most controlled economies, which is why they always end up failing. It is patently false as proven by the houses. Many houses sold for 2-3x the original price, but no further significant investment was made. In any sort of trade, both parties are getting something that they consider to be worth the price that they paid for it. That is the only true measure of economic value.

Let's apply this concept to medicine. All moral worth aside, the economic value of a doctor is whatever someone is willing to pay. Period. A decline in physician reimbursement is 100% related to a decline in the valuation of a doctor by whatever entity is paying for the doctor. The number of years of training has nothing to do with it, aside from giving the doctor a skill for which an individual might decide to ascribe higher (or even much higher) value to the doctor. In the current system, where the government takes over a greater proportion of medical payment, the value of the doctor progressively becomes whatever the government ascribes.

If we remember our high school supply and demand curve, we realize that this curve is an aggregate representation of a series of subjective decisions about the value of a good or service and the number of willing buyers and sellers at a particular price. Thus, in a world of no economic restrictions, more people are generally willing to buy a cheaper good or provide a more expensive service. Medicine is no different. By and large, a "shortage" is simply fewer people than "required" providing a service at the price being paid.

Let us remember though, that there is a subjective component when it comes to provision. An individual who is willing to sell a good or service at a certain price may be willing to sell or provide a different good or service at a different price. Thus, when the value of giving the service declines for the individual, the price often has to go up in order to convince the individual to continue providing the service.

Here's a final example:

A doctor loves medicine but hates administrative paperwork. He has a practice that generates $150,000/year and it is 80% medicine and 20% administration. He is satisfied. Due to a new restriction or rule, his practice becomes 50% medicine and 50% administration. He is now unsatisfied. Depending on his subjective value, $150k may no longer be worth it. Maybe it is. As an aggregate, the number of people who love medicine and hate administration willing to work for $150k will probably decline if the job goes from 80/20 to 50/50. Thus, there is now a shortage. Remember that many factors play into value, and the ability of the doctor to find a different position paying enough to get by is also important, which is why many people will continue to practice, regardless of the decline in satisfaction. Maybe the 50% medicine is worth the extra administration. It all depends, but it is all subjective.

Current declines in physician income are nothing but a decline in the valuation of physician's services by the entities paying the bills. Physicians have no inherint economic value, regardless of how positive their services may be. Just remember that as people begin to feel more entitled, they will pay less. As the government takes over, they are less invested in the health of the individual than the individual himself. As people become more fat and lazy, the may simply not care enough to pay you. Whatever the case, keep these things in mind when making decisions. Past performance is no indication of future results, and people's subjective whims will change on a dime.

New Posts

2007-05-16T16:19:00.000-05:00

I'd like to thank everyone who has kept the discussion going here at Medical Economics. As of right now, I am preparing for Step I, which I will be taking in early June. I'm not sure whether I'll have a chance to post again before then (It depends on how the studying goes). I hope to have you all return in mid-June. We're just getting warmed up.

Market Controls and Medical Training Part 2: Applying to Medical School

2007-05-03T21:32:00.001-05:00

The application process to medical school is one of those things that shows the true level of absurdity that can be achieved when artificial constraints are mixed with huge amounts of easily accessable money. Having gone through the application process myself, I can honestly say that if someone read on the internet that Harvard liked nudist animal impersonators, there would be 1000 pre-meds disrobing in Harvard Yard while clucking like chickens the next day. Some people's desire to get in almost seems to transcend logic. At times, the insanity and the competativeness will drive people into a mode where they forget why they're doing what they are doing, with the goal of getting into medical school transcending all else. This post will mix the usual economic banter with a touch of pre-med psychology (unofficial of course), in order to truly elaborate on this nearly mystical process for those that haven't had the pleasure of experiencing it.

You might say that some people are just naturally competative, and besides, I'm probably the biggest proponent of market competition on the face of the planet. Both of these things are true, but not all applicants are naturally this way, and this isn't true market competition. In fact, this may be the most sinister stage of the entire process. This is the true med school bottleneck, and beyond this point, even the most cynical students will probably become physicians. The golden handcuffs have yet to make their way to the wrists of all the bright eyed doctors of tomorrow. In general, no one actually understands what it is that they are trying to achieve at this point, but everyone is convinced that becoming a physician is something magical.

There are a couple of major factors that have to be taken into account here. First, the government provides loan money to all who choose to attend medical school. Recent changes in federal law regarding student loans have made it possible for all students to fund their school's arbitrary "cost of attendance" entirely on the government money. This creates more demand for the product, as money ceases to be a barrier. Second, the number of medical schools are limited. This has changed a bit in the last few years, especially with the AOA allowing for-profit institutions to start using its accredidation, but this is new. It is also highly limited. There are still only two institutions that can accredit schools. There are all sorts of government restrictions on what schools have to offer, and all schools have to follow essentially the same format to meet the requirements. This effectively keeps supply far below demand. Thus, government restrictions effectively create shortages.

With shortages in place, competition for limited resources sets in. The limited numbers of institutions have all the cards. Applicants who are at the top their classes in college will fly around the country, begging schools to let them in. These aren't the cushy recruitment interviews that their overachieving counterparts in other disciplines are engaging in. Students will pay for their own coach flights, often maxing out credit cards, in order to sleep on a medical student's couch and pray for acceptance. Some students will repeat this a dozen times in a cycle, with a small number that will apply in multiple cycles, repeating this process for multiple years.

Of course, this is only part of the expense. Almost all schools go through a specific application system called AMCAS. This sort of system imposes a huge amount of added expense on students. The current version of AMCAS' variable fee schedule is $160 for the first school, with $30 per additional school. Remember that spots are limited, so marginal students may actually apply to 50 or 60 schools, shelling out the extra fees. Any school that feigns interest in an applicant will then request a secondary application. This secondary application will then request a series of information, of which 50% is redundant with what they already received through AMCAS. Another fee of $15-$100+ dollars will then be attached to this, making the effective price per school somewhere between $45 and $130. Occasionally, a school will collect the money usually associated with the secondary application and then instantly reject an applicant without requesting a secondary at all. We'll ignore the fact that this looks a little bit like fraud.

Now, I don't pretend that there would be competition in a free market. There will always be institutions that gain a reputation for which people are willing to work. A big wallstreet brokerage firm will have people competing for spots as well. However, everyone who wants to trade stocks doesn't need to compete. My problem is not with competition in and of itself, but with the process that creates only a single, uniform, and expensive method of pursuing medical training. This is generally the same problem I have with healthcare delivery. The standardization is overly restrictive, expensive, and ripe for abuse by parties that find themselves in a favorable bargaining position due to government intervention. I am not implying that all medical schools are evil and corrupt institutions. However, the nature of the application process is definitely shifted in their favor.

I apologize for the long and somewhat disorganized post. I'll do my best to follow it up with an equally long and disorganized post as soon as I can.

Market Controls and Medical Training Part 1: The Introduction

2007-04-26T19:16:00.000-05:00

I will come right out and say it. Medical training doesn't remotely resemble a free market. It doesn't even pretend to resemble a free market. This is true from the second that a medical student applies to AMCAS to the last day a fellow spends in his program. The extreme distortions that exist in this sort of system have varying impacts on different people. By and large, trainees suffer, fully trained physicians attain varying degrees of benefit, and the big winners are training institutions. Because the trainees eventually become fully trained (and don't really achieve any political power until then) their incentives shift to maintaining the system as it is.

Let's look at it globally. There has been a systematic attempt to limit the number of spots in medical schools. With a limited supply of training institutions, there was insufficient supply to meet demand. Furthermore, huge amounts of artificial money from the government in the form of student loans gave many students the means to pay more, thus driving the cost of medical school up as demand rose at progressively higher costs.

Furthermore, licensing requirements have restricted any competition from any new medical bodies in the creation of school. Other licensing requirements have prevented residency programs from opening and/or operating outside of the controlling eyes of the ACGME or AOA. This has far reaching impact on medical training.

What does it all mean? High demand coupled with artificially low supply produces shortages. Shortages drive up the price. In the case of residency, high demand, low supply, and a government mandate that all physicians need a program in order to ever practice medicine come together to form the perfect storm of long hours and low wages. Period.

Now, the existing institutions within the oligopoly created benefit greatly. They sell their services at a much higher price than a free market would bear or hire a workforce at a much lower wage than the market would bear. Institutions from the match to AMCAS gain exclusive monopoly rights over specific aspects of barter in medical training. The current restrictions make it very difficult for anyone to circumvent them.

The benefit to trainees however, comes at the end. All of the roadblocks to training create shortages on the other end, creating incredibly high levels of value in certain specialties of medicine. Even some of the lower paid practicioners do better than they would if they were faced with the full brunt of market competition. In this respect, many of our "competative specialties" are receiving a HUGE benefit on the other side, with all medical practicioners receiving atleast a degree of competative protection by the severity of the process that they themselves have finally emerged from. Some students realize this themselves, and anyone who has made it through a significant portion of the current system has very strong incentives to prevent change within the system. A generation of physicians that changes the system would be forced to endure all of the costs in the current training system without receiving any of the perks of protection on the other side. Thus, I don't forsee change anytime soon.

Keep reading the blog. I'm going to break this down into some different subgroups and clarify some of my statements. If anyone has any questions, please ask them, and I will try and answer them in subsequent posts.

Politics and the Human Immune System

2007-04-18T05:53:00.000-05:00

This post has nothing to do with economics (except in the peripheral sense that everything does). This is a bad political analogy coupled with some philosophy. However, as the author of this blog, I have decided to take liberties. It's my blog, and I can do what I want.

Everything has to defend itself. Sometimes this protection is in numbers, and sometimes this protection occurs as a result of individual action. The defense can be against both internal and external insults. However, everything from the smallest cell to the largest empire employs some method of defense.

In the human body, we have the immune system as the primary player in self-defense, with some peripheral actions by different organ systems. The immune system tries to protect the whole body, while organ systems, such as the kidneys, have mechanisms like autoregulation to protect themselves. In this case, the whole body needs the immune system in order to survive. However, the selfish autoregulation of the kidneys is also important, as the body doesn't do as well without them.

In our industrial society, we have a government that is in charge of protecting everyone. The police protect against internal insults, and the military protects against external insults. Those of you familiar with my highly libertarian views might note that I have never suggested getting rid of these institutions. Someone will have the guns, and It might as well be a group made up of my neighbors. Similarly, we have individual defense models (everything from private gun ownership to lawsuits) in order to protect ourselves individually.

To stretch the analogy even further, the immune system is necessary, but too much of it is a really bad thing. On the extremes, a person can suffer from AIDS or Systemic Lupus Erythematosus. Both are devastating, and a balance needs to be maintained. Similarly, too much government is a bad thing and too little can also be a bad thing. On one extreme, we have a Liberia, and on the other hand we have a Communist Russia. When the defense mechanism becomes self-destructive, it needs to be relieved of some of its duty.

Similarly, it often creates a problem when the defense system tries to move into a realm that isn't defense. As an example, when your immune system goes beyond its usual minor impact on the CV system and creates a systemic inflammation, it often leads to shock. In this case, the defense system has taken over a self-defending system. Rather than protecting it from insults, your immune system is actually trying to control vascular dilation (Okay, so maybe it's not intentional, but you get the point). In this case, the powerful immune system has the guns and the vasculature doesn't stand a chance. The same thing happens when the government moves into the economy.

All of our blood cells come from the same precursors, but they serve vastly different functions. Our Megakaryocytes produce platelets. These are important in early healing. We also produce neutraphils, and these are important in fighting off invaders but very poor at healing. You wouldn't want a neutraphil trying to be a platelet. Things would get worse. Similarly, you wouldn't want the government playing doctor or oil tycoon or philanthropist. The government has a specialized function in defense.

When it comes to defense, this also has to be controlled. At the founding of the US, it was understood that too much government created more problems than it was worth. Much like lupus, when the government starts attacking everything and everybody, it's a bad thing. It needs to be curtailed. As many of my readers are current or future physicians, I urge you to look at what the government does in relationship to how you practice. Are they defending you, or is the current environment in medical care nothing but a raging case of Type III Hypersensitivity.

Okay, terrible analogy and rant over.

Miami_med

Medical Missions and Capital Markets

2007-04-10T21:23:00.000-05:00

I recently went on a medical mission trip to Managua, Nicaragua. At risk of totally blowing my internet anonymity, I'll admit that this wasn't my first trip to this location. As a veteran missionary, I feel that I may have developed some perspective. This post is going to quickly touch on some salient points that I think are often overlooked in foreign medical missions. This is more of a rant than a well organized post.

The problem in Nicaragua (or India, Malawi, Haiti, etc...) isn't a lack of medicine. The lack of medicine is a symptom. The problem isn't a lack of doctors; heck, Nicaragua has "universal healthcare." The problem is an underdeveloped economy. Let me clarify:

Most of the patients that I saw in Nicaragua live on less than $2/day. The majority of our interventions were minor. We gave out huge amounts of Ibuprofin and Amoxicillin, with the occasional package of iron pills . The first thing one might notice about this, is that all of these things are really cheap. In fact, they probably all cost less than the average american spends on coffee in the morning. Yet, my patients in Nicaragua couldn't afford them. You see, the problem here isn't a lack of access to healthcare; it's a lack of money. All Nicaraguans have access to "healthcare," but this healthcare often lacks even the most basic interventions.

Don't get me wrong, I actually love helping people in Managua. My work there is a selfish endeavor, and I derive a level of pleasure from what I do that probably supercedes what I can give to the people who I am helping. However, I cannot save Nicaragua. The larger organization that I work with is trying to start a long term clinic, but even this is unsustainable without continuous contributions from the outside. It is most definitely not self-sustaining. It can't be. To be self-sustaining, a project has to atleast break even. To break even, someone has to pay. For someone to pay, someone has to earn some money. For people to earn money, there has to be an economy.

In the end, I could probably do more for Nicaraguan healthcare by building a factory or even promoting tourism. A higher income by the average citizen would do far more to create a healthier life than I ever could. A water supply that didn't have parasites, which requires money to maintain, would do more for health than I could even dream of doing. Higher income correlates to higher education, better access to healthcare, and a better quality of life. Until then, I'll continue to go down and catch an occasional emergency in a sea of ignorance and poverty. It's sad, because I know that there is a way to fix it.

The Economics of Residency Part IV: Malpractice

2007-04-09T18:35:00.000-05:00

Every surgeon will cut for the first time. Every anasthesiologist or ER doc will perform his first intubation. Every internist will have to make his first solo decision, without having to run his plan by an attending. With all of the negative things that I have said about residency, one of the things that it did traditionally accomplish was allowing new physicians to engage in these sorts of practices in an environment in which backup was available and a wise elder was at most a phone call away. In fact, the whole argument for the necessity of residency stems from the idea that this should be necessary before physicians are independently unleashed on the world. Here's the problem, someone still has to be the first patient.

In the earliest days of yore, when life was simple and residents slept on call, most teaching institutions were charity hospitals. There was no entitlement to healthcare at that time, and residents engaged in a mutually beneficial exchange with the less fortunate. The destitute masses that had flocked to the cities and had no family to take care of them were taken in, given a warm place to stay, and nursed until death or disease resolution. In exchange, they gave their bodies as learning devices for the new crop of physicians. The outcomes might not have always been perfect, but we have to remember that this was a simpler time, and inexperienced decision making probably didn't lead down the same rapid road to death as often as it does today.

In today's world, charity is a lot more convoluted. Between Medicare and Medicaid, many of the former patients are now covered by insurance. Add EMTALA to that, and pretty much everyone has access to some entitled healthcare. In this modern world, there are no more good samaratins. There are only doctors, expected to be 100% correct at all times, expected to take the team approach and take care of patients perfectly. Everyone is a possible malpractice suit. Any mistake could be $1 million. Understandably, this has created an environment where everyone from the hospital CEO to the hall janitor lives in fear of the next subpoena.

In this environment, there is no one more dangerous than the resident. Every step of the way, he has to upgrade his level of responsibility. He has to try new things. For every new procedure or decision, someone is the first patient. This is no more evident anywhere than the surgical specialties, where someone is always the first to go under a new surgeon's knife.

This fear has in many ways defeated the entire purpose of residency. Programs are often afraid to let resident's operate autonomously. They should be, residents are a huge legal liability. It is no coincidence that many people who train in community programs with legal immunity often come out with greater technical skill, even if they often fall short academically of their university trained colleagues. A resident performing scut work is a cheap boon to the hospital, but a resident actually attempting to work autonomously is not just slower, but he is a potential legal disaster for the hospital. Thus, malpractice directly inhibits autonomy of residents. A resident who isn't gaining progressive independence is wasting his time as slave labor, period.

The most telling example of this is in the surgery programs, where many residency graduates will flock into a plethora of fellowships in order to actually get some independent operating experience with backup. Others will work independently for the first time as community physicians. They will have never made their own decisions. They still have to do it for the first time, but they will no longer do it under the protective cover of residency. This of course increases their risk of malpractice, and the cycle of destruction continues. There is never any protection from law suits.

In the charity hospitals of old, resident labor was cheap, and their services were almost given away. This was basic supply and demand economics. A man with no money and a raging appendicitis was willing to take the increased risk of a resident surgeon. He had no choice, it was that or death. The supply and demand curve yielded only training surgeons at the price of free. In today's controlled environment, where everyone gets paid the same for the same procedure, trainees can no longer bargain down their services in order to train. They are just a less experienced doctor at the higher price. No one wants that, and who can blame them?

Residents can't train by selling services at rock bottom prices. At the higher prices, they are still held to the standard of fully trained attendings. They cannot become fully trained without spending time practicing at a lower level of experience. They cannot get this experience without opening up themselves and the hospital to huge liabilities. Ah well, bring on the malpractice suits.

To any loyal readers

2007-03-31T15:23:00.000-05:00

I am going to be out of the country next week, so don't expect anything new until Easter or later. Best of luck with all of your endeavors.

The Economics of Residency Part III: Payment

2007-03-28T06:43:00.000-05:00

Many people don't know this, but Medicare, when they aren't collecting money from residents paychecks as employees, actually gives every residency program a student stipend for every resident that they take. This can be a six figure stipend. In that same vein, hospitals are not allowed to bill for the work that residents due. If my understanding of this process is correct, this stipend is actually modified as a ratio of the Medicare work done at the hospital (Someone please correct me on this one point if I am mistaken). Hospitals pay residents and provide all benefits given to residents with this stipened. The astute observer who read my previous post would notice that this leaves the hospital with a hefty payment in exchange for training the resident. This of course, leads to another contradiction.

Hospitals receive a significant benefit for having residents available. They cover the floors, they operate on low level cases with minimal supervision, they "move the meat" so to speak in the ED, and they provide 24 hour call coverage that often prevents attendings with hospital priveleges from having to come in at 2:00 AM. Hospitals cannot bill for resident's work directly, but they can bill for hospital services, and because residents often perform these services, the hospital bills for them indirectly.

Moreover, because resident's cannot bill when they are actually performing higher level physician functions, there is a perverse incentive to engage residents in scut work. A resident costs the same whether he does 100 blood draws or scrubs in on an interesting case beyond his current skill level. However, when he does 100 blood draws, the hospital doesn't have to hire a phlebotomist. This saves them money. If he scrubs in on an interesting case beyond his skill level (where he might learn something), the hospital not only cannot charge for his presence in the room, but he will actually slow down the attending physician who CAN bill. Thus, the incentive is exactly the opposite of what would be expected from a residency program.

Flying in the face of many years of tradition, I hereby move that the Medicare stipend be removed and residents be allowed to bill for the work that they do. This would accomplish two things:

1. Hospitals would have an economic incentive to use residents efficiently. Having a resident actually engaged in productive activity is probably better for educational purposes than having them engaged in scut. Also, this would put residents on the same billing level atleast as the hospital PAs and NPs, diminishing the backwards incentive for hospitals to not hire necessary coverage. Higher resident billing rates would reduce incentive for having them do the work of ancillary staff.

2. Programs would have an economic incentive tfor teaching residents skills early, as the program could actually benefit economically from having a resident who could bill for those cases. The resident should also be able to bill as an assistant. As unfond as I am of Medicare, if they absolutely must be involved, paying the resident as an assistant rather than giving the program a lump sum would be a much better incentive.

Also, as long as residency is required for certification, hospitals should be required to reimburse residents atleast a portion of what they actually generate. I'd love to let the market sort out this mess, but that can't happen within the controlled licensing system. Until the system changes, residents cannot fairly negotiate these rates themselves, and there has to be some sort of legitimate recompense for work completed.

There is however, a significant barrier to implementation of any change towards autonomy. Like most things these days, it lies in liability. Stick around for my next post on malpractice.

The Economics of Residency Part II: $5-$20/Hour

2007-03-25T12:42:00.000-05:00

There is relatively minor variation in pay between US residency programs and virtually no variation between specialties within the same program. This creates a rather odd pay scenario. After completing four years of medical school, all graduates who enter residency will be paid between $38k and $55k. This varies a little with regards to the military, which pays its residents more (You get to pay it back later, trust me). Most programs are close to $40k. This leaves a pathology resident who is assigned a 40 hour work week with a pay rate of about $20/hour. For our surgeon in a program that is adherent to the 88 hour work week maximum, the rate is closer to $7/hour if overtime were calculated. In a non-adherent program, this can be worse. Thus, a surgery intern may actually make less than the service worker in the cafeteria of the same hospital in which he works. This may actually put some residents below the minimum wage in the state in which they work. Most programs and specialties are in-between, with pay hovering in the $10/hour range. One might ask why this happens and how it is justified. Why do physicians put up with it?

Medical students owe a lot of money. Official numbers are about a $130,000 average per student, but anyone in medical school will tell you that this is misleading. For the most part, students who have to borrow money owe closer to $200,000, with some owing $300,000 plus. Some students are supported, at least in part, by their families, and this skews the numbers down to a less frightening statistic. Upon completion of school, with this crushing debt burden, the only way in which a student can turn this hideously expensive degree into earning potential is with a medical license. The only way to attain a medical license is to enter residency. Thus, most students have no other viable economic option. Most students will then trudge through residency with these debts accruing interest in some form of deferment or forebearance.

Residencies are mostly accredited by the ACGME (American College of Graduate Medical Education), with a few that exist for DO graduates accredited by the AOA. The only way that a residency is considered adequate for licensing purposes is for it to receive accreditation from one of these two entities. This stifles a competative market in post-graduate medical training. As a new physician, I cannot go apprentice with an internist until I am comfortable with internal medicine, as the internist isn't accredited by the ACGME as a residency program. Oddly enough, nurse practicioners(NPs) and physician's assistants(PAs) are allowed to do this. Independent NPs often do go the route of working for a few years under a physician and striking out on their own. This is illegal for a physician to do. A newly minted NP can find a job, usually in the $60-$80k range, work far fewer hours than the resident, and now in many states strike out on his own.

Now, one might think that it is strange for so many highly educated people to allow themselves to be pushed into such low paying jobs for such a long period of time. The fact is, that until recently, residency was almost universally considered to be training, an extension of schooling. The slow evolution of residency requirements meant that most physicians began to view it as a natural extension of the medical school training process. The idea of doing it a different way (which is now done by NPs as well as being done by the MDs of old) was just not on the radar screen at that time. NPs and PAs are a relatively new invention, and MDs were all being forced into residency. Most people viewed residents as highly autonomous students. Today however, the scenario looks a little bit more like this:
If it is in the best interest of the program to call the resident a student, he is a student. If it is in the best interest of the program to call him an employee, he is an employee. Similarly, residents are often, at least perceived, to be exempted from most federal labor protections, because they are considered students. The IRS however, will happily collect FICA from the resident as an employee, without the exemption given to students. Similarly, the legal system will view the resident as a liable practicioner in the realm of malpractice. The program however, will usually not allow the resident final judgement over actions for which he is liable. This is of course, because the legal system, which sees the resident as liable, also sees that attending physician as liable. Basically, whichever term is worse for the resident will be the one applied in any given situation. Oddly, the resident now has far less autonomy than he did when everyone thought he was a student.

To add insult to injury, government payment programs, which have now taken over nearly 50% of medical payments and set all sorts of arbitrary standards that have been adopted by almost all private third party payers, will not usuall reimburse physicians who have not completed a residency. Furthermore, the ususally have to become boarded in a specialty that is considered to be related to any particular medical activity for which they hope to receive compensation. Thus, the option of completing only the internship (or first year of residency) becomes a practical impossibility for most students, forcing them to complete the training. Furthermore, current malpractice law holds most physicians to the "standards of the community," which is a doctrine that often demands the same competence from non-specialists that can be seen with specialists. This essentially prevents a non-boarded physician from trying to sell his somewhat lower level of training for a lower price, because his risk is too high, and malpractice insurers will often not cover his performance of most medical activites for which a specialty exists in the area.

So you might be asking, "do you think that residency should exist at all?" You'd be surprised to hear that my answer is yes. This is an issue of force and supply and demand. My problem is with the former interfering with the later. I'll address the impact of government payers and board certification on the supply and demand associated with post-graduate medical training in my next post.

The Economics of Residency Part I: The Basics of Residency

2007-03-24T20:14:00.000-05:00

One of the first things that you hear about in medical school is the match. This life altering event, which the majority of incoming medical students have never even heard of, is the catalyst for thousands of newly minted physicians relocating to various corners of the country in order to train in their respective specialties. For those of you who are unfamiliar with the modern medical training system, candidates will interview at a number of different training programs across the country. After hearing about this process constantly for the first three years of medical school, every student will actively participate in the fourth and final year of school. After all of the interviews, the programs and interviews rank each other by order of overall preferance and the information is fed into a computer. The computer then determines who goes where. These training programs are called residencies, and the new physicians, soon to be called residents, will find themselves obligated to work with an annual contract.

Before I continue this post, I am going to add a disclaimer. I am not a resident. I probably will be one day, but I am currently just a medical student. After speaking to many people who are in various stages of training, I feel that I have gotten a pretty significant grasp on the whole process. I have friends who are going through the different stages as we speak. However, I am fully willing to accept any criticisms over my perception. This first post is primarily for background, and we will get to money in part II.

Residency training can be a vastly different experience for the different specialties. The internship year can mean anything from a 40-45 hour week with most weekends off to brutal weeks of 80+ hours with persistent sleep deprivation and 30+ hour shifts. Surgical specialties tend to have the worst hours of all. Currently, residencies are restricted from working their residents for than 80 hours a week, though some programs have managed to attain an exemption that carries this out to 88. Everyone doesn't play by the rules, and different programs have different degrees of compliance with this requirement. There is also a 30 hour shift time limit, that is also followed to varying degrees. Depending on specialty, residency training can also vary from 3-7 years in length.

The concept of residency originally came from an academic program at John Hopkins University. A few bright and single medical students would upon graduation, with academic ambition, actually live in the hospital in exchange for room and board. They were then exposed to highly varied pathology, and they covered the floors of the hospital as physicians. This old world hospital was essentially a boarding house for the sick who had no family to take care of them. The hours were long, but the pace was slow. The residents were give a half day off each week, and they still managed to, with a 156 hour work week, get enough sleep to be compatable with life. They had no family to speak of, due to the requirement of being single, and the length of training was only 1-2 years. Residency had NOTHING to do with medical licensing, there were no board certifications, and this relatively short sacrifice was almost a sure ticket to a prestigious career.

In time, an internship became required in order to even qualify for a state medical license. This was 1-2 years, which was no longer sufficient to qualify as a residency. In many states, this is still all that this required for licensure, though some states now require a full three years, consistent with the shortest of modern residency programs. That being said, just doing an internship and then practicing is almost unheard of these days. Most of these physicians are relegated to low level positions, with minimal chances for better pay, promotions, status positions, or partnerships.

Of course, this whole process is strange. What other occupation requires years of formal training after the schooling process in order to procure a license? Even in professions in which such training is possible, it is certainly not required for even the highest levels of private practice achievement. Lawyers finish three years of law school and learn on the job or engage in a trial by fire by striking out on their own. There is a similar process for engineers, architects, journalists, and everyone else. Sometimes a one year internship is built into the actual schooling process, but there is certainly nothing even remotely close to what exists in medicine. Why is medicine different? Stay tuned to find out.

Organ Transplantation: How to Bankrupt the Medical System

2007-03-18T14:31:00.000-05:00

Perhaps one of the most amazing things that we have accomplished in modern medicine is being able to remove an organ from a living or recently deceased human being and put it into another human being while allowing it to retain its essential level of function. Organ transplantation is a tribute to the genius of many hardworking men and women whose understanding of human anatomy, physiology, and function is so vast, that they have managed to save countless lives from the supposedly inevitable conclusion of poor lifestyle choices, infectious disease, or congenital defect. However, there is a dark side. I feel that I would be remiss if I didn't talk about the economic consequences of organ transplantation.

In the US, kidney transplantation costs about $100,000. Heart Transplantation can approach close to $1,000,000. These are astronomical costs. Also, many people with fatal conditions sit in highly expensive ICUs in sedated or non-functional states only to have no organs emerge in time and die after using huge amounts of resources. Waiting lists continue to grow, and donation is relatively flat.

I guess the first question that should be asked is, "How can we procure enough organs from donors in order to prevent these long ICU stays?" I think that the answer is simple. Let people pay for organs. Far from the astronomical prices that often come up on the black market, I'll bet that you could solve the entire organ shortage by letting people cover the funeral costs of an already deceased individual in exchange for their organs. In the face of the costs that I mentioned before, this would barely be a blip on the economic radar. It would also overturn this bizarre notion that because organ transplantation saves lives, we should ignore all economic laws of supply and demand when trying to procure organs. Anyone with a decent high school education who has seen a supply and demand curve can tell you that a shortage of a product on the market is probably the result of the price being set too low (in this case $0). At higher prices, there would be more donors.

Now, on the flip side of this, what would all of these donations cost? Because of the socialized and cost spreading nature of modern medicine, these costs would be directly (or indirectly) born by everyone. We'll start with kidneys. I recall reading that there are about 90,000 on the renal transplant waiting list. At ~$100,000 a pop, this would be a cost of about $9 billion in renal transplants alone, neglecting the cost of rejection, medication, lifelong immunosuppression, future hospitalizations, and the cost of training enough extra surgeons to cover 90,000 transplants. An ever aging population would insure that a steady supply of need would follow, and that the list would grow again in no time, causing a steady need for the expenditure. I realize that there would be savings in dialysis costs, but the longer life expectancy of the patients with the transplanted organs may offset those savings with increased need for medical care. Now, apply this to everything from cornea transplants to heart transplants, and the costs will easily soar. If we gave a conservative estimate of close to $50 billion for ALL additional organ transplants, while still ignoring the costs that come afterward, we will increase, almost perpetually, total costs by an amount that is equivalent to almost 2% of the ENTIRE FEDERAL BUDGET. It would be a MUCH HIGHER percentage of medical expenditure going to relatively few people at very high cost per person.

Now, I am not opposed to organ transplants. I believe that people should be able to pay for them like anything else. I believe that people should be able to get insurance to cover them like anything else, though I have no problem with different policies for those who want to be covered and those who don't want to pay the price of the expensive risk coverage. However, we shouldn't turn a blind eye to how the world of unreciprocated giving that so many see is the ideal is the reason for our shortages. We also shouldn't be afraid to point out that within the current system, the shortages are the only reason that we haven't gone bankrupt.

Medical Licensing: Quackery, Financing, and Mixed Market Economics - Part IV: Private Quality Control

2007-02-18T16:05:00.000-05:00

So here it is, the big finale.

As we've already discussed, the current licensing system in medicine creates all sorts of market distortions, limits access to care, and in many cases hurts the legitimate practicioners of medicine in favor of the snake oil salesman. The nagging question, which I know that you are all dying to know the answer to, is "how will we control the quality of medical practice?" This is a rather complex question, with a rather simple solution. The answer is that we should not try and control it at all in classic public police sense. What we should do is open up avenues of information.

Consumer Reports is a popular magazine that features all sorts of quality indicators regarding products in the marketplace. For a very modest sum, any American can gain access to this invaluable information. I can read consumer reports, make my own assesments of accuracy, and make my own cost-benefit analysis. If I'm still not satisfied, I can go to hundreds of different consumer web sites and find out more information. There is essentially no reason why a similar system couldn't be created in medicine.

High level medical practicioners had a basic monopoly in healthcare practice for many years. This didn't hurt many people, because they often cared for those that fell below their fees at a reduced rate. People felt no real reason to try and contain costs. Now however, all sorts of alternative practicioners have already entered the market. They've just done so with varying amounts of training and licensing requirements of their own. In an era of multi-level medical practice, we should question to what degree the license should be required at all.

On another level, the strict licensing system in the US probably gives people false hope in the quality of the care they receive. In the era of a purely physician run healthcare model this may have had SOME merit. Now however, many people treat all medical licenses, when receiving treatment, as though they came from an MD. Many people do not know the difference between providers, and the trust that we are conditioned to put into our physicians has been extended to all sorts of licensed and unlicensed medical practicioners.

I believe in physician training, and I don't believe that it is going anywhere soon. Current certification requirements in practice have already come into existance essentially out of the private market, with insurance companies and hospitals refusing to hire physicians to perform tasks for which they are not residency trained. One could argue that this level of quality control has essentially overshadowed the need for government meddling. With good quality indicators in place, determined preferably by people who actually work in healthcare, we will be able to evaluate the quality of work done at a center. This is a far better system for a patient than purely using the number of letters after a name. Let the centers compete for the letters in order to improve their quality. Informed individuals will then be able to balance quality versus cost in a private system. This is better than some medicare beauracrat determining some kind of "quality control indicator," for "licensed providers," in order to determine "efficient use of public resources."

In conclusion, many alternative practicioners already exist in medicine. The medical licensing system now does not keep out quacks and snake oil salesmen. Modern medical licensing also gives licenses to individuals with all sorts of variation in training as well. This system is progressively hurting the qualified practicioners in the name of those who are less qualified because of its requirements. With the abolition of specific licensing procedures, private sources of information could step in to fill the void in quality control. Rather than mandating a specific quality, information could be used in order to allow the individual to perform his own assesment of the cost and benefit of a medical treatment or provider. Some of this quality control already exists on top of the government licensing, though it disproportionately impacts legitimate practioners. By removing the government and politics from quality control, the market will be free to determine the amount of control necessary to impart quality healthcare.

Medical Licensing: Quackery, Financing, and Mixed Market Economics - Part III: More Quality Questions

2007-01-30T20:48:00.000-05:00

Of course, the world of healthcare isn't limited to licensed practicioners. Health is such a broad and all encompassing topic, that it is genuinely impossible to put healthcare within specific demarcations that exclude all but the trained practicioner. The obvious, but often overlooked, follow-up question to, "should we have a medical licensing system?" is, "What particular rights should be given to licensed practicioners that unlicensed practicioners shouldn't have?" It's less obvious than it seems.

Everytime a personal trainer gives advice on an exercise program or diet, he is dispensing medical advice. Of course, no one thinks that this sort of advice should be the specific domain of medical doctors. There is no specific licensing requirement for dispensing this sort of advice. However, with the modern focus on preventative medicine, one could argue that good advice in this department can do more long term for a patients health than anything that is routinely done in most medical practices.

Many people are also now spending billions of dollars on all sorts of salves and potions that can be purchased from alternative practicioners. In fact, I can walk into a GNC outlet, and buy vitamins that are supposed to cure everything from arthritis to prostatic hyperplasia from a pimply faced kid named Marco who makes seven bucks an hour. In spite of medical licensing, these industries have flourished, and all attempts to control them only seem to bring a public outcry and more popularity.

What I find the most interesting about this scenario, is that the majority of the unregulated practicioners operate under scientific evidence that is "questionable." Some people swear by these remedies, and others see no tangible benefit. What the current system has done however, is put the most qualified practicioners at a significant disadvantage in the medical market place. I can sell healing pelts from Nakaraka the Beaver god on the internet with minimal intervention. If the government bothers to shut me down, I'll just change my website and sell "new" pelts from Ukbaba the Beaver god's even more healing power endowed brother. I don't have to worry about regulations, license maintenance, or even accuracy in my claims. In fact, the only thing that would likely happen to me is losing my medical license. Someone who didn't actually have training would have almost nothing to lose in the above scenario.

Contrast this to the doctor who cannot operate his practice like a business, cannot operate without a license, has to see patients who won't pay under EMTALA, and always lives under threat of lawsuits. He is SEVERELY disadvantaged. Terms like "usual and customary fees," or "medical malpractice," do not apply to the dissemination of healing beaver pelts. Marco, the GNC employee, doesn't fear malpractice suits if his special vitamin mixture fails to heal my aching joints. The legitimate doctor is the only one who deals with most of the beauracracy. On top of all of this, he is also subject to ever increasing training periods, through which certification is increasingly required to collect from the government, which unthankully frees people from their money in the form of FICA and then sets all sorts of arbitrary guidelines on doling it back out for services utilized by the same people from whom the money was taken in the first place.

Is it really a surprise then, that in the face of the medical crisis, alternative medical practicioners are flourishing? A trained physician might legitimately argue that the quacks have an easier time getting to the people than he does. Marco's company can use the full weight of the market in both distribution and advertising to sell vitamins, while the physician is constantly compromised in his ability to give care and let people know that he has care to give.

So what are the obvious questions? Shouldn't the government regulate these other practicioners more? I don't think that it can be done. Snake oil salesman are always willing to move underground, and they are too numerous to just eliminate. The black market tends to grow by a rate similar to the rate of disappearance from the open market by regulatory decree. Also, this alternative market is the only way to get legitimate therapy out in some cases. With the FDA stranglehold in just about everything in medicine, there has to be some way to get some therapy onto the market that was created by people who angered some beauracrat.

But what about the quality of doctors? Even with the proliferation of practice rights among less trained individuals, the physician's license still implies a certain amount of training. People should have that knowledge when seeking a practicioner, right? Maybe so, but this doesn't necessarily require a license.

Stay tuned for the conclusion.

Medical Licensing: Quackery, Financing, and Mixed Market Economics - Part II: The Midlevel Proliferation

2007-01-29T21:47:00.000-05:00

As I mentioned in my last post, quality has become the major reason for the preservation of medical licensing. According to this logic, we have placed a medical license at the end of a nine year slog of servitude that exists in order to ensure the quality of the providers. However, physicians are not the only providers. Ignoring everything from chiropracters to naturopaths, who all have their own alphabet soup of practice scopes and licensing authorities, I am going to focus on midlevels. The same thing can be said about many of these other practicioners that I will say about midlevels, but they are the model that proves the point most effectively.

I am going to preface this by saying that I am NOT anti-midlevel. On the contrary, I believe that midlevels may end up being part of the solution to affordable healthcare in some places. However, their existance proves a point.

There is no longer a mandatory nine year training period in pursuit of a medical license. A physicians assistant (PA) can be trained in just three. A nurse practicioner (NP) can also be trained in just three. Variations in state law place these practicioners in positions varying from bound service to MD or DO practicioners to virtual independent practice. Unlike those who seek the traditional medical degree, NPs and PAs are supposed to "learn on the job." This is the understood function of their license.

Anyone who works with these practicioners can tell you that there is VAST variation in both knowledge and skill. There are some midlevels that have advanced to a position where they are perfectly capable (and comfortable) with independent practice in a certain field of medicine. Others are not. New PAs and NPs have spent fewer hours in a hospital than a fourth year medical student.

So what is my point? Getting a license as a midlevel DOES NOT even pretend to imply competence. This doesn't mean that all midlevels are incompetent. In fact, the license means nothing at all, save for the completion of some classroom and clinical work that the same governments and licensing authorities said was inadequate for the granting of a medical license. Some midlevels will then learn with the license and become competent, and some will not. Some will learn to a level where they can operate only under supervision, and some will learn to a point where they can operate alone in many cases. The license is nothing but a tax. Of course, tuition at PA and MSN programs has soared in recent years, as the gatekeepers to the licensing monopoly have gained power to stand between the PA or NP and the clinical training that is supposed to make them competent "on the job."

Recent proposals in government for containing healthcare costs have included expanded practice rights for midlevels in states from Ohio to California. These governments are creating a dual system, in which the two different medical licenses with vastly different training requirements are progressively leading to similar scopes of practice. These governments are giving up the "quality" mandate in exchange for cheaper service. If the government can do this, why can't private individuals choose to do the same thing? If preparation for independent practice isn't a requirement for a medical license, should a license exist at all?

Stay tuned for part III

Medical Licensing: Quackery, Financing, and Mixed Market Economics - Part I: Background

2007-01-23T08:43:00.000-05:00

Medical licensing was the sort of thing that I never gave a lot of thought to as I was growing up. Licensing in many professions is so ingrained into our psyche, that we never even question the process. During my first year of medical school, I had a class on "physician authority in society," and mixed with what I knew from beforehand, the information started to make sense.

A licensing requirement is a powerful thing. It gives those that are licensed a distinct market advantage, if not a complete monopoly. The more stringent the requirements for licensure, the more exclusive a monopoly that develops, atleast initially.

There is no more complicated licensing process in this country than that required to practice medicine. There are five years of MANDATORY training, in the form of medical school and an internship year, plus four distinct licensing exams (Step I, Step II and Step II CS, and Step III). Some states have now expanded licensing periods to six or even seven years, requiring more years of post-graduate training. On top of all of this, governments have given a set of schools (specifically those offering MD or DO degrees) a monopoly on the intial training required for licensure. This monopoly on healthcare training has created all sorts of soft requirements that many people have to complete in order to obtain a license. These include, but are not limited to, a bachelors degree, a reasonable MCAT score, community service, a reasonable GPA at an undergraduate institution, clinical shadowing experience, and many more. Thus, the AVERAGE newly licensed physician will now have:
A bachelors degree with a GPA over 3.7, an MCAT score of around 30, multiple years of community service and shadowing experience, four years of medical school, one to three years of graduate medical education in the form of residency, and a passing score on ALL of the step exams.

Though there are some exceptions to some of the soft requirements, this makes the defacto licensing process a minimum 9 year ordeal for most people. The special monopolies given to both medical schools and residency programs have also caused tuition to go up, while keeping training salaries low. This means that the nine years usually comes with significant debt, which can be anywhere from $100-$400k if you aren't a trust fund baby. Needless to say, this is an exclusive group, and the medical training monopoly has succeeded in producing a limited supply of healthcare providers for many years, who until recently, had almost absolute power over the treatment of everything from malignant melanoma to allergic rhinitis. I won't even go into the special district monopolies given to hospitals, allowing them to avoid competition and keep prices high.

One would think that this would make being a physician a very lucrative position, admittedly at the expense of people who actually need treatment. For many years, this is exactly what happenend, and the bottom of the barrel medical school graduates (the ones who you wouldn't let babysit your dog) were able to obtain very large salaries, even at very low acuity practices.

This of course brings us to an obvious question: Why should a licensing process exist? Well, the intial purpose of licensure was taxation. Before the early 1900s, a medical license could be purchased by anyone, and anyone could open a medical school. The license was just a way for the government to tax anyone who claimed to be a doctor, as they would have to pay a licensing fee. Thanks to some special maneuvering on the part of the early AMA, and AMA backed Flexner Report, the medical license suddenly became the exclusive domain of graduates of specific "qualified" academic institutions in the early part of the 20th century. Qualified in this case was a reference to looking a lot like John Hopkins Medical School. The creation of the medical license coincided with breakthroughs in technology all over the country, and the new academic medical monopoly also had breakthroughs. This was also about the earliest time that physicians actually started to have a clue as to what they were doing.

Thus, the rallying cry in support of licensure became quality control. This is only of the reasons why government mandates licensing in professions, but it became the most logical to ascribe to medicine. There is some truth to it as well, it is nearly impossible to get through the nine year training period without having some clue. I've seen it done, but it takes a special sort of person. For the most part, everyone who completes the nine year training process is perfectly qualified to deal with most common medical issues. So this is a good thing right?

A fundamental question was never asked: Is there an easier way? So we can promise a quality of education after nine years. What about eight years? How about seven? The thing is, that current medical training is VERY expensive, and the practicioners that it produces are likewise VERY expensive, as we would expect a limited supply of heavily indebted, highly educated people to be. Without a free market operating in medical training and licensing, there is no competition to create more efficient training.

Atleast we maintain quality in healthcare delivery by training physicians with the current system, right? Not so fast. Stay tuned for part 2.

A Libertarian in a Collectivist World: What do you see in the Future of Medicine?

2007-01-18T17:49:00.000-05:00

The purpose of this thread is not to start a debate. In this case, I'm looking for people who think a little bit more like me. I'm trying to determine exactly what people think about the future of healthcare delivery in this country. What do you think things will be like in 10, 20, 50 years?

It's sometimes difficult for me, when I think about my position. Here I am, a medical student, severly in debt, and staring at a future that is uncertain for sure. With a country that has allowed the pendulum to swing back in favor of a Universal Healthcare Model, I often feel that I am moments away from being completely at the mercy of parasites in Washington masquerading as crusaders of public good. With the steps first taken in Massachussetts, followed by those which are currently being proposed in California, the country is definitely heading in the direction of Universal Healthcare. Furthermore, with the abysmal approval ratings of the current president, it almost seems that healthcare monsters who manifest themselves in the forms of Hillary Clinton and John Edwards, might actually find themselves electable. We are really being set up for the perfect storm.

So what comes next? Sometimes it seems that we will be forever forced into mediocrity. Our government will sell rationing as a social good, all while ignoring the very laws of scarcity that make the rationing necessary in the creation of policy.

Of course, failure of the US healthcare system could cause a chain reaction that brings down much of the advancement in Healthcare delivery. If the government does successfully bring the whole system under its thumb, it will be the death of the last genuine vestiges of healthcare capitalism in the Western World. Will we see innovation grind to a halt? Will we fall into a dark age reminiscent of Atlas Shrugged, where the intellectual doctor is replaced by a rule following automiton?

Maybe we'll witness a power shift toward the developing world. Some desperate third world country might just develope the will to let its healthcare system operate unhampered. Perhaps they'll see a surge in medical tourism, as the American universal healthcare racket fails to convince the most productive members of society that it has much to offer them.

Maybe we'll just evolve into a two tier system, trucking along the way that we always seem to, with a cash system that buys quality healthcare for its members and a universal system that survives by robbing money and ideas from the cash system. Degradation in quality for the masses will be slow, reflecting a shift that damages quality in the name of access. People will continue to scream at the politicians that the two tiers are unfair, but our great leaders will have to keep the upper tier alive in order to use its services and suck its blood.

Who knows? What do you think?

New Posts

2007-01-13T18:16:00.000-05:00

After many people have come by and browsed this blog, we have finally begun a constructive debate in the comments section of the previous post. I want to keep an open, civil dialogue at all times. Anyone who wishes to post may. Do not take any disagreements I make with your posts personally, and I will happily publish any other articles or thoughts on this blog that argue other sides of this debate from my own.

As soon as I get some more time, I'll add some more posts.

Thanks Everyone.

The Right to Life vs. The Right to Healthcare: How are They Not the Same?

2006-10-21T11:27:00.000-05:00

The right to life is part of a broader spectrum of deep-seeded belief that is highly prevalent in western thinking. The origins of this idea can be traced back atleast as far as John Locke, who wrote that all men are given the right to "Life, Liberty, and Property." Locke, an Englishman whose writings go back the mid 1600s, believed that government existed by a social contract based on these rights.

Later, Thomas Jefferson wrote about "Life, Liberty, and The Pursuit of Happiness," in The Declaration of Independence. This was a throwback to Jefferson's Lockean philisophical underpinnings. Jefferson argued that men are "endowed by their creator," with these rights. In effect, these rights cannot be argued away because they are given by God. However, it is apparent by the number of athiests who still believe in these rights that belief in God is not necessary to believe in these natural rights. The text of the Declaration of Independence effectively bases the entire existence of the USA on the right of a people to overthrow a government that does not respect the natural rights first proposed by John Locke.

Though there were doctors in the 1700s, they were sometimes rare and usually relatively ineffective. In fact, many men would have lived were it not for the actions of their doctors, giving them toxic compounds or bleading them to death. The right to life, even at the founding of the United States in 1776, had nothing to do with healthcare. It also had nothing to do with welfare. There were no accompanying proposals to provide every American with free healthcare in the 1700s. No such proposals were ever seriously made until the 1900s. Obviously, no one who was involved in the making of early American philosophy or law saw the right to life as being in anyway connected to a right to medical treatment.

I have heard it argued by many people that the right to life encompasses all sorts of things. It is used as a justification for almost anything. A person needs shelter to live, a person needs food, some people need healthcare, and I've even heard it argued that the right to life means a low stress life because stress can kill you over time. Of course, none of these things have anything to do with what Locke or Jefferson meant. Obviously no one lives forever, and this was never meant to be an argument that no one should ever die. Life, liberty, and property (or the pursuit of happiness) exist without any action. A man who is left alone in a forest or on a deserted island has all of these things. He is alive, he has the liberty to do as he pleases, and whatever property he takes or manipulates is his (be it a stick, a house he builds, a fishing pole, or anything else). This man also has the the right to pursue happiness, as he will inevitably attempt to do things that bring him pleasure over those that do not.

The Lockean (and later Jeffersonian) rights are all negative rights. They exist in a vacuum. Everyone has them unless they are taken away. This stands in contrast to positive rights that have to be taken from someone else. In fact, attempting to give someone positive rights usually infringes on the negative rights of someone else.

Let's think for a second about the majority of the new "rights" that the United Nations and many individual countries have attempted to confer upon all of humanity. These include things like healthcare and a "living wage." These things violate the negative rights of others. Because healthcare doesn't exist naturally, it must be created. To confer healthcare as a positive right, it must be confiscated. For example, in Canada, a physician must work for the pay of the government insurance. He has lost his liberty to work for himself. He has lost his right to pursue happiness if he believes that operating a private pay healthcare enterprise will make him happy. Without interference, he has all of these things. The government has taken his natural rights away in order to confer an unnatural right on to whoever is receiving the care. The government also pays for this with taxes, which are confiscated property. For those that did not want to pay these taxes, they have lost the right to property. Similarly, the "living wage" must be taken from someone in order to be received by the worker. The employer loses his right to property and liberty.

Thus, the right to life doesn't equal the right to healthcare. Life is mostly infinite in the sense that it can exist without outside action, while healthcare is scarce. One has a natural life. It may be artificially extended or benefited in quality by healthcare, but this is not what is referred to by Locke or Jefferson as a natural right. Healthcare, like any othe commodity, responds to scarcity. It doesn't exist unless it is created, and creating more healthcare costs more human energy (and thus more money). Like all things which are scarce, its creation and distribution will be infinitely more efficient on a free market.

Is it Worth It?

2006-08-30T19:42:00.000-05:00

Spending to death: How much is living worth?
Costly new cancer drugs and heart pumps bring wrenching choices
The Associated Press

Updated: 9:46 a.m. ET Aug 13, 2006

Dying of lung cancer, Carolyn Hobbs tried a new biotechnology drug that produced an unanticipated side effect: acute sticker shock.

She was waiting for her second treatment in a hospital near Denver less than two years ago, when someone from the business office marched in to warn that her share would cost more than $18,000, since the drug wasn’t insured for her type of cancer.

How to decide?

In her six decades, she had shared in a long marriage, raised three children, worked in a nursing home, painted as a hobby — and wasn’t ready to leave it all behind. But she was also a careful spender who sometimes returned new clothes to the store, deciding she didn’t really need them.

Maybe this new drug, Erbitux, could extend her life by a small fraction, but she wouldn’t be cured. “She was just very frugal, and she said it wasn’t worth it,” her husband Larry remembers.

So she refused the treatment.

More patients are confronting this wrenching decision, as the latest generation of pricier cancer drugs and heart implants stretches out the final months of advanced disease. Is the chance for several more months of life — maybe a year or more with luck — precious enough to spend a small fortune? This dilemma is also challenging governments, employers and insurers, who all help finance America’s longer life spans and innovative technologies.

Care or research?
Extraordinary care for dying patients can make for inspiring medicine, but its extraordinary costs make it an increasingly debated choice to promote public health. Many economists, doctors, and ethicists say this care too often buys too little for too much — and that its expanding share of medical resources might better pay for screening and treating diseases in earlier stages.

Already, up to 30 percent of annual payments by federal Medicare insurance go to the 5 percent of members in their last year of life, research shows.

“People still have an underlying belief that there’s an infinite amount of resources that can be invested in health care,” says Dr. Harlan Krumholz, a Yale University heart specialist who studies quality of care. “But I think we’re coming to a realization that we’re going to need to confront these issues explicitly.”

Maybe so, but any retreat from last-resort care still raises objections from many patients, doctors and medical companies. They denounce “rationing” of care and defend expensive treatments for the dying as a moral imperative.

A costly chance at life
Within the last decade, an array of expensive new treatments has given some patients their first real fighting chance against common diseases once routinely called “terminal.” These treatments include:
# Cancer drugs manufactured in living cells, instead of beakers. These biotech drugs target just diseased tissue, unlike chemotherapy. Thanks to these drugs, some late-stage colon and blood cancers are no longer hopeless.
# Implants that help the heart pump blood. These devices — the most common is the left-ventricular assist — are heir to decades of research in artificial heart technology. They provide an option for some patients with failing hearts.

Some of these therapies, like the biotech drug Gleevec for leukemia or implanted defibrillators for some heart problems, work wonders in many patients. The trouble with many treatments, though, is that average patients gain only several more months of life, studies have found. A lucky few may survive for years, so many seek treatment in the hope of beating the odds.

“Very few people, when told of a potential life-saving intervention, will not be willing to listen. So the question is now not whether it will help or not, but who pays?” says Dr. A. Mark Fendrick, at the University of Michigan.

Whoever pays, costs are up. This care costs several times more than the older treatments it supplements or replaces. A last-resort cancer drug can cost up to $50,000 a year — if patients survive that long — with insurance typically picking up at least two-thirds. A mechanical heart pump can cost more than $200,000, with hospital care.

Death as a personal choice
Reports of these breakthroughs, which often fail to mention the price, may have intensified the distinctly American tendency to view death almost as a personal choice, suggest doctors and ethicists.

“I have two small children, and dying right now is not an option,” colon cancer patient Rebecca Dague, of Medina, Ohio, said recently.

Faced with such a disease, more than a third of Americans now would want “everything possible” done to save their lives, up from just over a fifth in 1990, according to a poll by the Pew Research Center for the People and the Press.

For many on the brink of death, the choice of desperate measures is hardly a choice at all.

“It’s better to pay the money than sleeping with the worms,” said Jake Rogers, 62, of Chicago, of his implanted left-ventricular assist device. His doctors implanted a second one in June, when his first wore out after 15 months.

From their first day of medical school, doctors are trained to do their utmost for patients like Rogers. “I think probably there’s more tolerance for high cost at the end of life, when all the options have been exhausted,” says cost analyst Milton Weinstein, at the Harvard School of Public Health. “I think there’s a moral force that causes us to want to do anything we can, irrespective of the cost.”

Huge insurance payouts
While doctors advocate for the interest of dying patients, they may also be subtly swayed by earning their livings partly from providing this care. And many patients don’t fret, because they are insulated from huge payouts by insurance.

Robert Graham, 73, of East Brandywine, Pa., chuckled when he heard the high price — up to $250,000 — of heart pumps like the one implanted in him last November. It was covered by insurance.

“I got to live a long time to be worth that!” he said. Yet the average patient in the best medical test so far lived less than nine more months.

Federal safety regulators do not regulate the price of end-of-life treatments. They evaluate only if drugs or devices work, not how well they work for their prices.

Medicare, which insures about 80 percent of dying Americans, makes no acknowledged evaluation of cost in deciding what to cover. It is not allowed to negotiate for lower drug prices. Its coverage umbrella sets a standard for private insurers.

Under such pressures, the $1.9 trillion spent on U.S. health care in 2004 will balloon to $4 trillion by 2015, federal forecasters project. In that year, health spending, which claimed 16 percent of the economy in 2004, would consume 20 percent and cost the average American $12,400.

Some believe the country can afford to spend even more — and that it’s worth it. Others fear a crash, with insurance perhaps turning into a luxury item. Nearly everyone, though, agrees there’s an upper limit somewhere on the horizon.

“So far, we’ve given everything to everybody,” says economist Lester Thurow of the Massachusetts Institute of Technology. “We haven’t made the tough choices yet.”

Hard choices
Yet choices are being made every day, case by case.

Some insurers refuse to cover a treatment. Doctors send patients home to die, sometimes out of mercy. Some patients say enough is enough.

Dr. David Johnson, at Nashville’s Vanderbilt-Ingram Cancer Center in Tennessee, pitched Erbitux to his brother-in-law, a 57-year-old married truck driver with advanced colon cancer. However, the drug has barely been proven to extend average survival at all.

The doctor remembers his brother-in-law refusing and saying: “Are you stupid? I’m not giving up my limited resources.”

The drug’s marketer, Bristol-Myers Squibb, did not reply to repeated requests for comment.

Insurance's subtle controls
Employers and insurers are discreetly controlling costs through premiums, deductibles, co-payments, caps, and even outright exclusions. “Benefit costs would go through the roof if there were no considerations given to the costs,” says Karen Ignagni, president of the trade group America’s Health Insurance Plans.

Despite official denials, the federal Medicare program makes subtle cost evaluations, says Dr. William Maisel, a Boston heart specialist who chairs a federal committee on cardiac devices. “I think they are concerned about people using the term ‘rationing’ or ‘withholding therapies,”’ says Maisel, at Beth Israel Deaconess Medical Center.

One way to control costs, without saying “no,” is to keep reimbursements low. For example, Medicare’s $140,000 reimbursement last year for heart pumps is widely acknowledged as below-market.

“We can’t say, ‘No,’ explicitly. We say, ‘Yes, but,”’ explains Peter Neumann, who runs a Tufts University center on medical cost-effectiveness in Boston.

Yes, but start with a cheaper drug, get prior authorization, or make a bigger co-payment.

Or, for the 45 million uninsured: Yes, but go to the emergency room and rely on charity for extended care. The nonprofit Patient Advocate Foundation reports that nearly half of its cases or requests for help involved co-payments last year, up from just 5 percent in 2002.

“If you’ve got a thick wallet or a full purse, you can get any care you want. If you don’t, there’s rationing for you,” says former U.S. Health Secretary Joseph Califano, who later dealt with escalating health costs as a board member at Chrysler Corp.

“We’re going to have to think very hard about how to provide some of these truly exotic treatments,” he adds.

Calculated decisions
Many now press for more systematic thinking about cost controls applied by insurers, hospitals, and policy makers. They say medical guidelines should more strongly steer older, sicker patients — and other inappropriate candidates — away from the most expensive treatments.

Cost-effectiveness analyses should be applied, they say. One common approach calculates the cost of a treatment for each year of life it saves. Many health economists view $50,000-to-$100,000 as a reasonable upper limit for what public and private insurers should pay.

Such calculations include adjustments for lost quality of life. For example, a heart pump is clearly less valuable if it puts a patient in the hospital for three of his last five months with a miserable infection.

Heart pumps were first used as a temporary bridge to a heart transplant and only approved as regular implants in 2003. About 1,000 were implanted last year, but the ultimate annual market is estimated in the tens of thousands. Yet an analysis last year put their cost-effectiveness at between $500,000 and $1.4 million per year.

Even one of their pioneers, Dr. Eric Rose at Columbia University, concedes that would make their value “more than challengeable,” but he expects improvements.

“It’s hard for me to justify in a society that’s falling short in basic health care,” adds heart doctor Steven Nissen, at the Cleveland Clinic, a federal adviser who voted against expanding use of heart pumps beyond patients waiting for a transplant.

Dr. Barry Straube, who heads the Medicare unit that decides what to cover, believes “it would be helpful in setting priorities when we have limited budgets to look at cost-effectiveness.”

$20,000 buys five months of life
Take also the example of the new biotech drug Avastin, which treats colon cancer for about $4,400 a month. Effectiveness? It is proven to extend average life by up to five months. In a survey this year, only one-fourth of 139 cancer doctors felt that represents “good value.”

Genentech, which makes Avastin, believes its drug prices provide reasonable value to patients and powerful financial motivation in-house to improve treatments for a terrible disease, says Walter Moore, a company vice president. However, he says Genentech may impose its own lifetime cap on a patient’s charges for Avastin.

For now, many hospitals partner with drug companies to treat dying patients for free, especially in the early stages of testing. Dr. Roy Herbst, at the M.D. Anderson Cancer Center in Houston, says the price of biotech drugs has forced the subject of cost into his discussions with colleagues for the first time.

“If we lost $30 million a year on Avastin, those are things that couldn’t go into research and support programs,” he says.

Others, too, question the current priorities of U.S. medicine.

“We’ve prioritized end-of-life care as more important than preventive care or chronic care,” says Dr. John Santa, medical director for the Center for Evidence-based Policy in Portland, Ore.

Doctors, says University of Pennsylvania heart surgeon Dr. Michael Acker, should keep away from “high-tech, expensive technology just to postpone the inevitable.”

“In the highest-benefit patient, you don’t get that much benefit, and it costs a lot,” adds Alan Garber, a Stanford University doctor and economist who chairs a Medicare coverage advisory panel and questions the value of both heart pumps and Erbitux.

Carolyn Hobbs’ husband disagrees, at least in her case.

Though she initially refused Erbitux because of cost, she ultimately arranged to get that drug and three other biotech drugs for free, with help from her doctor, hospital, Medicare and the drug industry. Her husband says she managed to keep a reasonable quality of life, even through most of her final months.

She died in November. To this day, her husband isn’t quite sure how much was spent.
© 2006 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

URL: http://www.msnbc.msn.com/id/14235415/

Social Justice- The Last Post of the Day

2006-08-30T14:55:00.000-05:00

I am a regular at studentdoctor.net. Today, I spent a great deal of time at that site, as well as working on this blog, because I am off of school due to a hurricane that never arrived, and I don't have a whole lot of work to do before Labor Day Weekend. Anyway, during what has become a rather lengthy debate on that site regarding Walmart, health insurance, government oversight, and walk in clinics, I was accused of not leaving room for social justice in a capitalist system. This got me wondering, what is socal justice?

I think that I will break social justice down into two categories, though I am not necessarily a big believer in the concept. These are two definitions that are used: 1. Social Justice is an obligation given to society to provide the greatest good to the most people within the society. 2. Social Justice is defined as a right or deserved stake or interest in something given to a person or group through some sort of ethereal decree or concensus of the members of that group. As I believe that definition two is nothing but the political ravings of special interests, I will focus on definition one.

In order to provide the greatest good, one must first define good. Is there an objective or a subjective definition of this? Is good defined by an amount of money or security, or rather by a subjective definition of happiness. Anyone who hasn't been living in a box knows that most people today (even the poor) in most of the developed world have more than just the basic necessities of life. The residents of even the poorest areas in the United States have electricity, food, and shelter (This being with the exception of those that choose not to take advantage of the shelters provided to homeless people in almost every metropolitan areas by both public and private groups). Some may argue about the food, but I haven't seen any massive death by starvation in the U.S. Nobody is living in mud huts, worrying about hunting food, and urinating in the bushes in the US (except for those that do this by choice and find it fun). What amount of money or security would then be correct? In 100 years, as technology advances, will we then be unjust for having people living in the same conditions they do now, or is social justice some abstract concept of everyone having access to every innovation?

So this brings us back to social justice. Good could probaby be defined by most moral (non type-2) proponents of social justice as providing the highest possible quality of life for the most people in society, with quality being defined as a mixture of subjective happiness and objective material security and comfort. At the root of American Social Justice, Thomas Jefferson wrote into the Declaration of Independence the idea of "Life, Liberty, and the PURSUIT of Happiness," an idea that he took from Lockean political thought, "Life, Liberty, and Property." We created a Constitution, outlining what the roles of the government were in the provision of "social justice."

So one might ask how social justice can be brought about, and more importantly, what does any of this have to do with healthcare? The socialists will cry, the communists will curse, and the fascists will scream, but consistently, the highest quality of life has been given to the most people by Capitalism. This is highly visible both in the U.S. and abroad.

I live in Miami. Here, there is a large population of Cuban exiles who fled the Communist Castro regime. I often hear people quoting statistics out of Cuba regarding their healthcare system, putting it up as a beacon of socialist efficiency. I get a far different story from the Cubans I talk to, who tell me stories of hospitals with no sheets and a far different system that is available for the average worker than the toursits or government officials. The healthcare shortages, coupled with statistical falsehoods, are the norm in all areas of communist life, in stark contrast to most goods and services in more capitalist markets.

In the US, we constantly scream about education and healthcare. They are falling apart. They are inefficient. They are expensive. These happen to be the SAME two services that are most regulated by the government. As they fail more, we give the government more power to regulate them. Nobody ever seems to think that the government intervention in the market may be causing the problem (I will expand on this charge in later posts). The system is full of shortages, regulation, and inefficiency. Even the history of American Health Insurance, the private side of healthcare in the US, goes back to government wage regulations during the great depression.

So by the above definitions, capitalism provides the greatest social justice. As I alluded to in my previous post about Coke, capitalism seems to bring a service to the most people for the cheapest price. Therefore, the greatest good is supplied by Capitalism (Capitalism doesn't necessarily=conservativism, so I don't want rants about corporate welfare. That is not capitalism). The greatest good is supplied to society by the providing the greatest good to individuals. Capitalism is the ONLY economic system that doesn't put the power of regulation in a small number of beauracrats. Because the market regulates the system, every individual is a consumer, and everyone is a regulator. Thus, the greatest good is done for the most people as everyone has a say in the market. Any intervention by the government distorts the market in favor of one group over another, creating false market incentives. This creates LESS quality of life for everyone in favor of a minority.

Thus, leaving definition #2 behind (Unless you happen to belong to a special interest), capitalism does the greatest good for the most people. Capitalism provides the most goods, the cheapest quality, the most security, and greatest access to necessities by all members of society. In our society, it is the most heavily regulated industries that are available only to the wealthy. So a vote for capitalism is a vote for social justice. For those that see healthcare as a social good, that should be only more of a reason to let the market provide it. That would be the quickest way to make progress towards "social justice."

The Cash Incentive

2006-08-30T14:04:00.000-05:00

Have you ever really wanted a Coke? It's a hot day, you didn't sleep well the night before, and you're looking for a little caffeine. What do you do? I personally go to my local grocery store, buy a 2-liter for $0.80, and go home and enjoy. If I really want it badly, I'll pay a little more for a little less (paying for convenience), buy the 20 ounce out of that little fridge in the front of the store and have my desired beverage within minutes of my initial thirst.

The above is really an amazing process. Having visited the Coke Museam in Atlanta, GA as a child, I recall how fascinating everything was in the manufacture and distribution that made all of this possible. Even now, I can have Coke in almost any convenience store, vending machine, or restaurant in the country.

So, why is it that Coke is so omnipresent in my life, but healthcare is so hard to come by? Coke effectively supplies billions of people across the globe with a variety of products and with extreme accuracy. Healthcare, on the other hand, requires waiting, huge expenses, and a variety of other inconveniences that I don't deal with when I want a Coke. For those who think that Coke and Healthcare don't correlate, the above scenario plays out with all sorts of complex undertakings all over the globe, including cars, computers, building supplies, and even the manufacture of the machines used in the execution of healthcare.

Why is Coke so efficient? The answer, the cash incentive. Coke has to compete with Pepsi and hundreds of store brands around the country. If Coke were hard to come by, people would eventually just start purchasing other brands. If Coke didn't taste good, people would start buying other brands. Thus, in order to compete and make money, Coke has to be efficient and tasty. Increased efficiency and better service provide Coke, its stockholders, and its executives with a direct financial incentive to do a good job. The industry is relatively unregulated compared to other industries, and Coke operates with minimal intervention in its quest to provide the consumer with a tasty and efficient product, which correlates to wealthy owners of Coke.

So I can take in huge amounts of Coke for almost no money, but I cannot get treatment for simple medical problems. Why? There is a lack of cash incentive.

Medicine is funded almost entirely by the federal government, the state government, and a huge number of well regulated insurers. It operates under constant threat by a legal system that sets an arbitrary standard of care and spends billions of dollars chasing down those that don't meet that standard. Doctors, no matter how responsible, are still motivated by money like anyone else. As a doctor, the current system pays you to spend less time with patients (By not compensating for more time). Inefficiency is the norm, as every small office visit becomes a nightmare of paperwork and red tape. Worst of all, almost every decision is now made not to provide the best care at the lowest cost, but to prevent litigation. Preventing litigation is the medical profit motive, as the government money will be there for more and more tests, but the doctor pays if he/she is sued. Thus, excessive testing and slow inefficient care are the NORM.

Every new and profitable venture in medicine that actually provides basic care for a low price or excellent care for a high price is attacked constantly in the press. Think about the Walmart urgent care clinics that are the subject of such controversy, allowing people access to basic treatment with no waits and efficient resource utilization. Think about the concierge clinics that were berated for so long until they were repeatedly shown to have BETTER outcomes. If Coke took such a barrage, I doubt that I could have it whenever I wanted.

Worst of all, think about the poor, the usual trump card of the anti-capitalist medical proponents. Almost every poor person in the US has access to Coke. If you have ever spent any time around public housing, you would see that many of these people have access to TVs, Stereos, Cars, and many things that are more expensive than Coke. Why can't they afford Medical Care?

The answer is simple. Right now, there are no Walmarts or Cokes of Medical Care. It is all high priced. It is all highly regulated. Many companies have managed to make a LOT of money in high volume, low margin services to the poor. Usually, this is to the mutual benefit of both. In medicine, we let the government do it, and the number of underserved keep growing. Of course, the government has no profit margin.

Medicine and Economics

2006-08-30T13:31:00.000-05:00

This will be my first rant (uh post) on this blog. I am hoping that we can delve deeper into the taboo subject of money and healthcare in a public forum. I am generally of the opinion that there are laws under which the world operates. Just as there are laws of physics, chemistry, mathematics, and nature, there are also laws of economics. I believe that in the healthcare industry (An industry that constantly deals with life and death) that these basic laws are often overlooked or ignored completely. This has brought about a bizzare system, wrought with shortages, that is progressively offering worse care at a rising price. Though this is handled differently in different countries, this is a definite trend all over the world, leading to excessive waiting and limited healthcare choice in countries such as Canada and the UK, while causing huge cost bloating and limited healthcare access in the United States.

After this post, I intend to post possible solutions. My e-mail is available publicly, and any well written dissenting opinions may be published as well. I am also hoping for a good debate in my replies section. I hope to include individuals with diverse backgrounds, with experiences outside of the medical system as well. If you work in Medicine, Law, Business, Economics, Anthropology, or any other discipline that uses or studies money or healthcare, your opinions are welcome here.