Sunday, October 12, 2014

Paging Abraham Flexner

Those who know who Abraham Flexner was may already suspect, based on the title, where this is going.  Let's start with a thought experiment:

You need to get a lawyer.  You get the names of some suggested lawyers, and check out if they specialize in your need, if they are with a good firm, and perhaps what law school they went to.  The wrinkle is that, in this scenario, there are two different kinds of law schools.  They have similar curricula but are based on different legal philosophies, which may or may not impact the legal advice or services you receive, so knowing which type of law school a lawyer attended is a consideration.

Unlike in the U.S., where lawyers go from law school to practicing (after passing the bar), in this scenario lawyers have to spend several years receiving additional training via extended apprenticeships at large legal institutions.  Despite the fact that these budding lawyers work long hours for modest wages during those apprenticeships, those institutions receive billions of dollars in federal subsidies for this training, none of which either the institutions or the lawyers are expected to repay or even show a quantified public benefit for.

Oh, and I forgot to mention that, for several types of legal work -- say they include property law or intellectual property law -- you won't use a lawyer at all.  You'll use professionals who have trained in entirely distinct programs, are practicing a form of law, yet are not considered lawyers.  Not paralegals, just legal experts with their own domains.

If anyone were to propose such a Byzantium system of legal training and practice, I'm sure the legal profession would be up in arms, suing anyone who had the audacity to suggest such changes.  The rest of us would probably be wondering if whomever had proposed it was high.

As convoluted and nonsensical as this system would appear to be, it is, within my powers of simple analogy, a representation of medical education in the United States.  Thus my call for Mr. Flexner, whose 1910 landmark report on medical education set in motion greatly needed reforms in the medical education of the day.

The distinct types of medical schools are, of course, allopathic (awarding M.D.s) and osteopathic (awarding D.O.s.)  The latter form of practice originally was based on manipulation of bones and joints, but has morphed into education and practice not dissimilar to allopathic.  Osteopathy's cousin -- chiropractic medicine -- still maintains its emphasis on manipulation, and has its own form of education and resulting practitioners (D.C.).

The list doesn't end there.  If you had mental health issues, you might see a psychiatrist (M.D. or D.O.), but you might also see a psychologist (probably Ph.D.).  If you had issues with your eyes, you might see an ophthalmologist, but might also see an optometrist (O.D.).  If you had oral health issues, you may use an oral surgeon, or a dentist (D.D.S.).  Foot problems could be treated by an orthopedic surgeon specializing in foot/ankle, or by a podiatrist (D.P.M.).  If you need a prescription, a physician has to prescribe it but generally can't dispense it, whereas a pharmacist (PharmD.) can dispense but, in most cases, can't prescribe it.

If any of this makes sense to you, it probably is just because we've been raised in a society where "it has always been like this."  That doesn't mean it has to be.  Barbers used to double as surgeons but that's a tradition we managed to do away with.

It's worth noting that the U.S. model where D.O.s have the same scope of practice as M.D.s is only true in 65 countries.  Many countries restrict osteopathy's scope of treatment to forms of manipulation.  I don't know which approach is "right," but if we're going to treat D.O.s like M.D.s, I'm hard pressed to see why there should be two parallel tracks of education.  There have been calls for integrating the two tracks (see, for example, Cohen 2009), to no avail. 

One begins to wonder if the education process has become an end in itself.  Writing in JAMA in 2012, Emmanuel and Fuchs called for shortening U.S. medical education by 30%, noting that it takes far longer to train physicians in the U.S. than most other countries -- roughly 14 years in total here but several years shorter in Europe.  Maybe the $100b in annual revenues for U.S. medical schools has something to do with it.

Then there is the $15b in annual graduate medical education.  It's not clear to me why public funds are subsiding GME at all; you don't see graduate legal education subsidies, by contrast.   Earlier this year the IOM called for numerous reforms in GME, but didn't question the underlying premise of why we're doing it in the first place.

Similarly, in 2010 -- the centennial of the Flexner report -- the Carnegie Foundation called for an updated reform of medical education, but its reforms strike me as wanting to do the things we do now better rather than fundamentally rethinking what we are doing. 

If the medical school route is going to end up taking 14 years, maybe those prospective students -- who typically are good in math & science -- might be better off going into computer science.  They wouldn't incur those big medical school debts, wouldn't face the prospect of battling insurance companies, hospital administrators, or malpractice lawyers, and could at least hope to be comfortably retired due to a couple of successful IPOs by the time the medical school cohort is finally starting to practice.  The medical profession should be very worried.

Whether the training duration is 6 years, 10 years, or 14 years, there is still the problem of all the different kinds of "doctors," each with their own training and licensure.  Who is looking after my health comprehensively, not just pieces of it?

E.g., does it make sense that I get primary care for my teeth from a dentist (or, in reality, largely from a hygienist) and for my eyes from an optometrist, but my "medical" primary care from a physician?  Frankly, I think the only people to whom that makes sense are physicians, especially since it is almost always covered by health insurance, whereas we need dental and vision insurance -- which are not nearly as common -- for the other forms of primary care.  We know, for example, that oral health is closely related to general health, but treat them distinctly.

It's nonsense.

I don't have any quick fixes to any of this, but I'm pretty sure it is a problem.  I'm also sure that the various educational institutions and corresponding professions would fight vigorously to preserve their turfs.  It's naive, but I wish we could all step back and ask the simple question: what is best for the patient?  If we were starting with no preconceptions, but with the knowledge and capabilities we have available, how would we choose to train and organize the health care professions that we license to use them?

To fix things we'd need someone like Abraham Flexner but on steroids.

1 comment:

  1. I couldn't agree more with this post. We need to figure out how Humpty can be put back together again.