Wednesday, January 14, 2009

Adding Worse Doctors, Getting Better Medicine?

Edwin Leap worries that, if doctors no longer earn a decent profit, the best and brightest will find no good incentive to enter the healing profession.

He writes:

Physicians have to be paid well in order to continue to practice medicine. It wasn’t always this way. Because, there was a time in modern medicine when the rewards of the practice of medicine were considered higher than mere cash. Why did early physicians expose themselves to epidemics and death? Why did they go to battlefields and learn surgery? Why did they labor with the miserable and poor? Because they sensed the value of human-kind. They were taught, and believed, that every life was valuable in God’s eyes, and that if they ignored their calling, and ignored suffering, they would face God’s wrath. They also believed that if they did right, if they endured under hardship, if they died of the diseases they fought against, they would be rewarded by their Creator.

We are too modern for all that, now, aren’t we? We don’t need mumbo-jumbo, irrational, anti-scientific theories about human worth. We’re post-moderns! We will do right, because it’s good for mankind and good for society and because our reward will be…well, it will be science and knowledge…I mean, it will be the survival of all the fittest for the collective good of mankind in a few eons…it will be…a good review from my boss and a nice retirement with a boat…it will be a vacation and a car and….well, some money will do nicely, if you please.

Reject transcendence if you will. But if you do, prepare large boxes of cash. Because doctors without a sense of temporal and eternal purpose will have to be rewarded financially in order to stay in a long, arduous educational system, in order to work all hours, in order to expose themselves to risks physical, emotional and legal and in order to come back day after day to a job that is sometimes amazing but often quite tedious and frequently quite maddening.

Given that it may make more sense, from a purely economic perspective to become a UPS driver than a doctor, and that the average GPA of pre-medical school matriculants is still about a 3.7, the risk of a sudden doctor dry-up is rather low. I am not sure if it is due to a continuous devotion to "transcendence," but Pre-meds are still undergoing Fear Factor level feats to contest for every last available medical school chair in the country. When all else fails, many pack their bags for four sunny years in Grenada.

The unaccepted applicants are, all things considered, less-qualified on average. Some unaccepted applicants bombed their MCATs, some got a C in Orgo Sophomore Year, some had a stain on their tie during their interviews, and some were simply "more average" all around.

Would these potential physicians be worse doctors than the current matriculants, assuming economic conditions lured the smartest college students to law, business, or package delivery? Perhaps. However, the brutal admissions process doesn't measure some of the most crucial skills necessary to become a doctor: Good patient rapport, observation skills, manual dexterity, superhuman ability to function without any sleep, a healthy self-esteem that can endure frequent criticism, and the motivation to keep up with the latest in science-based medicine (a criterion that automatically excludes many working spinal surgeons). There is no reason to believe that Team A possess these skills to a much greater extent than Team B.

Let's say, however, that the currently shut-out applicants would actually become inferior doctors. Maybe they'd miss a few more crucial diagnoses, screw up a few more procedures, or show up to work with that stained tie, every single day. . The fact is that the stuff they do right might outweigh the probability that they would make a few more mistakes. In other words, while medical errors are an enormous problem, many people do not even have the opportunity to be at risk of being victims of medical errors. They do not have doctors, period, and have no chance to be diagnosed and treated, altogether. If you see the slow-growing elephantiasis and massive tumors being sported in our ED's waiting room, you'd see what I mean.

Imagine a mediocre doctor who goes into a small town with no primary care physicians. The doctor misses a few diagnoses, but also recognizes a whole bunch, all of which would have been undetected otherwise. He administers a lot of STD tests, and performs tons of vaccinations. All things considered, I'd say it's a win.

In other words, we shouldn't only focus on the quality of doctors. Even the best doctors can only see so many patients. Those physicians should be doing the trickiest procedures, managing the most complex clinical cases, and addressing actual emergencies. But let's allow nurse practitioners, physician's assistants, and less-stellar doctors to take care of everyone and everything else. Because poor people without any medical care could really benefit from a lot more "good enough."

HT: Kevin, M.D.


grolaw said...

Any person seeking entry into "a profession" for the money - should be disqualified entry on that basis, alone.

Heal Spieler said...

Hi Grolaw,
I agree that I wouldn't want a doctor, who is just in it for the money. But I'm not exactly "for the money" means. For instance, if there was a job that provided me with 95% satisfaction, and I really felt that I was doing something meaningful, and it paid a nice salary, and then there was an 100% job that paid a very bad salary, I'd probably take the former. In other words, while I would never do anything exclusively for the money, (because I know that in life, time is much more valuable), I still think that salary is a legitimate component of a job, that should be properly weighed, along with other (more important) factors.