Category Archives: Future

Fixing Healthcare – Part Three

Physician’s Assistants (PAs) and Advanced Registered Nurse  (ARNPs) are helping lower costs and increase access. While some nurse practitioners, can operate relatively independently; other nurse practitioners and most physicians’ assistants, cannot. Why?

Physicians are adamant that they maintain a high degree of control over these and other healthcare workers. This is a throwback to the nineteenth century—which is kind of interesting in a weird sort of way. The story, and I cannot vouch for its accuracy, although all my research seems to support it, is that the country was besotted with traveling medicine shows hawking patent medicines (You’ve seen it in the movies—“One for a man, two for a horse”). The physician industry supposedly promised to get things under control if they were put in charge of medical practitioners, i.e., physicians and surgeons (MD). It, at best, minimized, if not blackballed, osteopathic physicians (DO), chiropractors (DC) and chiropodists, now known as podiatrists (DPM).

A physician, at the time, could authorize any hireling under his license to perform any duty under the concept that the doctor was “the captain of the ship” and was responsible for everything. Therefore, he had authority to authorize any employee to do anything—hopefully, but not necessarily, after some training.

Today, many non-physician healthcare workers are licensed in their own right; in most states this includes nurses (of all levels), therapists (of all varieties), and technologists (ditto). These people are trained and possess technical skills that physicians do not. Generally speaking, only television doctors leave their practice in order to operating high technology devices. It’s good theater but bad economics.

Many of the other healthcare careers such as nurse practitioners, physicians’ assistants, etc., have made significant advances Unfortunately, old attitudes die hard, and there are too many physicians who try to maintain an inordinate control over everything, including these other professionals. Nurse anesthetists and physicians’ assistance must be “supervised” by a physician, although such supervision does not require actual observation or even the presence of the supervising physician.

Efforts to keep others under control have led to some bizarre arrangements. In radiology, for example I’m told that the technologists are now required to periodically retake the examination that initially proved their competence even though there has been continuing education requirements for 40 years. If true, I believe this is a unique requirement, but a warning to all others. Of all the physicians’ assistants, only those specializing in radiology are not permitted to interpret x-ray or other diagnostic images.

Why?

Some blame the American Medical Association, a very powerful organization with effective lobbyists. However, it apparently speaks for a self-selected group of physicians. Out of 923,308 practicing physicians, the most recent numbers available indicates that only 228,000 belonged to the AMA. If you don’t round, that’s just less than 25 percent.

Nobel Laureate Milton Friedman and his wife, who wrote the book Free to Choose, asserted that the AMA functions more like a guild with the goal of increasing physicians’ wages and fees by limiting both the supply of physicians and the competition from non-physician groups.

This is yet another issue that must be addressed if we are truly interested in fixing healthcare.

Medical School Rationing

Fixing Healthcare – Part 2 — Doctors

I’ve known many intelligent, talented, committed young people who aspired to become doctors, but couldn’t get into medical school. Some were resigned to their fate and used their degree in biochemistry to become medical technologists; others made arrangements to attend medical school outside the United States—primarily in the Caribbean. In one case, in order to study at a school in the Caribbean, the aspiring medical student’s parents sold virtually everything to finance her education. She’s nearly complete with her rotations back here at US hospitals and plans on serving rural or tribal underserved areas.

While we don’t have enough graduates of United States medical schools, we grant 85,000 special visas to foreign medical graduates every year because it’s a “critical shortage.” Today, roughly one quarter of all practicing physicians are foreign medical graduates. I’ve worked with many, and while their initial desire is to return home, after about six months the sports car and the arm-candy significant other appears. When I ask if their plans have changed, I’ve been told, “If I return home, I will be paid in chickens and melons. If I stay here, I will be paid in dollars. I like dollars better than chickens and melons.”

So, we import thousands of non-American doctors every year even though we have many Americans who want to study medicine but are turned away.

A decade or so ago, when more students wanted to study law, the educational industry had no difficulty in adding seats—even if they had to build new schools. Why won’t (not can’t) we do the same for medical schools?

Some claim there wouldn’t be enough residency opportunities if we graduated more doctors from US schools, yet foreign medical graduates can and do get residency positions at US hospitals. In any other industry, this might be viewed as restraint of trade.

I suggest that the goal of US medical schools should be to increase their capacity so that by 2030 ALL US residency openings can be filled with US citizens who graduated from US medical schools.

Next, I would change the entry criteria to include the following:

  1. Accepting students with a commitment to actually practice medicine; better yet a commitment to practice whatever type of medicine is in short supply, wherever needed, for at least three years. After that, every accommodation should be made to place that individual in a residency or fellowship of their choosing for which they have the talent, without a decrease in salary.
  2. While academic achievement is important, the ability to work as a team is critical. History is full of brilliant people who didn’t succeed because they could not work with others, and medicine is now a team sport—whether the person with MD or DO after their name likes it or not, they are teammates with the nurses, technologists, therapists, etc. No one is a superstar.
  3. Children of doctors or other elites should have to prove themselves more—not less—than other medical school candidates. They’ve grown up exposed to the field, often in an environment of privilege, so they should demonstrate their desire to serve, not their pedigree.

In short, we need more doctors, but our current method of selecting them is less than optimal.

The Candidates (Revised)

After being politically correct for the past few weeks (some by omission), here we go.

The Clintons at the Trumps’ 2005 Wedding

 

Now that the presumptive candidates (and, they’re both quite presumptuous, thank you [rim shot—bada-bing]) are in place, the world is beginning to react.

Great Britain: “I say, old chap, do you miss King George the Third yet?”

Vladimir Putin (AKA Russia): “Of course this is all according to my plan, but I assure you that no Russian military troops were involved!”

Mexico: “Here’s our counter offer:

  1. “We are willing to pay to build a wall, but we propose a different—but better—location. The wall would be more beneficial to the citizens of both countries if it were constructed about fifty meters outside the right-hand lane of I-495, thereby encircling Washington, DC. This would help maintain control of politicians’ entry into the United States of America mainland.
  2. “The wall will be funded by charging a toll for travel through the numerous tunnels that already exist under the border between our two countries. Since the tunnels are well-engineered, structurally sound, well lit, and either paved or equipped with rail service, it should be easy to add electronic toll transponders. Of course, after the election, there may be many US citizens who will utilize the tunnels to head south in a search for a more placid place to call home, and they would be responsible for paying the toll as well. Please ensure that the EZ-Pass transponder system deposits the fees into Los Estados Unidos de Mexico National Bank.
  3. “Incidentally, we revised our immigration laws in 2011. If you’d like a copy, you can easily get it online.”

North Korea: “As a gesture of confidence in our future relations, we would be most willing to host any of your e-mail servers. I assure you that the DPRK has many well-trained computer specialists, and we would treat your computer as we would treat one of our own.”

Canada: “Hey! No way, hoser! Take off, ay? There are reasons that we prefer to be neighbors rather than family. We like our prime minister just fine, thank you, since he’s cultured and refined. Besides, our beer is much better than yours!”

Content vs. Quantity

brown

 

There’s a famous quotation attributed to various people, but the supposed authoritative sources credit to Blaise Pascal:

I’m sorry I wrote you such a long letter; I didn’t have time to write a short one.

When I first started writing this blog I thought that my goal should be to write and post something every day. Of course, at the time, I had plenty of ideas—some worth sharing, some not. Good, bad, or indifferent, I posted them. Like the codfish, I laid 10,000 eggs hoping a few would hatch. Now, I try to limit myself to thoughts worth sharing. Iay—or may not—be succeeding.

I’m a science junkie. If it were 1955 or 1985 (or for that matter, 1895) I could have been Doc Brown in Back to the Future. The biggest difference is that he had a family fortune to support him while he experimented, while I’ve got a steady job (just as valuable, but less conducive to experimentation). Nevertheless, as kindred spirits, he in fiction and I in reality, we try to see what the next step might be. Which brings me to today’s issue.

Today there is a huge emphasis on STEM—science, technology, engineering, and math in the education biz, today—but there is no real commitment. It’s a lot of talk, but no real action. I’m not blaming the educators. God knows that I understand that there’s only so much you can do in guiding a teenager. However, among today’s teenagers, any interest in science is ridiculed. A student interested in STEM requires the commitment of the Maquis (that was the French Resistance in World War II); one must be willing to maintain a low—if not invisible—profile, only confide in a few trusted souls, and be willing to die a thousand deaths (of embarrassment) if discovered.

Kids today don’t realize that the person they call “nerd” today, will probably be called “boss” tomorrow.

In our effort to be politically correct and not impact anyone’s self-esteem we dare not put scientists, engineers, or mathematicians above athletes, gangstas, or “celebrities” who are famous for being famous. Personally, if I’m going to get my brain scrambled, I’d rather it happen in an experimental space craft rather than having repeated concussions playing football or via cocaine, meth, or whatever is the celebrity drug du jour.

Whatever happened to science fairs? High school science clubs? Achievement awards? When did it become shameful to be interested in science beyond the specific items included on the standardized test?

Think about it. To paraphrase Doc Brown, “Our future depends upon it.”

A Dismal Future?

220px-Marvin_(HHGG)

Marvin the Paranoid Android from The Hitchhiker’s Guide to the Galaxy (We already miss you Alan Rickman!)

Hollywood—so politically correct and socially conscious—loves to produce movies about a dystopian future. I admit, I’ve watched–and enjoyed many of them: Blade Runner, Terminator 1, 2, 3, 4, 5, and counting, Mad Max 1 through nx, I Robot, Planet of the Apeses, etc. What’s the point?

 

Is Hollywood trying to convince us that in our world with global warming, bigotry, greed, corruption, and disease, things are only going to get worse? And they promote this in the name of entertainment? I suppose it makes sense. After all, this is an industry that insists on making more Adam Sandler movies.

Why not make movies predicting a future in which:

  • No one has to deal with the DMV. In fact, historians cannot even find out what DMV stood for.
  • Whenever mail (physical or electronic) includes an unwanted advertisement, it’s normal procedure to call the postal inspector—with every reason to believe that there will be an immediate arrest of the perpetrator.
  • Issues concerning climate, medicine, nutrition, are debated ONLY by experts in those fields, with minimum criteria for the validity of the data, hypotheses, and conclusions they reach. Soundbites would be based on these factual notions, and periodic updates would be published to reflect the peer review process. Celebrities without a PhD and current peer reviewed publications dealing with the question at hand need not apply.
  • Cute kittens would be adored by their owners but prohibited from cluttering the internet.
  • In the entertainment world, the media focus would be on the characters that actors portrayed, whether Petrucio, Spock, or Professor Severus Snape—not the actors themselves.
  • Blog writers would be universally revered as geniuses, giants, and heroes.

Okay, the last one was a reach, but I had to take my shot.

All Right! I Confess!

I admit it. I’ve been trying to write blogs lately, but:

  • There was Christmas.
  • My son, daughter-in-law, and grandchildren drove 12 hours to visit.
  • My daughter, who has started reading my blog, says all my blogs are the same.
  • I keep coming up with ideas that are incomplete—which got me thinking.

Some of the Beatles songs, including much of Abbey Road were actually the parts of songs that had never fully developed. Therefore I tried to piece together ideas:

My New Year’s resolutions. After “I will never be a staffer for Donald Trump,” I got stuck.

I tried to write about the era of Downton Abbey and how people were once born into wealth and/or married into it, and how that is rare today.

Then I thought of:

  • The Bushes
  • The Clintons
  • Miley Cyrus
  • Jaden Smith
  • Colin Hanks
  • Drew Barrymore
  • Prince Charles

Which brought me back to square one, so, attempting to steal from the Beatles, using the tune from “She Came in through the Bathroom Window”:

My son and daughter trashed the bathroom,
I think they lost my silver spoon,
So I sat there and I pondered,
I should not get mad so soon.

My kids have always been expensive,
Cost me more than I could know,
But I wouldn’t change a minute,
So now I have these joys to show

Is it any wonder?

Let me close this year with my thanks to God for my NORMAL family (the emphasis is there to remind me that despite the condition of their bedrooms and bathroom, my kids are normal; on the other hand, given their outstanding academic, athletic, and musical accomplishments, I owe it to them to differentiate between normal and average).

For you, may 2015 be the year that was just before when everything became wonderful.

Wow!

NCIS (But you knew that!)

NCIS
(But you knew that!)

Life is funny, and it sure gets in the way.

I’ve been so busy with my day job, my kids…

My kids—two are already grown up and the other two are suddenly almost there. My younger son just got his acceptance letter from his first choice college—and an early admission at that. Now, it’s kind of hard to chastise him for not taking out the recycling.

My daughter is a few years younger, but also a great student (My grades were never that god), musician (I was never first chair bassoon), and athlete (let’s not even go there). However, after her last birthday she seems to believe it’s necessary to remind me every 15 minutes or so that in in a few months she’ll start driving.

Naturally I’m proud of both of them, but I wonder, if I hadn’t blinked would they have grown up so fast?

Thankfully I have a Sherpa guide who has looked out for the kids and advised me. I’m speaking of my wife, of course. This is a challenge for her, I’m sure. She hasn’t had to resort to the Gibb’s slap on the back of DiNozzo’s head yet (for the benefit of NCIS fans) but it’s not because I don’t need a >HINT< from time to time.

So, thanks to her, even though I’m sports impaired, I’ve been a soccer dad, in spite of myself, which makes a world of difference to my kids.

However, in all fairness, I’ve done just fine as the science, music and school project parent.

If I haven’t been blogging as much as I should, lately, it’s because life has gotten in the way, and the people who are special to me—well, you know.