It’s not easy being an American doctor these days. First Senate candidate Sharron Angle suggests paying doctors in chickens. Now Peter Orszag, Obama’s former OMB director, compares doctors to drug stores and wants them to work weekends. He also thinks doctors should be evaluated the same way TV networks compete for Nielsen ratings.
Doctors – especially those engaged in primary care – are already thoroughly depressed and distressed about their working conditions. Even surgeons complain that they’re not treated as professionals, but as employees hired to do bureaucratic shift-work. Is this the way to treat the people responsible for our health?
Here’s the opening paragraph from Orszag’s New York Times editorial:
Doctors, like most people, don’t love to work weekends, and they probably don’t enjoy being evaluated against their peers. But their industry can no longer afford to protect them from the inevitable. Imagine a drugstore open only five days a week, or a television network that didn’t measure its ratings. Improving the quality of health care and reducing its cost will require that doctors make many changes — but working weekends and consenting to quality management are two clear ones.
Note the assumption that what doctors do is an “industry.” In the late 20th century, medicine in the US changed – unfortunately — from a profession to a business. One could argue that doctors have only themselves to blame. If the AMA hadn’t fought so successfully against national health care in the 1940s, primary care physicians might be a lot better off today.
But that’s spilt milk seen with 20/20 hindsight. Primary care doctors in countries where the medical profession did come under government control – like Europe and the UK — don’t seem very happy with their current situation either. All highly developed countries now live in a modern maelstrom of hi-tech medicine, over-hyped expectations, and the profit motive.
The business of medicine is unique
Orszag is an economist who wants the medical “industry” to be run as efficiently as any other business. “[I]f you can’t measure it, you can’t manage it,” he says. But medicine is not like other business ventures. For one thing, its services are responsible for the life, death, and suffering of human beings. This is unique.
Also, it doesn’t operate with the usual economic model of supply, demand, and shopping for competitive prices. When health hangs in the balance, time is limited and choices are few. You don’t decide to forego surgery the way you postpone the purchase of a new car.
There’s a more fundamental way in which medicine differs economically from other business interests: a relative lack of power when it comes to government policy. Even though the cost of health care has grown to over 17 percent of GDP – and economists and politicians worry it will bankrupt the nation – there’s still some truth in this comment by Paul Starr
The medical profession does not have the same basis of power as large corporations. Private capital is not simply one of several interest groups in society: the economy and hence the government’s own tax revenues depend on “business confidence.” Hence business confidence generally acts as a constraint on policy without businessmen ever having to lobby on behalf of their interests as a class. If government threatens to undermine business confidence, it jeopardizes its own stability by bringing about a reduction in investment and a general economic crisis, with rising unemployment and lower tax revenues. The medical profession clearly does not have this degree of “structural power.” Government can lose the confidence of doctors without grave economic repercussions. If threatened, doctors can try to withdraw their “human capital” – that is, to strike or even to emigrate. But these threats are much harder to carry out than a shift of business investment. Opposition from doctors is a potentially serious problem, but it is far from insuperable. [emphasis added]
Perhaps this is an underlying reason doctors don’t “get no respect” from economists like Peter Orszag. In his opinion, if medicine was a real business, it would give priority to the convenience of its customers. “Wouldn’t it be nice to be able to schedule your elective surgery on a Saturday if you wanted?”
Well, sure. But as Dr. Richard Reece points out in response to Orszag, many doctors work 60 to 80 hours a week already and are concerned about how they’re going to find time for the 32 million new patients who will soon have health insurance, as well as the 36 million new Medicare patients.
Orszag’s published opinion did not include an option for reader comments. I look forward to reading the response in upcoming letters to the Times.
Special thanks to Roberta at More Thyme Than Dough for pointing out the Orszag piece to me.
Update 10/10/10:
24/7: The Hospital That Never Sleeps (The New York Times)
Letters to the editor in response to Peter Orszag’s column. From a psychiatrist, commenting on measuring the complex variables of health care.
The measurement approaches touted by many of those pushing for reform are imported from business models that involve far simpler systems than what occurs in medicine. Measuring one component of health care delivery and forcing changes based on that measurement, while neglecting other important but harder-to-measure variables, may worsen efficiencies and lower quality of care.
We should certainly explore new health care delivery approaches, but let’s not assume that squeezing one side of a water balloon doesn’t increase tension on the other.
From a professor of political science:
I was troubled by Peter Orszag’s suggestion that doctors should start working on weekends. His proposal suggests a lack of awareness of what social scientists call “greedy institutions.”
Sociologists spend a lot of time worrying about the 24/7 economy and the corresponding pressure to work longer hours. These greedy workplaces (hospitals foremost among them) are a source of considerable work/family stress and perpetuate gender inequities both at home and in the workplace. (How many mothers can work the Saturday-Sunday shift in the E.R.? Who is likely to be appointed chief of cardiology as a result?)
New health-care law may prompt more people to come back home for medical care (The Washington Post)
How the “medical home” concept in the new health care bill may increase patient access to doctors in off hours. Includes these statistics:
[In the US,] only about a third of doctors said they offer evening or weekend appointments.
This is in stark contrast to other countries, where primary-care doctors are routinely available after hours. In a 2009 survey, 97 percent of primary-care practices in the Netherlands had arrangements for after-hours care by a doctor or nurse, according to the Commonwealth Fund. In the United Kingdom, the figure was 89 percent, and it was 78 percent in France.
More Americans Bypassing Their Personal Physician When Immediate Treatment Required, Study Finds (ScienceDaily)
Report on an article in Health Affairs: Where Americans Get Acute Care: Increasingly, It’s Not At Their Doctor’s Office. Americans increasingly use emergency departments for acute care visits, such as a cough or sore throat.
“Timely access to care is important, especially for those who are acutely ill. First-contact care has been a central tenet of primary care. But over the past few decades, the focus of primary care has shifted as a result of a growing elderly population, the growing burden of chronic disease and the challenge of coordinating care across multiple physicians,” says Pitts. “Low rates of reimbursement have accelerated this trend by forcing many primary care physicians to pack their daily schedules with 15-minute office visits — leaving little time for patients with acute health problems.” …
“Busy schedules also discourage primary care physicians from taking the time they need to treat patients with complex, undifferentiated complaints. It is faster and simpler to refer them to a specialist or the nearest emergency department.”
Related posts:
Physician as lone practitioner
The doctor/patient relationship: What have we lost?
Doctors in the trenches speak out – Parts One, Two, and Three
Resources:
Image source: The New York Times
Peter Orszag, Health Care’s Lost Weekend, The New York Times, October 3, 2010
Richard Reece, Health Reform as the Mother of Health Improvement, Medinnovation, October 4, 2010
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