5 ms·
The current trend, as I understand it, is to reduce the independence of doctors. This is happening on 2 fronts: 1.) The FDA is imposing stricter limits on how
by lkrubner 16y ago
The current trend, as I understand it, is to reduce the independence of doctors. This is happening on 2 fronts:
1.) The FDA is imposing stricter limits on how doctors prescribe.
2.) The insurance companies are imposing limits on what doctors can do.
The trend has been developing for several decades, but it only came into clear focus during the 1990s, when the HMOs first gained prominence. Doctors have lost a great deal of independence compared to what they had 100 years ago, or even 50 years ago.
#1 has at least 2 parts:
a.) The War On Drugs: this has lead to limits on how aggressively doctors can manage pain. Too aggressive and the doctor comes under scrutiny.
b.) The widening powers of the FDA. Over the last 50 years the FDA has become a general clearing house for all new technologies that effect health. Whereas its focus was once on drugs, it now has substantial say over every kind of medial procedure, including such things as pacemakers.
A simple model of the contending forces might include these main actors:
1.) patients
2.) doctors
3.) government
4.) hospitals
5.) patient insurance companies
6.) doctor liability insurance companies
A simple model would simply assert that each of these is trying to lower their risk, partly by moving the risk onto one of the other players. (A more complicated model would have trial lawyers as their own element, but here the trial lawyers are assumed to be part of #1). In a simple model, you could assert:
risk = the power to make decisions
The more each group tries to get rid of its own risk, the more it also loses the power to make its own decisions. This is a simple model, but it clearly has some truth.
What we've also seen in the last few decades is that when risk in the system goes beyond what private sector actors can manage, then the risk, and the decision making, gets taken over by the government. This was a long term trend, but the trend was made very explicit and visible during the crisis of 2008/2009, when lots of private sector actors failed (Lehman, General Motors, etc) and were taken over by the government.
I keep looking for some sign that this trend might abate, but for now, it seems likely to continue, if in modified form.
Conclusions?
You can become a doctor. You will be respected. You will be well paid. You will lack the independence that has been traditionally associated with the role. But despite that, you may enjoy the work.
- yoden 16y agoRE: FDA: It's a lot worse than pacemakers. Desktop medical image viewing software is also regulated under FDA-510k procedures. Our iPhone viewer has been tied up in the FDA morass for more than two years now. We're submitting a 510k for our cloud image sharing service, just in case. Basically, if you market your product with the intent for it to be in any way involved with medical procedures, you fall under the purview of the FDA. Which is much, much harder to deal with than the iso equivalents. To the extent that we, as a small american company, have been launching things first in europe.
- lkrubner 16y agoI had the same experience. A friend developed software for monitoring outcomes with regards to pacemakers. I helped a little bit on this project. This was done for a British company. At the time the software was fairly innovative, treating the patient as the center point of the all of the data, rather than the pacemakers, and able to consolidate and compare all "events" (negative events such as failure of the packmaker). The idea was that eventually the software, and the equipment, would be released in the USA. This never happened. It is in use in the UK, but bringing into the US would require far more of an up front investment than anyone is willing to make. In theory, the FDA exists to keep Americans safe. However, it is possible to look at some of its regulatory moves as aiming at consolidation within the industries that supply drugs and equipment to the medical field. I imagine it is easier to regulate an industry with 10 companies than an industry with 10,000 companies. However, the true cost is that a lot of innovation gets squeezed out.
- br1 16y agoI would include lawyers in 0.) diseases.
- _delirium 16y agoEvidence-based medicine is another factor pushing in that direction. There's been a move away from the idea of doctors as professionals exercising case-by-case judgment, and more towards scientifically validated treatment methods. I'm not entirely sure what I think about that. On the one hand, it seems bad, that instead of having the freedom to exercise situation-specific judgment, doctors are increasingly being pressured to follow predefined flow charts and rubrics, turning it into a sort of cookie-cutter medicine. On the other hand, the statistical evidence in some cases is actually pretty good: for at least a few kinds of things that have been tested, doctors who mindlessly follow a validated process have, on average, better outcomes than the more traditional approach. One explanation that's been advanced for that is that humans are not very good at conditional probabilities, so doctors often make intuitive decisions that, if you run the numbers, aren't statistically the best choice, based on available data. If so, they're better off strictly following a data-derived procedure rather than trying to improvise.
- deleted 16y ago[deleted]
- anthonyb 16y agoChecklists (http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_...) are another area where control has been taken away from doctors (medical staff apparently are allowed to physically restrain doctors who don't follow them), but with drastically improved results.
- Alex3917 16y agoConsidering that currently about 1 in 3 Americans die from mistakes made by doctors, limiting their independence might not be such a bad thing. [1] http://www.ourcivilisation.com/medicine/usamed/deaths.htm http://www.ourcivilisation.com/medicine/usamed/deaths.htm
- phunel 16y agoNo offense Alex3917, but really - Philip Atkinson is your authoritative source?? Not sure why this is getting upvoted. Quote from his site, re: his experiences growing up - "Everything about us was different, and we were naturally resented. While the neighbouring [sic] adults never confronted my father, their children were delighted to bully his children. My siblings and myself became social half-castes, accepted by no class and despised by all. The result in my case was an initial bitter resentment of my community, along with the traditional notions that I should pursue a university education then a career; so I dropped out of school to take a job as a bus conductor... With determination, skill and a little luck I forged a career in computers before being forced into retirement in 1991... Of course I could have restarted the education that I abandoned in my teens, but by then the true nature of universities had become obvious; they were no longer centres of learning pursuing truth but centres of profit pursuing customers. Inevitably striving for popularity with youth has made universities bastions of Political Correctness, and full of the kind of people who wanted to burn Galileo for daring to question that the sun circled the earth. So I spent my enforced idleness applying the skills acquired as a system's analyst to discover why my society is disintegrating into delusion and impotence... In January 2000 I became an Internet publisher, placing a variety of books 'online' at my own expense, in an attempt to preserve some of the vanishing wisdom of humanity... Indeed I am the first philosopher to realise that philosophy is the study of understanding." Hmmm...
- Alex3917 16y agoIf you're going to question the source then at least question the actual journal articles instead of just ad homineming the guy citing them. They're all from respectable sources like JAMA.