New Paradigms for Patients

Three articles particularly struck me this week: Eric Topol's Why Doctors Should Organize, Jonathan Tepper's The Doctor Monopoly Is Killing American Patients, and Farhad Manjoo's Abortion Pills Should Be Everywhere.  They come from vastly different perspectives, and seek different ends, but I think there is an underlying problem that they all agree on.

Too often the healthcare system is looking out for itself, not us.  The existing paradigms aren't working.

Dr. Topol laments what is happening to physicians.  Long hours, too much data entry, deteriorating patient-physician relationships, and physician burnout.  When physicians try to speak up on social issues, even public health ones, they're told to "stay in their lane," as happened when some spoke up about gun violence. 

He wonders: "But there have been no marches on Washington, no picket lines, no social-media campaigns. Why not? Why aren’t doctors standing up for themselves and their patients?"  

Dr. Topol notes that the physicians' professional organizations could represent these interests, but "there is no single organization that unifies all doctors. The profession is balkanized."  Even more concerning, he adds:  "The power and impact of medical organizations is further diminished because their priority—supporting their constituents—is often at odds with the needs of the public."  He describes medical societies as "primarily a trade guild centered on the finances of doctors."

Dr. Topol calls for a different future:

It’s possible to imagine a new organization of doctors that has nothing to do with the business of medicine and everything to do with promoting the health of patients and adroitly confronting the transformational challenges that lie ahead for the medical profession.  Such an organization wouldn’t be a trade guild protecting the interests of doctors. It would be a doctors’ organization devoted to patients.

Now, there's a radical idea. 

Mr. Tepper concern is the impact of physician shortages has on our care.  They are a problem for our care, and for our health.  However, they did not happen by chance.  He charges:

U.S. doctors operate as a cartel to restrict trade and reduce competition. The American Medical Association (AMA) artificially limits the number of doctors, which drives up salaries for doctors and reduces the availability of care.

As a result of the physician-run accrediting bodies control over medical schools and state licensing, he believes "becoming a practicing physician requires navigating a maze of accrediting, licensing, and examining bodies."  Mr. Tepper calls for breaking the "the monopoly that current accrediting bodies hold over graduate medical education." 

Mr. Tepper is not the first to call licensing boards, including medical ones, cartels.  A few years ago, Aaron S. Edlin and Rebecca Haw Allensworth wrote a paper Cartels by Another Name: Should Licensed Occupations Face Antitrust Scrutiny, followed by an op-ed in The Wall Street Journal.  They believe that, as the result of a Supreme Court ruling, "Many professional boards in the U.S. will be vulnerable to antitrust suits for anticompetitive regulations."

So Dr. Topol and Mr. Tepper are not fans of physician organizations.  What does that have to do with abortion pills? 

As abortions have become harder to obtain -- some states, like Missouri and Mississippi, are down to only one clinic -- the so-called abortion pill RU-486 is increasingly an alternative for women needing an abortion.  It is both very safe and very effective. 

But it is not easy to get, at least not legally.  According to Mr. Manjoo: "It can be prescribed only by doctors who meet certain qualifications, and can be dispensed only in clinics licensed to provide abortions, not retail pharmacies."  Many other, riskier drugs are not subject to similar restrictions.

However, we live in a digital world, so, as Mr. Manjoo says, "restrictions on abortion pills are becoming increasingly difficult to enforce. Despite the F.D.A.’s restrictions, activists have created a robust online market that makes getting pills surprisingly easy."

As a test, Mr. Manjoo ordered the pills from four different online pharmacies, usually with success.  He marveled: 

Each time I got a pack of pills in the mail, I was increasingly bowled over: If this is so easy, how will they ever stop this? I’ve been watching digital markets for 20 years, and I’ve learned to spot a simple, powerful dynamic: When something that is difficult to get offline becomes easy to get online, big changes are afoot.

The point I was particularly struck by was this:

For providers and users, legal risk is also relatively low. Regulators have little capacity to enforce restrictions on foreign distributors. In March, the F.D.A. sent a letter to Aid Access demanding that it cease operations immediately. The organization sent a letter back saying, essentially, nope. What happens next is anybody’s guess.

I'll take a guess.  The center cannot hold.  The cartels cannot maintain power.  The healthcare system cannot survive if it is more about the people profiting from it than the people who are supposed to be served by it.  Not in the 21st century.  Not in a world where technology gives us many options and where there exist healthcare professionals who do still care primarily about patients.

Dr. Topol thinks physicians should organize to give them a more powerful voice in issues not about the business of medicine but rather the practice of medicine.  I say, more power to him and to such organizations.

Meanwhile, some of my Twitter friends say, that's all fine and good, but what we really need are patient organizations to give us more agency about health issues -- personal and societal -- that impact us.  And to them I say, more power as well.

But what Mr. Manjoo brings up poses perhaps the biggest change.  The parochial nature of our healthcare system, largely overseen by these various existing physician organizations, is already breaking down.  

Xiaoyi passed the Chinese national medical exam (China Daily)

We can order pills from overseas.  More importantly, we could do online consultations with overseas physicians, and soon enough we'll be able to consult with, and get treatment from, artificial intelligence and robots.  Who is going to license them, how?  

As I've written before, we can't even decide if human physicians should be educated and licensed as M.D.s or D.O.s, so how the heck are we going to deal with A.I. "physicians"?  We're still struggling with human telemedicine across state lines.

Time to rethink everything.  Time to move from healthcare's parochial, self-serving interests to a system that empowers and supports each of us in our health.  Time to get back to healing, helping, and caring. 

Time for new paradigms.