3 ms·

Regardless of the validity of the primary thesis (that there's a bottleneck in physician education, especially residency), I think the perspective in this is to

Regardless of the validity of the primary thesis (that there's a bottleneck in physician education, especially residency), I think the perspective in this is too narrow. There isn't just a bottleneck in physician education, there's a bottleneck in medical training in general, due to dated conceptions of professional identity and necessary training. The entire system is broken in my opinion. Service provision should be more skills-focused, and less degree-focused, and deregulated to allow more competition in the types of services and professional identities that exist. Currently in the US, access to care is too restricted or difficult. The response "let's open the floodgates to more physicians" is one response, but another response is "yes, do that, but let citizens receive care under different kinds of training models." Right now the assumption is RN -> LPN and MD->specialty->subspecialty, maybe with PA->specialty training, but there's many other forms of care from other types of providers that could exist. Pharmacists and psychologists are one example, where you might have specialized training -> broader training, or specialized training -> augmented skill set. There's also undoubtedly many other types of providers we can't even imagine now because the certification regulations are so strict; I also suspect a lot of care could be opened up to the general public on their own (many refills, for example, probably don't need repeat visits). My sense is this is just the tip of the iceberg when it comes to medical certification overregulation.

lumost 5y ago
The problem with direct specialty programs is the "you only have a hammer" problem. It moves the onus of diagnosis to the individual seeking care rather than the provider of care. This is likely somewhat the case already, but such approaches would start to formalize it. There is a middle ground where we address the bottlenecks in the current medical professional pipeline by deregulating the number of licenses issued per year and sponsor the creation of new medical schools to educate more professionals at lower cost.
- derbOac 5y ago
  I agree with the "only have a hammer" problem but that already exists, and in a formal way vis-a-vis specialty boundaries. E.g., if you go see a neurologist, they're likely to see things through a neurology lens regardless of generalist training because of time in specialty and incentives. The legal consequences sort of keep it in check. I also think to some extent it exists in the other direction as well, in terms of generalists not always recognizing when something needs to be referred to a more specialized setting. It's largely addressed via training and consequences. And in any event, there's always the issue of "why not broaden training instead of assuming it always narrows?"
  - lumost 5y ago
    Training will only broaden when there is economic incentive for it - from a practical perspective a neurologist isn’t going to learn general practice after they make 500k per year as a neurologist in order to have an opportunity to make 150k per year. This is problematic if we expect neurologists to be good well rounded doctors, but not if we just expect them to be good neurologists. I don’t expect my dentist to be able to deal with a heart murmur.
slg 5y ago
>The entire system is broken in my opinion. Service provision should be more skills-focused, and less degree-focused, and deregulated to allow more competition in the types of services and professional identities that exist. In a country with a medical system that is already too profit-minded and with a population that is growingly anti-expert, this has the potential to go catastrophically wrong. We don't need to make it easier for people to sell horse paste and essential oils as miracle cures. So while reform may be needed, we would also need to be mindful that making it easier to provide medical services will also empower people with misaligned motives to take advantage of people.

lumost 5y ago

The problem with direct specialty programs is the "you only have a hammer" problem. It moves the onus of diagnosis to the individual seeking care rather than the provider of care. This is likely somewhat the case already, but such approaches would start to formalize it. There is a middle ground where we address the bottlenecks in the current medical professional pipeline by deregulating the number of licenses issued per year and sponsor the creation of new medical schools to educate more professionals at lower cost.

derbOac 5y ago
I agree with the "only have a hammer" problem but that already exists, and in a formal way vis-a-vis specialty boundaries. E.g., if you go see a neurologist, they're likely to see things through a neurology lens regardless of generalist training because of time in specialty and incentives. The legal consequences sort of keep it in check. I also think to some extent it exists in the other direction as well, in terms of generalists not always recognizing when something needs to be referred to a more specialized setting. It's largely addressed via training and consequences. And in any event, there's always the issue of "why not broaden training instead of assuming it always narrows?"
- lumost 5y ago
  Training will only broaden when there is economic incentive for it - from a practical perspective a neurologist isn’t going to learn general practice after they make 500k per year as a neurologist in order to have an opportunity to make 150k per year. This is problematic if we expect neurologists to be good well rounded doctors, but not if we just expect them to be good neurologists. I don’t expect my dentist to be able to deal with a heart murmur.

slg 5y ago

>The entire system is broken in my opinion. Service provision should be more skills-focused, and less degree-focused, and deregulated to allow more competition in the types of services and professional identities that exist. In a country with a medical system that is already too profit-minded and with a population that is growingly anti-expert, this has the potential to go catastrophically wrong. We don't need to make it easier for people to sell horse paste and essential oils as miracle cures. So while reform may be needed, we would also need to be mindful that making it easier to provide medical services will also empower people with misaligned motives to take advantage of people.