reflection upon exiting medical school

As I graduate medical school and begin my training I would like to reflect on some observations about the economics and practice of medicine I made while a student.

Physicians’ sensitivity to financial incentive is greater than I thought-

When I first came to medical school, I was more idealistic about the role of physicians in society. I had chosen this profession because I believed it was a path to living a just life. I had very little understanding regarding the economics of medicine. As I listened to conversations between my superiors on the wards, both residents and attending physicians, I was surprised by the preoccupation with money. This critique is more directed at the procedural specialties but can apply to us all. American physician reimbursement is the highest in the world, and it is creating a serious financial incentive to enter medicine, even in today’s more highly regulated healthcare setting. It is also creating an even more powerful incentive to specialize. This drive to use medicine for personal enrichment is supported by the preferences of competitive medical student applicants to enter highly reimbursed specialties. This financial incentive attracts those who prioritize financial reward; this adversely impacts the humanity and compassion of the profession as a whole. Those who choose lucrative specialties with minimal patient interaction offer much rationalization. Still, in doing so they stray from the classical definition of physician as a healer. Under the guise of a physician concerned with the sick and unhealthy, these specialists operate as highly skilled technical specialists. It is masquerade. The rational conclusion is that far too many doctors, and those entering the field are motivated by money.

The advent of hospitalists and salaried shift physicians will herald the loss of physician autonomy unless physicians become more organized politically.

As physicians continue to specialize, their interests have diverged greatly and solidarity has suffered both philosophically and politically. Desires for reductions in workload and relinquishing responsibilities of practice management have resulted in the creation of shift working physicians. Autonomy and controlling interest has been traded for better work hours and less administrative work, such that physicians are now managers without ownership. This phenomenon is compounded by narrowly focused specialist physicians, now more closely resembling technicians, blinded to both larger economic trends in healthcare delivery and the interests of their colleagues. Whereas allied health providers are strongly organized and unionized; organizing physicians has been likened to “herding cats”. Role confusion of specialist and shift physicians will adversely impact us all. Physician autonomy will now compete with newly established firmly adhered practice guidelines (to which practicing physicians may not have created). Finally, the much sought after salaried shift work no-call hospital physician position will face increased price pressure as the owners attempt to constrain costs of these generous salaries. Physicians now neither owners nor effectively organized will face these pressures divided and unleveraged.

The entitlement of subspecialty physicians in a fee for service model of inappropriately priced healthcare procedures-

Fee for service medicine creates financial incentive to increase procedural volume. Those sensitive to this incentive are subject to a conflict of interest in the administration of their service. They naturally pursue their rational interest to maximize profit. In the setting of increasing medical specialization, new medical technology (imaging, procedures, pharmaceuticals) is increasingly expensive and offers ostensibly better medical care yet possesses marginal utility in health outcomes. Though these procedures, improperly vetted by an underpowered governmental reimbursement body are still provided by third party payers. These payers in turn ultimately disperse the cost of these procedures onto that population whom comprise their risk pool. In combination with this, subspecialty physicians now with ever-narrowing scopes of practice proliferate and still require same broad physician privileges (in terms of patient contact, leadership, and management) afforded generalists in previous eras. Thus several “teams of doctors” may be involved in any single case many times voicing conflicting medical opinions. This is both confusing and exhausting as the parade of consulting physicians each have their 5 minutes with the patient, seldom altogether.

An ounce of prevention is worth a pound of cure, which is why if you want to make money it makes sense to sell cures by the pound.

Preventive medicine is inappropriately valued because prevention is too often not profitable for physicians and unpopular for patients. As well, these solutions many times reduce economic consumption and thus do not propagate a deficit-sustained society. They are of no interest to policy makers because their economic impact has not been believably quantified. Until real cost savings can be demonstrated, preventive medicine (especially where prevention means “doing nothing”) will not have a role in modern western medicine.

How healthcare expenditure is required for increased GDP and the necessity of increasing healthcare spending in maintaining American sovereignty.

Calls to reduce medical expenditure must account for the fact that healthcare spending is greater than 17% of GDP and increases every year. Therefore, significant reductions in spending would adversely affect GDP and increase federal budget deficits. Every dollar of health care spending eventually goes to someone, in some form. Reduction in federal health expenditure thus reduces "federally subsidized" economic output. Increased budget deficits (already scheduled for $1.2 trillion in 2012) decrease US borrowing capacity, which undermines US economic stability and sovereignty. Thus, much talked about reductions in healthcare spending and subsequent GDP reductions must be accounted for either by increased economic activity or further reductions in non-GDP contributing government spending.

The individual mandate is constitutional only in the setting of health insurance being purchased from a governmental body unconcerned with profit.

If healthcare is a public trust, then an individual mandate is a civil duty. However, the purchase of health insurance from private for profit corporations without allegiance to the citizenry violates the definition of a public trust. Thus, the only tenable means by which the individual mandate can be upheld is through compulsory purchase of government insurance or tax because it is the government who must by law serve its citizens and it will be the government who ultimately bears the cost burden of the uninsured.