By we, I want to be explicit, it is not just certain doctors that are to blame; it is us as a larger society who set up broken systems and enforce these excessive practice standards in environments that can’t or won’t support the cost. The overworked and increasingly less-compensated clinicians are not the primary failure point.
We talk about being evidence-based when we give our patients care. By definition, if we have evidence-based practices that deliver sizable patient benefits and we do not even attempt to apply them, we are letting the patients die that we could have saved. We would punish a doctor who allows his patient to die when wheeled into the ER, or who rushes or does half the procedure – but we do the very same thing when understaffing hospitals and clinics.
One of these situations has been coming up with organ transplants – due to lack of staff or preparation (also partially an allocation issue), patients can’t get operated on when staffing pressure gets tight.
The mass clinics (dental etc.) that go on in rural areas of the 48 states, and the closure of the rural hospitals, is another instance. The care just doesn’t happen.
Organ transplant isn’t a simple thing to do, nor are many of the other procedures. All of them have risk. But if your options are death, or suffering for years, then having a non-generalist, technical level person providing care, even if the tech fails 10-20% of the time where the fully trained generalist doctor would have succeeded, that’s likely better in these situations than not providing treatments at all.
Question is payment models? So to explain in three scenarios:
- In universal care, you could be smart and train the specialist properly, or just train them all as general doctors, and pay them, because that’s the assumption of proper universal care, anyway.
- In a free market/ability to pay system, the tech’s training costs whatever it costs, the tech works for whatever they can get. Since we are talking about highly specialized techs, you are talking about $50K a year plus benefits to $75K a year and say $25K for materials in an average case (not organs), and 1000 procedures a year (4 a day) with 50% unreimbursed, that’s $200 a procedure. Quintuple it to $1K, so you can get your lower quality tech to try something where a fully qualified doctor isn’t available. That won’t get you to universal access, but it will get the willing payers for major care something where they would have had nothing.
- In the hybrid system, which really is a free market/ability to pay system in the end, you pay the tech out of pocket just like capitalism. If you get help from state medical reimbursement, that’s even better.
But in any event, the payment model is one obstacle. The malpractice, and the board certifications/license to practice, are others.
The only way around malpractice is to force patients to sign a waiver that only in cases of gross negligence can there be any lawsuits, and then you have to back it up with your judicial selections and process. That is, your standard for grievances is lower than that of the full doctor specialists, in the same way that the standard of training is different. Relatively inexpensive techs, aren’t cheap anymore once you have to hire lawyers on a regular basis to fend off claims. The middle class and rich still will pay for the fully trained specialist, so it’s that the market provides both types of care.
The boards and licensing folks just have to accept that this is the better of the two non-optimal alternatives.