Occupational Licensing

Medical Licensing vs. Basic Health Care

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Kevin Carson makes some points about medicine that can't be made too often:

doctorscoutThe professional licensing cartels outlaw one of the most potent weapons against monopoly: product substitution. Right-wing libertarians are fond of using "food insurance" to illustrate the effect of third-party payment: if there were such a thing as grocery insurance, with low deductibles and a flat premium, people would be buying a lot more filet mignon and a lot less hamburger. The problem is that we've got a medical licensing system that criminalizes the sale of hamburger and mandates the sale of filet mignon. While healthcare consumers fall into many tiers of income, the state mandates only one tier of service regardless of ability to pay.

Much of what an MD does doesn't actually require an MD's level of training. Unfortunately, no matter how simple or straightforward the specific procedure you need done, you have to pay for an MD's level of training. The medical, dental and other lobbies make sure that legislation is in place prohibiting advance practice nurses or dental hygienists from performing even the most basic services without the "supervision" of an MD or DD.

In an open-source healthcare system, someone might go to vocational school for accreditation as the equivalent of a Chinese "barefoot doctor." He could set fractures and deal with other basic traumas, and diagnose the more obvious infectious diseases. He might listen to your cough, do a sputum culture and maybe a chest x-ray, and give you a round of zithro for your pneumonia. But you can't purchase such services by themselves without paying the full cost of a college and med school education plus residency.

I'm not sure what would be "open source" about such a service, but I agree that it ought to exist. I also appreciate Carson's call for something like the old lodge practice system that existed before the AMA destroyed it, in which a fraternal society would pool its resources to hire a doctor who handles its members' medical care. Put those ideas together, and you'll have neighborhood clinics

staffed mainly with nurse-practitioners or the sort of "barefoot doctors" mentioned above. They could treat most traumas and ordinary infectious diseases themselves, with several neighborhood clinics together having an MD on retainer (under the old "lodge practice" which the medical associations stamped out in the early 20th century) for more serious referrals. They could rely entirely on generic drugs, at least when they were virtually as good as the patented "me too" stuff; possibly with the option to buy more expensive, non-covered stuff with your own money….No doubt many upper middle class people might prefer a healthcare plan with more frills, catastrophic care, etc. But for the 40 million or so who are presently uninsured, it'd be a pretty damned good deal.

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  1. Physical Therapists are next. New requirements will require PT’s to have a Ph.D. Another rip-off.

  2. There was a story on PBS about what may be a modern version of the “Lodge Practice”.

    A lefty labor lawyer is now devoting her time to something called the “Freelancers Union”. It is supposedly free to join (no dues I think) and obviously cannot strike against employers.

    It main purpose is to negotiate health care insurance for its members.

  3. My brother is a Physician’s assistant* in Utah. He has a whole slew of people who see him just as if he was a regular general practice physician. If I lived there, I would see him myself.

    *similar to Nurse Practitioner, I think.

  4. Ah. I believe that they actually made the argument in the past that the reason for inefficiencies is . . . to many doctors. Also, in Alaska they are attempting to ban dental hygienists from doing most kinds of dental work. Cartel is the correct noun to use alright.

  5. Aren’t those mini-clinics in Wal-Mart-type stores, that are staffed by nurses and PhysAssts already doing this to some extent?

  6. PAs and NPs have similar practice areas, but not entirely overlapping.

    While I agree with much of the article, I disagree with the discussion of NP(and other advanced practice nurses/PAs roles). While technically supervised, this does not really affect patients much. The role of supervision varies greatly between different practitioner pairs.

    For example, a psychiatric (let’s speak quietly so Sullum can’t hear us) NP might meet with their psychiatrist supervisor once every two weeks and not talk about anything except for the one patient they were a bit unsure of. They might even only call occasionally as something comes up, and otherwise just meet to upkeep their relationship.

    While I don’t think it’s necessary, and I love the idea of having more independent care, especially for NPs and PAs, I think the current supervision role is, in some cases, very similar to what that would be like. If you pay out of pocket, it’s less than a doctors visit. If you have insurance, I imagine it’s the same (my office visits are if I see a NP (an NP?) or a doctor. It’s up a bit, because the doctor is paid a portion, I believe, but not very much at all.

  7. I’ve been saying this for a few years now as one of many ways that together can lower overall medical costs and the cost and availability of private insurance. Thanks for posting it.

  8. More autonomy for NPs and PAs would be great though. This cannot be argued for enough.

  9. But for the 40 million or so who are presently uninsured, it’d be a pretty damned good deal.

    No kidding. You *never* hear about bringing costs down; it’s all about “insuring the uninsured.”

    The AMA is a criminal enterprise.

  10. in other words: “Fuck the poor”

    This is a non-solution to a non-problem. People with diabetes or cancer DO NOT have a choice of a lower-cost treatment. End of story.

  11. Depends on which type of diabetes, or so I’m told

  12. This is a non-solution to a non-problem.

    Are you a member of the UAW, by any chance?

  13. People with diabetes or cancer DO NOT have a choice of a lower-cost treatment. End of story.

    Yes, and because everybody who needs medical attention for any reason has diabetes or cancer, your non-argument is actually not idiotic!

  14. Ray,

    Donate your all your pay checks to worthy charities then. And take your damn hands out of my wallet buddy! Grrrrrrrrr!

  15. People with diabetes […] DO NOT have a choice of a lower-cost treatment.

    Eh?

    Most of the things that diabetics need simply don’t require a physician. A lot of them are better delivered by peer counciling or single purpose education (diet, exercise, pump operation, etc).

    Most MDs—even some—endocrinoligists have a very primitive understanding of how to tune a blood sugar control regime.

  16. Xeones,

    To many double negatives. Translate for me please.

  17. In an open-source healthcare system, someone might go to vocational school for accreditation as the equivalent of a Chinese “barefoot doctor.”

    This is stupid, nothing more than a patch on the problem. GET RID OF THE AMA’s MONOPOLY ON LICENSING!

    This is a non-solution to a non-problem. People with diabetes or cancer DO NOT have a choice of a lower-cost treatment. End of story.

    Yes they do – it is called “Free Market Medicine”, and it has been the norm in many countries taken by the Ugly Americans as “backward”. Mexico has a reasonably free market health care system where doctors can be as cheap as $4.00 per visit for simple things, you can get Paramedic service for as little as $12.00 per MONTH (I am not kidding). People buy insurance for CATASTROPHIC events and not as a payment system, and the licensing system is totally different than in the USA, with little to zero artificial caps on how many people can graduate as doctors, as long as the students make the grades.

    Many doctors work from rental offices with ONE, maybe TWO receptionists, with NO army of medical payment processors needed because you simply pay ONE fee with cash or check. I could see a specialist for as little as $30.00 (!!!), and I do not mean COPAY, I mean FULL FEE.

    YOU as Americans do NOT have a free market health care, you have a heavily regulated and monopolized system.

    My Mother in Law suffers from Diabetes – she visits her endocrinologist every 2 months, pays $50.00 per visit, and buys about $200.00 worth of medicines each month – THAT’S IT (she also suffers high blood pressure, that’ why the $200.00.) That’s in Monterrey, Mexico. DOCTORS ACTUALLY COMPETE FOR YOUR BUSINESS. Instead, there are SO FEW DOCTORS in the US that they cannot be unemployed, EVER, thanks to the AMA union and the Insurance Cartel.

  18. Ray,

    if we reduce the demand for services from MDs by sending half their patients to PAs or NPs, then the MDs will reduce their fees, lowering the cost of services to the poor. Further, by shifting from high-cost to low-cost providers, insurers will realize cost savings, which would be passed along if we allow them to compete, improving access.

    In other words, yes, a competitive market will improve things all around.

  19. Naga, i will try to use words that are more small and less hard. What Ray up there was saying is that a thing might not work in one case (the article, which he did not read/understand, addresses this), and therefore cannot work at all, and besides, LA LA LA THERE IS NOTHING TO SEE HERE YOU LIBTARDS MORE CENTRALIZED CARE PLEASE.

  20. But for the 40 million or so who are presently uninsured, it’d be a pretty damned good deal.

    It won’t be for the AMA, who will lobby the State to crack down on such “Open Source” services, just like they did with many so-called “alternative therapy” doctors in past years (regardless of the effectiveness of those doctors or quacks, the point is that the AMA does not have a right to restrict people’s choices just because they *think* they know what’s better than the rest of us.)

  21. What? The AMA and all professional licensing exists to enrich the guild members at the expense of the public? Rent seeking? What? No, no, no. It’s purely to ensure the safety and efficacy of care provided to you, the consumer.

    Excuse me, I have to go study for my Principles & Practice exam for my PE license.

  22. I’m going out on a limb here to say that almost all of the time (especially in recent history) that the AMA has disagreed with alternative practitioners, they’ve been right.

    Doesn’t make alot of what they do any less wrong, politically or morally, but really…

  23. As a practicing attorney, I can tell you with complete assurance that the U.S. would turn into a Third-World country if we did away with licensing requirements for doctors and lawyers. This is where libertarians go too far with their unrealistic schemes for a free-choice utopia. [/satire]

  24. Ray Butler –
    Right! Because you rather them die of pneumonia or suffer from complications from a simple infection!

  25. What? The AMA and all professional legally mandated licensing exists to enrich the guild members at the expense of the public?

    Fixed. I think free market licensing would be a very smart thing to have. In fact, similar in style to the current system, but not mandated, licensing would probably be a net benefit.

    And separately, under our current not likely to change system: just to clarify a misunderstanding that appears to exist, most doctors and professional organizations want to increase the rate at which physicians are graduated now. There is a strong push, as a profession, to increase the amount of doctors, but starting and expanding medical schools isn’t so easy, for a variety of reasons. It’s not guild profits so much as bureaucratic inertia that is currently slowing down an increase in supply.

  26. This is stupid, nothing more than a patch on the problem. GET RID OF THE AMA’s MONOPOLY ON LICENSING!

    I’ve pointed out in EVERY THREAD where this comes up that MALPRACTICE INSURERS function as medical gatekeepers as much as, if not moreso, than medical boards. And it’s not because insurers are a corrupt cartel; it’s because they have to pay the lawsuits. If you eliminated medical boards, you would still have provider restrictions that probably wouldn’t differ too much from what we see today. They would just be established by insurance companies instead of medical boards. You might see more basic surgeries, like herniorraphies, done by PAs, but I don’t expect much in the way of cost savings.

  27. Also, I find it funny that the health care system practiced extensively by the US military is considered inadequate for civilians. The number of times I saw an actual MD during 6 years in the Army was minimal. For almost everything, an enlisted medic checks you and sends you to a PA, who gives you a prescription or a profile and sends you on your way. I saw MDs when I had surgery, eye exams, and physicals.

    And my command ordered psych evals, but let’s not go there.

  28. As a practicing attorney, I can tell you with complete assurance that the U.S. would turn into a Third-World country if we did away with licensing requirements for doctors and lawyers.

    The obvious question: Why would that be? What’s so special about licensing?

    To me, this reads like a very clumsy non sequitur. Can you tell me if doing away licensing of beauticians would turn the US into a Third World country as well? Or is it just the licensed lawyers and doctors that hold the US by its tether?

  29. FTG, I am going to go out on a limb a second time in this thread and say that, in a free market, there probably would be alot more demand for private licensing of doctors than beauticians.

  30. Also, I find it funny that the health care system practiced extensively by the US military is considered inadequate for civilians. The number of times I saw an actual MD during 6 years in the Army was minimal. For almost everything, an enlisted medic checks you and sends you to a PA, who gives you a prescription or a profile and sends you on your way. I saw MDs when I had surgery, eye exams, and physicals.

    The military medical population is different from the civilian one. The military, for example, provides most of its medical care to the young and basically healthy, whereas the reverse is true in the civilian world. Also, healthcare providers in the military do not have to worry about malpractice… see my comment above.

  31. It’s not guild profits so much as bureaucratic inertia that is currently slowing down an increase in supply.

    Not really – the US can perfectly import all doctors the market needs. The problem is that the State makes any foreign doctor almost go through medical school all over again just to get the license to practice, no matter how advanced the schools are in his country (and I can say without hesitation that many Mexican medical schools are top notch, especially the one at the University of Mexico and the one at the Technological Institute in Monterrey.)

  32. FTG — Please read my comment again, paying special attention to the tag at the end. 😉

  33. Here’s what you do. I’m telling you straight out.

    You open an ‘alternative medicine’ clinic, staffed by people with the lower tier medical training. Then, in addition to basic suptum cultures and chest X-Rays, you give them some energy healing or some shit like that.

    You tell the government that the primary purpose of the clinic is alternatic medicine, but in practice, what you are doing is second-tier health care.

    They try to shut you down, and you just whip out your acupuncture credentials and start screaming.

  34. Lib Dem,
    FTG, I am going to go out on a limb a second time in this thread and say that, in a free market, there probably would be a lot more demand for private licensing of doctors than beauticians.

    That MAY be so, but one cannot simply assert that, without licensing, the US would become a 3rd world country.

    The issue with licensing is not that it exists, but that it is monopolized by the State on behest of a private organization, namely, the AMA. That is unethical.

  35. Not really – the US can perfectly import all doctors the market needs. The problem is that the State makes any foreign doctor almost go through medical school all over again just to get the license to practice, no matter how advanced the schools are in his country (and I can say without hesitation that many Mexican medical schools are top notch, especially the one at the University of Mexico and the one at the Technological Institute in Monterrey.)

    I have no idea how good medical education is in Mexico. That said, I was addressing our current system without reduction of our current regulations in the US. Some doctors have to repeat medical school, others just have to take the USMLE exams, it depends hugely on the country. I imagine from your comments that Mexico is in the first category, which means they don’t trust the education (or some other reason). The fact that other doctors can enter the country and practice without re-attending medical school means that the lack of doctors isn’t about profit but again about perceived quality (or whatever). There are also differences in immigration laws that make it less nice for foreign doctors.

    It’s not a strong argument against my point, which is that most of the professional physician organizations want to expand the supply of (qualified by their standards) doctors.

  36. The military medical population is different from the civilian one. The military, for example, provides most of its medical care to the young and basically healthy, whereas the reverse is true in the civilian world. Also, healthcare providers in the military do not have to worry about malpractice… see my comment above.

    Oh, indisputably. These points are all true. But if you propose not requiring a licensed physician’s supervision to have somebody slap 6 stitches in a cut, somebody comes out of the woodwork screaming how people are gonna die. I’ve had enlisted medics dig crap out of my leg and suture it back up under the supervision of a PA. Propose that out here in the real world and see what happens.

  37. FTG, I agree with you. The original statement was a joke, and I was just responding to your criticism of it, because I don’t think it was a completely valid analogy even had the original comment been serious.

  38. FTG — Please read my comment again, paying special attention to the tag at the end. 😉

    Sorry, JP – got carried away three ;-D

  39. There are a lot of misconceptions here.

    The number of doctors in the US is NOT limited by the number of US medical schools. It is limted by the number of post-graduate training programs, with the difference in US med school graduates and training slots made up for my foreign medical graduates (FMGs). Increasing the number of US medical school grduates will simply displace more FMGs without increasing the number of practicing physicians.

    The number of post-graduate training slots is essentially controlled by federal subsidy through medical. It cannot be increased indefinitely, however, because training programs have to meet certain accreditation standards (google “acgme”). You can’t, for an obvious example, run a neurosurgery training program at a hospital with no neurosurgeons. You need hospitals that have enough of the procedure or patient that you’re training on, and enough trainers. This will naturally limit the potential number of training slots if the type of case or patient is less common – one reason, for example, that there are fewer neurosurgeons than general surgeons.

    If you are a graduate of medical school (not necessarily US) AND have graduated from a post-graduate training program (with as little as one year of training), then getting a medical license is essentially a formality. The state board will not limit the number of pracitioners. They will simply confirm your credentials, do a background check, may make you take a test on medical law in the state, etc. If you don’t get a license, it’s probably because your credentials are bad, or you have significant ethical or legal problems in your past.

    What determines the number of physicians in an area is the local market.

  40. Oh, indisputably. These points are all true. But if you propose not requiring a licensed physician’s supervision to have somebody slap 6 stitches in a cut, somebody comes out of the woodwork screaming how people are gonna die.

    I don’t think it’s a safety risk. But an unsupervised PA would have a higher malpractice rates than a full physician, while having substantially less gross income. You can pull this off in the military, where you don’t need malpractice insurace, but in the real world, it’s going to limit the number of people seeking the job.

  41. Tacos mmm, while your point about residency is a good one, and one I should have touched on as well, I have some slight disagreement.

    I believe there are generally enough residencies for all American graduates and quite a few FMGs, but that they might not be in the right field. I think Family practice and other GP residencies often have empty potential slots (sometimes filled by people that want other fields but give up trying).

    Of course, more residencies are necessary too, which is a great point.

  42. Maybe that’s not actually a disagreement, just a clarification…

  43. The issue with licensing is not that it exists, but that it is monopolized by the State on behest of a private organization, namely, the AMA. That is unethical.

    When I consider the problems facing our medical system today, the ethics of licensing is probably second-to-last.

    Licensing schemes will exist. If they are not drawn up by boards of doctors or the government, they will be drawn up by actuaries. Personally, I actually prefer the medical boards on this one, since they reflect the public obligation of the profession.

  44. I believe there are generally enough residencies for all American graduates and quite a few FMGs, but that they might not be in the right field. I think Family practice and other GP residencies often have empty potential slots (sometimes filled by people that want other fields but give up trying).

    This is true, but we don’t incentivize these fields in terms of the ratio of work to compensation, and none of the solutions posited in this thread, which largely seem to be centered around forcing down providers charges for primary care, are likely to change that.

  45. Also, healthcare providers in the military do not have to worry about malpractice… see my comment above.

    This is not entirely true but for the point you were making (because the govt mostly self insures) it is.

  46. Thanks, Jesse. I used the term “open-source” partly as a tie-in to my venue (the P2P Foundation blog), but I think it’s appropriate; “open-source” medical care is free from barriers to the free transfer of skill and knowledge, in the same way that free software is free from analogous barriers like copyright and patents.

    Ray: Your response is typical of the liberal response on many issues. Your kind assume, in just about every imaginable field, that the existing scale of production, the production technology used, and the technical means currently predominating, are the inevitable results of some technological imperative. Galbraith’s view of the “technostructure” is a good example. But in fact the opposite is true. In just about every case, the scale of operation and the technical means adopted reflect a choice between alternatives, and the choice reflected the institutional needs of those in control of the system rather than any objectively superior “efficiency.”

    Hazel Meade: If you really believe the FDA and medical licensing boards are LESS likely to clamp down on a practice because it uses the term “alternative medicine,” you’re sadly mistaken.

    I think Ray’s and Hazel are operating from almost mirror-imaged assumptions. Ray, blinded by the goo-goo assumption that all government intervention must be intended primarily for the public welfare (apparently never heard of “Bootleggers and Baptists”), that he dismisses the whole universe of cooperative clinics, Ithaca Health, Andrew Weil, etc., as monstrous conspiracies to “fuck the poor.” And Hazel is so adamantly convinced that government is instinctively on the side of all the “goddamned tree-hugging hippie crap” that she hates, that she thinks the term “alternative medicine” will actually protect a cooperative clinic like a hex sign over a barn.

    Government regulators absolutely LIVE to spy on “alternative health” clinics and catch them doing anything that some licensed professionals have a legal monopoly on. Just the same as they LOVE shutting down hippie-dippy food-buying clubs operated out of someone’s home, whenever they can entrap them into crossing the line and “stealing” business from licensed grocers (hard as it is to believe, putting “organic” over the door doesn’t ward them off, Hazel).

  47. The state has no business licensing any occupation, particularly health care. State medical, dental, nursing and other licensing bodies do a tremendous amount of damage to health care, innovation, consumer education and liberty.

  48. P.S. Shirley Svorny’s article on licensing for CATO includes quite a bit of evidence that the licensing bodies almost never revoke licenses after the fact, even in some of the most egregious cases of malpractice. So a license is more like a “seal of approval” from a trade association–a source of false confidence.

    As Tacos mmm… said, malpractice suits in the civil court system (which we’d have even without licensing) have far more of a real-world effect.

  49. Kevin, you’re taking me far too seriously.

    But doesn’t it strike you as pretty absurd that an alternative medicine clinic can offer any kind of service, as long as there’s no proof that it actually works? But if it’s backed by science, the government steps in and shuts them down?

  50. Kevin-

    You speak the truth. I can vouch for that in my own personal experiences.

  51. As Tacos mmm… said, malpractice suits in the civil court system (which we’d have even without licensing) have far more of a real-world effect.

    Malpractice insurers ARE the true governning bodies. The derth of, say, OB/GYNs in south Mississippi is not due to medical boards, it’s due to malpractice costs. Medical boards are quite useful, in theory, with dealing with a small group of seriel offenders – individuals who commit gross negligence, get sued, and then simply go bankrupt or vanish and set up shop at another locale. Without medical boards, sorry as they can sometimes be, there would be no real check on this kind of practice, while well-delivered care would be unlikely to increase.

  52. The number of doctors in the US is NOT limited by the number of US medical schools. It is limted by the number of post-graduate training programs

    Certainly true for specialists, but I believe a med school graduate without an internship, fellowship, or board certification can get a license and practice as a general practitioner.

    They won’t be able to get on most hospital medical staffs, true.

    Fun fact: The federal government, via Medicare, effectively caps the number of graduate medical education slots in this country (GME is a notorious cost sink for hospitals, and Medicare will only take up the slack for a specified number). Medicare has been trying to drive down the number of GME slots for years.

  53. Kevin-

    Wait a minute-you just got my seal of approval and then you concur with Tacos’ point that the elimination of the state sanctioned monopolies do not have much real world effect. What gives?

    The harassment of wholistic and alternative providers is not some infinitessimal/neglible phenomenon. The costs of harassing providers who do not cowtow to the cartels include;

    (1) Death by Medicine.

    (2) The Continuation and Expansion of Ignorance.

    (3) Spectacular Misallocation of Resources.

    (4) Loss of Liberty.

  54. Certainly true for specialists, but I believe a med school graduate without an internship, fellowship, or board certification can get a license and practice as a general practitioner.

    It varies from state to state and board to board (allopathic vs. osteopathic) with international medical graduates sometimes needing more, but no state permits less than an internship, and some require up to three years (Maine, Nevada)

    Medicare has been trying to drive down the number of GME slots for years.

    Very true. Residencies are subsidized heavily, but it’s difficult to imagine them existing without subsidies.

  55. One of the leading causes of death in this country is iatrogenic death. Death by medicine, death by medical doctor, death by the same tired prescriptions of pharmaceutical drugs, surgeries, vaccines, anti-biotics, death by nurse, death by hospital- death by allopathic jihaddists.

    Tacos, with no monopoly, there would be no third party payment regimes. Why does it cost $200.00 just to see a medical doctor for 10 minutes? Very little of that cost is attributable to malpractice insurance premiums. How about FDA approved junk science pharmaceutical garbage? Do you think that very much of the cost of these vessels of death is attributable to malpractice premiums?

  56. For anyone who wants government or socialized healthcare, I say they should get serious about their proposals. I say let’s cap healthcare salaries at $30,000 per person. They can sacrifice for the greater good. That should solve all problems.

  57. Tacos, with no monopoly, there would be no third party payment regimes. Why does it cost $200.00 just to see a medical doctor for 10 minutes?

    Your quote is a high for ten minutes, but cost-shifting from medicare/medicaid/private insurance runs up prices on private-pay patients. A general physician’s time should cost about $200 for a complex visit of about an hour, and $50-100 for a shorter visit, but this varies significantly by locale.

    One of the leading causes of death in this country is iatrogenic death. Death by medicine, death by medical doctor, death by the same tired prescriptions of pharmaceutical drugs, surgeries, vaccines, anti-biotics, death by nurse, death by hospital- death by allopathic jihaddists.

    This doesn’t merit response except to say that when it comes to medical nutcasery, the far left and far right are virtually indistinguishable.

  58. I say let’s cap healthcare salaries at $30,000 per person.

  59. Tacos-

    Yes, the $200.00 tab for 10 minutes may be a bit high for Fargo, but not the greater Boston area.

    You have not really addressed the relationship between price and state mandated cartels by means of licensing schemes. That relationship plays a far bigger role in the setting of a physician’s fee than does a malpractice insurance premium.

    Pray tell, what is medical nutcasery? One would be a nutcase to claim that iatrogenic death is not one of the leading casues of death in the US.

  60. You have not really addressed the relationship between price and state mandated cartels by means of licensing schemes. That relationship plays a far bigger role in the setting of a physician’s fee than does a malpractice insurance premium.

    I think you’re missing my point. Without a licensing scheme, anyone practicing medicine would still need malpractice insurance. If Joe Schmo the mechanical engineer wanted to do surgery, even if it were legal, he still couldn’t get insurance or a hospital (worried about their liability) to let him use their OR. The field of medical practioners would still be narrow, but it would be insurance actuaries determining who could practice, not state medical boards.

  61. so…what is the lower-cost treatment for the following illnesses?

    diabetes
    cancer
    lacerations
    ulcers
    heart disease

    Hey LibertyMike – let me know the next time you have a strep infection. I’ll going shopping for a black suit while you get your aura cleansed and avoid “allopathic medicine”. See you at your funeral.

  62. so…what is the lower-cost treatment for [] diabetes

    For all patients:

    Lifestyle issues (diet, exercise, sleep habits, stress reduction, etc.).
    Regular blood sugar monitoring
    Quarterly Hemoglobin A1C measurements
    Year ocular exams

    For all type I and some type II patients:

    A well designed insulin regime using a minimum of insulin and a the most suitable delivery mechanism (pump, inhaler, injections)

    For some type II patients:

    Drug therapy

    All patients need occasional physician consults, but most of these can be delivered by technicians with much less, but more focused training than an MD. Moreover, my observation is that peer councilling is more effective for more people for the lifestyle issues than most formal support.

    As for lacerations: I wouldn’t flinch from having a PA or NP do my stitches. I mean, excepting from the needle, ‘ya know. Hell, I wouldn’t worry about having an RN do them if that’s what was available, though I would want to know that there was a physician they could go to if they got into trouble.

    But casting about for a list of problems that do require highly trained care does not imply that all complaints require the same level of skill. So kindly start being enginuous, ‘eh?

  63. Hazel: The thing is, though, I don’t think “alternative” providers can do anything that’s not officially approved as a treatment for disease, and just get away with it because it’s called “alternative.” Look at Hoxsey’s Red Clover treatment, for example. The authorities are looking very closely for anyone selling herbal supplements and making medical claims for them, so they can jump on them with both feet.

    Libertymike: I just agreed with tacos that licensing wasn’t effective in carrying out its ostensible purpose (i.e., eliminating malfeasors from practicing medicine). The licensing cartels are quite effective in shutting out unwanted competition up front.

  64. dr dmv:
    Why cant I just study on my own and pass all the licensing? If you are not smart enough to pass, then go to medical school. I am guessing most will just study on their own and pass. Medical schools make alot of money selling licenses, why is this?

    dr. skynet:
    software has been around that can outperform humans (MYCIN, TREAT, Isabel), problems are industrial not technical, in that how do you get the data in? However, now we have Google, Walmart, Microsoft health vaults, so a streamlined industrial standards are emerging. For diabetes, since some have discussed this, DIAS exists. Automated bayes net- able to predict hypoglycemia (sensitivity 5/6, specificity 50%)- suggest reduced insulin dose (thereby prevent hyper-gly)
    http://www.miba.auc.dk/~okh/dias#Clinical

    endgame: The cartel is too strong, it will not allow NP/PAs/alternative credentialing. However, what is stopping a generalist/specialist war? Radiologists and gastro go at it all the time over reading colonoscopies, why should a generalist refer a diabetes patient to a endocrinologist? What could a cardiologist unable to outperform software do to a generalist who does not refer the arrythmia patient?

    dr. lechter: Technology will cause canabilization within the ranks of medicine. What effect will that have on clinician salaries or patient costs can be guessed at? Will the $300K/yr anesthesiologist be making $70K given the widespread use of clinical diagnostic decision support software? I was recently told curtly by an aspiring medical student interested in anesthesiology, “good luck with that”

    good luck with that:
    so what am I missing here? if in ten years, seeing a human for diagnosis is considered poor level of treatment, what will Reason be critical of? If doctors are making $70K, patient costs are down, and patient quality is up, what will be the problems of the day? Will I go to Walmart for heart arrythmia, or cancer treatment, and get free care after just watching some advertisment…

  65. Doesn’t This looks like an awesome place to begin your academic program! The True Blue Campus at St. Georges University.

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