Arnold Kling  

My Ideas on Health Care Delivery

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A new essay:


The autonomous, self-directed doctors produced by our medical schools are not suited to treating complex patients. Instead, what we need are team players, implementing consistent corporate policies. Independent skilled craftsmen, flying by the seat of their pants, can add a deck to your house. That will not work for building a skyscraper.

It's an extended essay giving my thoughts on health care from a business process perspective. I still carry a lot of anger about the way my father's course of treatment went.


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COMMENTS (7 to date)
manuelg writes:

> The autonomous, self-directed doctors produced by our medical schools are not suited to treating complex patients. Instead, what we need are team players, implementing consistent corporate policies.

This is a _hard_ problem. I am management for a engineering design and manufacturing company. Even with the authority to fire for insubordination, people enjoy being "autonomous, self-directed", and do so against rational self-interest.

Complexity, handled by groups of people, is regularly punctuated with catastrophic failure. Catastrophic failure is only avoided by systematically eliminating _EVERY_ excuse for _ANY_ failure (to the extent you can). This kind of discipline is in very short supply, because it is not usually rewarded in human society.

Human being are _very_ tolerant of catastrophic failure, when it happens to others. And it usually happens to others, and, so, they are usually _very_ tolerant.

Les writes:

Unfortunately, I believe you are fully correct, and making things yet worse is the increasing shortage of primary care physicians who can act as quarterbacks coordinating the various specialists.

What do you think of the organization of salaried physicians in group practices like the Mayo and the Cleveland Clinics?

jurisnaturalist writes:

So what if circumstances require that you move away from your "team" of doctors?
What is really being lost is a lot of information. Only one person could hold onto all of that information at any given time - the patient.
My dad is 100% now. He was hurt in the Marines. He has had to adjust to the VA way of (not) doing things. He has had to become his own doctor.
He knows everything about his medical conditions, what has been tried and considered, and what has not.

Dr. T writes:

The premise is incorrect. Our medical schools and residency training programs do not produce very many "autonomous, self-directed doctors." Our training programs produce doctors who are highly dependent upon hospital-based resources and entwined networks of physicians (interns, residents, chief residents, attending physician, consulting physicians, radiologists, and pathologists) and other health care experts (clinical pharmacologists, physical and rehabilitational therapists, dieticians, and clinical psychologists). Most newly trained physicians who try to be autonomous and self-directed fail. They end up joining group practices, becoming hospital-based physicians, or changing specialties (a number of pathologists and radiologists previously practiced internal medicine or surgery).

I agree that most physicians can not treat complex patients, especially during hospitalizations. Fixing this problem in hospitals is simple: use hospitalists and intensivists (for ICU care). In the outpatient realm, the problem is more difficult unless one is practicing in a good multi-specialty group. Here is where good medical informatics could play a big role. If the primary physician and the specialists could interact electronically and have unrestricted access to the patient's medical records from each physician, then nothing would be missed, tests wouldn't be duplicated, and there would be less risk of prescribing drugs that don't play nice together. We have the technology to do this securely, but few electronic medical records programs support this type of data sharing.

My background: Clinical pathologist who has taught medical students, doctor of pharmacy students, and pathology residents for 25 years. Currently at University of Tennessee Health Science Center.

BGC writes:

Important posting, this one.

By analogy with a building project, the best form of organization might be for the patient to employ an agent who is 'on the job', ie. in and around the hospital frequently, monitoring what goes on (rather like the clerk of works, as we call it in the UK).

And on the hostital side, there should be a 'foreman' who can hire, direct and (when necessary) fire the medical specialists.

The point being that the process needs a specific management function to coordinate the medical specialists.

And this hospital managment function needs to be complemented by an agent for the patient who will keep an eye on the whole process - this could be a family physician/ general practitioner - paid on a daily retainer.

Randy writes:

Its self directed .and. team, not self directed .or. team. I work a tech support desk. I'm the first point of contact for customers when they have problems.

If I know the solution to the problem with near certainty I give it to the customer immediately.

If I'm pretty sure that the problem is caused by one of two or three possibilities I give the customer a procedure for checking them all in order of probability.

If I'm not really sure of the cause of the problem I refer it to an engineer who specializes in that part of the system. The problem is that engineers are busy and may not prioritize this particular customer's problem as highly as the customer would like.

If the engineer isn't certain then the problem gets kicked to a team. The problem here is again prioritization and time. Team efforts to solve problems take longer - often a lot longer. The efforts of a team are nearly always successful, but clients have been lost in the time it takes for the team to succeed.

AlbNY writes:

I agree with Dr. T, the bottom line is for years the assault has been directed towards American physicians. We attempt to undercut the physicians by increasing the number of mid-level providers. My wife spent the majority of her time during residency pulling call. I thought her teaching faculty could have given her more, with two years out of residency she is a fine physician. She can make complex decisions and manage complex cases in and out of the hospital. The entire V.A. health care system should be a educational system for all American physicians. We should have no government health care for Americans. The V.A. health care system should be responsible for delivering low income health care. This would free necessary dollars to improve America's Medical Residency Programs.

As Chairman Bernanke outlined in his health care speech earlier this week the "U.S. Military's Health care system" is a starting point for reforming the American health care system. V.A. is a broken system and the wasted funds could be used to educate all American physicians. Unfortunately Americans will not wake up until the last soldier leaves Iraq and then we realize we have a problem.

It is not young American physicians in residency programs causing the health care problem it is government interfering in the industry. This is why we have a housing crisis and a health care crisis. The Residency Teaching Faculty are busy practicing defensive(CYA)medicine and don't have the time to properly train these kids going through residency. We economist need to start talking about Health care price inflation. The majority of our problems are coming from South of the border. Pemex is selling 2 USD a gallon gasoline in Mexico, but Americans are running a 100 billion USD trade deficit with Mexico and paying 4 USD for gallon of gas.

If it has not occurred to anyone we have two military health care systems when we should have one. As the 2007 Walter Reed Wounded Warrior scandal proved we are wasting educational and training dollars that could be used to improve private and military sponsored residency programs. Our problems with health care are not the physicians it is politicians and misguided government officials practicing health care Reaganomics. EMTALA, Medicaid and other clever government tricks destroy our health care system and reduce the quality of American health care. The late Dr. Madeline Cosman pointed out the damage illegal aliens have done to America's health care system. The breakdown in L.A. County's health care system only caused medical price inflation for the rest of the country. As Dr. Lawrence Huntoon pointed out comptroller's nationwide are identifying, Medicaid budgets that are rising in price and federal matching dollars being reduced.

It would be nice to have an economist/physician on the Feds Board of Governors so that this can be explained to the American people. There is health care price inflation and it is caused by illegals using the U.S. health care system and the failed Government Social Security programs. Our physicians need to be trained in geriatric medicine and funds should go to educating physicians and not to Health Care Administrators. Health Care Administrators in the Department of Defense and civilian sector are not seeing patients, but are in charge that is amazing. We need more physicians in the U.S. military and private sector.

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