More education is the usual prescription for our problems - but health care reformers urge the opposite.
There is too much waste in American medicine, argue Ezekiel Emanuel and Victor Fuchs, in the Journal of the American Medical Association. It “drives up costs [and] threatens the government’s long-term fiscal stability.” Their plan to aid the U.S. Treasury is to shorten doctors’ training by 30 percent.
“Years of training have been added without evidence that they enhance clinical skills or the quality of care,” they write. A year or two of college, a year of medical school, the research training that some subspecialists get could all be sacrificed. Some programs have done it and claimed no ill effects.
Good effects, they think, include less physician autonomy. They prefer “team-based care.” Doctors need to be “comfortable with group decision-making, standardization of practices, task shifting to nonphysician providers, and outcomes measurement.”
What better way to make doctors more subservient than to make them less capable and less confident?
Basic science in medical education has already been reduced. My class in 1970 was the first to experience a 50 percent cut in the gross anatomy course - without any formal outcome measurement. I have felt disadvantaged ever since, and have invested significant time in remedial self-study. There is no substitute for doing a careful dissection yourself, under direction of a skilled anatomist, and for having time to absorb the material. Some curriculum reformers say there is no need to know details of hand anatomy. But those who don’t will miss diagnoses or have to refer all hand problems to a subspecialist.
Dr. Emanuel and Mr. Fuchs don’t seem to recognize that clinical education has already been reduced by 20 percent just by restricting the number of hours that house staff may be in the hospital. They all have an invisible time clock sitting on their shoulders. Faculty members are reluctant to take up time for teaching because young physicians in training have to finish assigned tasks and leave at the appointed hour. There’s no time for informal interaction with other staff.
Big chunks of the physical examination are simply deleted: the ears, the back of the eye, most of the neurologic exam, percussion of the chest, meticulous characterization of heart murmurs. These are considered low-yield, inefficient and not needed when you can just order expensive imaging. As a result, young physicians cannot gain skill in performing the exam or a broad base of experience of normal variation.
Then another 20 percent is probably lost because of time spent facing the wall and typing into a computer. Information technology, supposedly so efficient, in practice reduces productivity by around 20 percent.
At the same time that Dr. Emanuel and Mr. Fuchs want to cut education, powerful special interests want to subject all physicians to constant rounds of test-taking and data gathering from their practices, just to maintain their licenses. There is no evidence that this improves patient care, and 70 percent of physicians who have gone through the “maintenance of certification” programs thought that it did nothing to improve their performance as physicians. Nearly 80 percent would not voluntarily do it again.
A lucrative testing industry wants to have a guaranteed market of physicians paying thousands of dollars to take tests, and more thousands to cram for them in proprietary review courses - while taking many hours away from patient care. The Federation of State Medical Boards and the American Board of Medical Specialties want state legislatures to mandate this to “protect patients” - from doctors who think for themselves.
Doctors with limited education, programmed by computerized protocols and tests, with scant time for anything else, along with nonphysician “team members,” will be the “providers” of centrally planned health care. It’s a fairly short step to replace them altogether. In fact, one of the nation’s largest insurers has already hired “Watson,” a supercomputer famous for playing “Jeopardy!” on TV.
Your life may be in jeopardy, but the checklists in your chart will be in good order.
Dr. Jane M. Orient is executive director of the Association of American Physicians and Surgeons and author of “Sapira’s Art and Science of Bedside Diagnosis” (Lippincott Williams & Wilkins, 2005).