I saw a fascinating article about how Fidelity, through their research arm Fidelity Labs, has released a virtual reality tool to portray financial information in a more visual manner -- not even using numbers. I immediately thought about how this approach could apply to health care.
The Fidelity tool -- which can be viewed using virtual reality goggles or as in simulated 3-D on a browser -- is pretty cool. Stocks are buildings, the height is their price, the size of the base is the trading volume. Weather reflects whether markets are up or down, day/night indicates if markets re up or closed, and so on. You can build your own "city" or neighborhood based on your portfolio or stocks/sectors you are following.
Fidelity got interested in this after Facebook acquired virtual reality company Oculus earlier this year (for a very real $2b), figuring Facebook might have some hint of where consumers were headed. To date, virtual reality has been mostly thought of in terms of gaming, but Fidelity is thinking out of the proverbial box.
Financial information certainly can be very dry and numbers-laden, but I think health care can make a case for the title of most confusing. Lots of confusing language, lots of data that sometimes is information and sometimes just adds to the noise. Think of your medical record (if you've ever been able to see it) or a set of lab results. Now add all the data that is or is soon going to be added to your information via wearable or remote monitoring devices, and the sum total is certainly a situation that is crying out for better visual representation.
Yes, I know that many of those fitness devices, as well some lab results, may come with charts or graphs, but people who don't like numbers may not like charts and graphs much better. And that's still just a slice of our health information.
We know understanding health care data is a problem. In a recent study, The University of Michigan found that people with low literacy and numeracy skills were less than half as likely to understand their lab results -- and even among those with higher such skills, only 77% were able to.
All that health care data is crying out for visualization. Visualization of Big Data is becoming a hot trend generally. From an evolutionary standpoint, humans aren't very good at making sense of numbers, but we excel in looking at patterns -- and pictures.
To help address this, University of Michigan has a "Visualizing Health" initiative. They've created a gallery of of recommended ways to graphically represent health information that they've validated through user testing, and are making them available for free. It's a great project, but looking through their 54 examples, I think it is just a first step.
GE Healthcare has their own data visualization effort, and I'm sure there are others. Still, more and better charts and graphs are nice, but Fidelity has raised the bar.
I'm thinking holograms.
To some, holograms are still the stuff of science fiction, but they're becoming more mainstream and they've already started to be used in health care. Last year, Realview Imaging showed how holographic images could be used to assist surgeons in cardiac surgery, allowing the surgeons to view, touch, even mark the 3-D images generated from ultrasounds and X-rays. Realview just went through a $10 million investment round and expects to be in the commercial market by 2016.
I want to see a holographic medical record.
Think about it. The current generation of EHRs isn't wowing anyone. Health future Joe Flowers recently suggested that they are so flawed that we should just ditch them and start over again. No wonder, because, as best I can tell, they did for medical records what 1990's websites did for paper: they simply made the content digital, added a few links and a modest amount of interactivity. We called that "brochureware" then and I'm not sure EHRs have done much more for the old paper records.
No wonder they're so clunky.
On the other hand, imagine if your doctor comes into the exam room and instead of holding a paper chart or tablet with your record, her smartphone projects a holographic image of a human body. Of your actual body, if preferred. That scar on your knee, all your X-rays and CAT scans, your balky shoulder, your asthma -- all those are represented in the image.
The doctor can view and update a current snapshot of your health, go back to a previous version and contrast, add or listen to verbal notes. She can zoom in to specific organs or other body parts in order to highlight specific areas of concern. When she takes your vitals, they automatically get uploaded into the record. The hologram can take advantage of Fidelity-like symbolism to give a literal picture of your health, down to lab results, Fitbit readings, and even your own subjective comments (e.g., the image gets blue when you are depressed, or degrees of red indicate where and how much pain you are feeling).
Advances in haptic technology may mean that anything your doctor feels when examining you (like a lump) can be uploaded to your holographic image -- and that the image itself has tactile qualities. The "hands-on" advantages of the exam can be fed directly into your record, with no manual input (pun intended).
Rather than you feeling that the doctor is reading the record when he/she should be paying attention to you, the record would become interactive with the exam, in a way that is both highly visual and available to both of you. It also would become another tool for the doctor to explain to you any diagnoses or recommended procedures; she can touch and manipulate the image to show you exactly what is going on or will happen.
That's an EHR that could add to, rather than detract from, the clinical experience. Equally as important, it is an approach that consumers would probably be more willing to use on their own in managing their own health. That Big Data that everyone expects us to be collecting about ourselves would become not just more numbers or charts but part of an interactive display of...well, us.
One way or another, better visualization of health care data is going to be essential if we don't want to get lost in all the data. I sure hope health care doesn't come late to the party, like it did to digital information. Holographic technology isn't the complete answer, but it is here and will soon find applications throughout our daily lives. It will play a more important role in health care, and I can't think of a better place to start than revamping our idea of what an EHR is. You can't tell me that the folks at Realview aren't already thinking about health records.
I just wonder if the people at Epic or athenahealth are.
Monday, November 24, 2014
Tuesday, November 18, 2014
Who Ya Gonna Call
Imagine, if you will, a health care system without doctors.
On first blush that concept doesn't make sense: what would a health care system be without doctors? But I would argue that the notion is not all that far-fetched, and, even more, that we need to be open to ideas like that if we really want to change our health system.
Let's start with the basic assumption that, within a few years, we'll be able to track our health at virtually a molecular level, in real-time or close to it. That's one of the goals of Google X's Life Sciences team, using something they call nanodiagnostics. They envision a swarm of nanoparticles swimming around in your body, detecting diseases in their earliest stages, and connected to wearable devices so we can act on the information they glean. Instead of waiting for diseases to manifest, we'd be able to catch them in their formative stage and head them off.
It's not just Google that sees this future; researchers elsewhere, such as at Northwestern and Vanderbilt, also see exciting opportunities in nanoparticles. The Northwestern research, for example, helps identify circulating cancer cells faster and more easily.
Just think: we wouldn't need a physician to give us their best guess at a diagnosis; we'd actually know exactly what was wrong.
Well, even if we could replace physicians for diagnoses, we'd still need them to treat us, right? Not so fast. Take another hot field: the microbiome. We're finding out that our bodies have a lot more bacteria than "our own" cells, and that what is going on with those bacteria has important implications for our health. Imbalances in them have been linked to a number of common maladies, including allergies and other auto-immune disorders, cancer, and obesity. If we can figure out how to address those imbalances, much of what ails us could just go away.
I always think about the example of stomach ulcers, which used to be blamed on stress and diet, when in fact it turns out that most are caused by a bacteria infection. We were thinking about it wrong and treating it incorrectly, and I suspect that the more we learn about our microbiome, the more examples like this we'll find.
The microbiome is already a serious field of research. The NIH Human Biome Project -- whose mere existence should illustrate how quickly the field is becoming mainstream -- is funding a number of demonstration projects. MIT and Massachusetts General Hospital (MCH) just announced the launch of their joint Center for Microbiome Informatics and Theraputics. The field is starting to generate significant investment.
Deloitte estimates that in 2010 consumers were already spending some $56b of their own money on "nutrition/supplements," despite the alarming lack of evidence of their benefits. Imagine how much we'd be willing to pay to be able to manage our own microbiome.
So I'm wondering; if good health is about manipulating our microbiome, do we still rely on physicians -- or perhaps microbiologists instead?
Then there is gene therapy. This effort to replace defect genes is still in the experimental phase, but is showing promise. For example, there is an Alliance for Cancer Gene Therapy that hopes to fix the root problem -- defective genes -- without the need for traditional medical interventions like surgery, chemo, or radiation, each of which has its drawbacks.
Similarly, a company named Spark Therapeutics has just received an FDA "breakthrough-therapy" designation for a gene therapy that addresses a group of eye diseases called inherited retinal dystrophies (IRDs). Fierce BioTech notes a number of other companies are also making big bets in gene therapy.
When gene therapy reaches a more mainstream status, should it be physicians who oversee it, or geneticists?
Well, certainly we'd still need physicians to do surgeries and other procedures, right? Perhaps, but many of those, while technically impressive, can actually be viewed as markers of failure -- failure to diagnose earlier or treat more conservatively. That's not through anyone's fault, as the techniques for earlier detection and less invasive treatment haven't always been there, but they may be available in the not-so-distant future.
Why get a hip transplant or go through back surgery when, say, our ability to regenerate bones or nerves might make those approaches obsolete? Indeed, in a hundred years -- or hopefully less -- much of the current practice of medicine may look as archaic as medieval medical practices do to us.
The question is, will we be ready?
All is this not meant to bash the medical profession (although when I read about things like pain doctors routinely testing Medicare patients for angel dust simply because they get paid for the expensive tests, it's hard to refrain). My big concern is how limiting the "practice of medicine" to the medical cartel can stifle disruptive innovations in health care, by forcing them to funnel through the established practitioners. It's ostensibly for patient protection but often looks more like protection of income (see Stay Off My Turf).
Telemedicine should be forcing us to rethink our historical criteria from where we receive our care, just as physician alternatives and even advances in artificial intelligence should also be forcing us to rethink our reliance on physicians. Instead, we're trying to make the new options conform to the old rules.
Yes, I know the AMA just approved the interstate compact proposed by the Federation of State Medical Boards to facilitate more interstate licensing for telemedicine, but even that proposal reduces the degree of difficulty from, say, a 9 (on a 1 to 10 scale) to maybe a 6 or 7. It is a compromise that might have been progressive in the 1990's. Not in 2014.
It is the kind of inertia that typifies our existing health care system..
With all the new kinds of approaches, I'll be happy if they still have to go through FDA approval, so that we still require some (relatively) objective testing about efficacy and safely. What I don't want to see is their falling through the rabbit hole into our crazy Alice-in-Wonderland health care system, which is what I fear happens if we require that only physicians can dispense them and expect them to be covered by health insurance. That's the wrong way to go.
When Google starts selling their nanoparticles, and they or someone else starting selling a maybe home 3D printer to produce the necessary corrective actions that the personal health AI prescribes, I hope they're selling them direct-to-consumers. More importantly, I hope that the medical-industrial establishment doesn't succeed in demanding control.
I have no doubt that there are still going to be physicians in our future health care system. However, if we truly want innovation in our health care system -- and it's not like anyone is particularly happy with our current one -- then we have to stay focused on our health, even if it means displacing the central role physicians have always played.
As entrepreneur Elon Musk says, when it comes to innovation, start from "first principles."
Tuesday, November 11, 2014
The Future Is Still Not Here
US News & World Report had some fun looking back at what experts in 2004 predicted for health care in 2014. Not surprisingly, they found that we're not quite there yet, but might be by 2025. The future, it would appear, is always ten years away.
Those 2004 pundits expected that health care would be one of the industries most impacted in these past ten years; specifically:
To be sure, there have been several important changes in our health care system over the past ten years. Some of the more important ones would have to include:
The absolute number of the uninsured has only dropped from 42.0 million in 2004 to 40.7 in 1Q 2014. Increases in spending have moderated, thank goodness, but most experts attribute this to the recent economic downturn rather than to any structural changes. Half of Americans now have a chronic disease, and our life expectancy rates still lag most other developed nations -- and may be declining.
If this is progress, I'm not sure we can take much more of it.
By way of contrast, think about the technology world in 2004:
Certainly there have been plenty of important clinical innovations -- new treatments, new devices, new drugs, new techniques -- in the last ten years. Still, I'm hard pressed to think of changes that have become part of people's everyday lives the way that the above tech changes have,
Critics might claim that smartphones, social media and video streaming don't improve the quality of life, but just dare to try to take them away from people. By contrast, if you offered to swap health insurance plans from 2004 with today's, I bet most people would jump at the chance, since they cost about 40% less and typically had much lower cost sharing requirements (Kaiser Family Foundation).
I'm also waiting for reports of either physicians or patients being delighted by all those EHRs.
The U.S. News & World Report article mentioned telemedicine as an example that many (still) predict as a key part of the future. Honestly, if a big breakthrough for 2024 is wider use of telemedicine, I'll be disappointed.
Don't get me wrong: I'm a big proponent of telemedicine, but in ten years shouldn't we be hoping for something more radical -- like, say, holographic or virtual reality visits? I'm willing to bet that the technology for those will exist, and that consumers would be very interested in using them, but I wouldn't risk much money betting that our moribund reimbursement and regulatory mechanisms will embrace them, or that providers would jump on those bandwagons either.
Or maybe the future is wearables, as everyone is trying to get in on the expected gold rush (e.g., Fitbit, Jawbone, Apple Healthkit, Microsoft Health, Google Fit). I suspect that wearables in 2024 will bear as much resemblance to today's as our mobile phones do to 2004's, but the real problem won't be the technology as how we'll use all that data. By 2024 we should be using real-time data to prevent hospitalizations (e.g., as Sentrian claims it can already do) and other acute episodes, but who will pay for, and act on, the monitoring and interventions?
One company -- Pact Health -- has already figured out a way to use results from activity trackers to adjust coverage, such as raising and lowering deductibles. It is a solution imperfectly crafted on top of a normal health plan, but at least it's a start. Too bad existing federal and state requirements for health coverage don't directly allow for such innovative approaches. That's a problem.
Some people might argue that other ACA initiatives, like ACOs or value-based purchasing, simply haven't had enough time to prove their worth. That may be valid, but I'm still not seeing the where-did-that-come-from aspects of either.
All those ACOs and other integrated health systems aspire to be Kaiser, but, as I wrote about previously, the Kaiser model may be more the past than the future. After 70 years, they hold dominant market position in California, but it is their only market where that is true. Their enrollment growth since 2004 averages a paltry 1.5% per year, and, for all their integration, their costs and cost increases really aren't any lower than competitors.
If in ten years we're all getting care through integrated delivery systems like Kaiser, that might be better for us, but it wouldn't be a breakthrough.
I've made some predictions about the future previously (Living in a Jetson's World), but what I really hope for is a system that doesn't just look like today's health care system modestly improved. I'm hoping for changes that seemingly come out of nowhere to radically reshape the system. Maybe that's gene therapy or nanotechnology (or, better yet, nanotechnology delivering gene therapy -- as is already being piloted). I don't know what they'll be, but someone is already working on them.
Whatever the changes are going to be, I worry that if they go through our existing delivery and financing mechanisms, they'll suffer the same fate as telemedicine -- slow, halting, incremental adoption that at best integrates with instead of reshaping.
As I wrote in Getting Our Piece of the Pie, I want to see health care's versions of Napster: innovations that are willing to wreck the system in order to reshape it. I want to see something that connects us to our health in the way that Facebook has connected us with our social circle, that democratizes health information and even treatments like Wikipedia has done for reference, or that untethers us in the way smartphones and YouTube have.
Let's not wait ten years.
Those 2004 pundits expected that health care would be one of the industries most impacted in these past ten years; specifically:
2004 prediction: In 10 years, the increasing use of online medical resources will yield substantial improvement in many of the pervasive problems now facing healthcare—including rising healthcare costs, poor customer service, the high prevalence of medical mistakes, malpractice concerns, and lack of access to medical care for many Americans.Whoops.
To be sure, there have been several important changes in our health care system over the past ten years. Some of the more important ones would have to include:
- PPACA has assisted several million more people to obtain coverage.
- HITECH has spurred EHR adoption.
- Share of coverage through employers has dropped significantly.
- Provider consolidation continues relentlessly.
The absolute number of the uninsured has only dropped from 42.0 million in 2004 to 40.7 in 1Q 2014. Increases in spending have moderated, thank goodness, but most experts attribute this to the recent economic downturn rather than to any structural changes. Half of Americans now have a chronic disease, and our life expectancy rates still lag most other developed nations -- and may be declining.
If this is progress, I'm not sure we can take much more of it.
By way of contrast, think about the technology world in 2004:
- Apple was selling the heck out of iPods, with the iTunes Music only a year old. The iPhone, iPad, and App Store were only gleams in Steve Job's mind.
- Google had just gone public. Google Maps had yet to debut (2005) and its Android mobile platform was years away (2007).
- Most mobile phones did not have cameras, the Motorola RAZR was the cool phone, and the Blackberry still set the standard for what passed as smartphone, with the Palm Treo giving it a run for its money.
- Facebook was still limited to university users, and Twitter was two years away from its first tweet.
- YouTube did not exist (2005), and Netflix hadn't started streaming (2007).
Certainly there have been plenty of important clinical innovations -- new treatments, new devices, new drugs, new techniques -- in the last ten years. Still, I'm hard pressed to think of changes that have become part of people's everyday lives the way that the above tech changes have,
Critics might claim that smartphones, social media and video streaming don't improve the quality of life, but just dare to try to take them away from people. By contrast, if you offered to swap health insurance plans from 2004 with today's, I bet most people would jump at the chance, since they cost about 40% less and typically had much lower cost sharing requirements (Kaiser Family Foundation).
I'm also waiting for reports of either physicians or patients being delighted by all those EHRs.
The U.S. News & World Report article mentioned telemedicine as an example that many (still) predict as a key part of the future. Honestly, if a big breakthrough for 2024 is wider use of telemedicine, I'll be disappointed.
Don't get me wrong: I'm a big proponent of telemedicine, but in ten years shouldn't we be hoping for something more radical -- like, say, holographic or virtual reality visits? I'm willing to bet that the technology for those will exist, and that consumers would be very interested in using them, but I wouldn't risk much money betting that our moribund reimbursement and regulatory mechanisms will embrace them, or that providers would jump on those bandwagons either.
Or maybe the future is wearables, as everyone is trying to get in on the expected gold rush (e.g., Fitbit, Jawbone, Apple Healthkit, Microsoft Health, Google Fit). I suspect that wearables in 2024 will bear as much resemblance to today's as our mobile phones do to 2004's, but the real problem won't be the technology as how we'll use all that data. By 2024 we should be using real-time data to prevent hospitalizations (e.g., as Sentrian claims it can already do) and other acute episodes, but who will pay for, and act on, the monitoring and interventions?
One company -- Pact Health -- has already figured out a way to use results from activity trackers to adjust coverage, such as raising and lowering deductibles. It is a solution imperfectly crafted on top of a normal health plan, but at least it's a start. Too bad existing federal and state requirements for health coverage don't directly allow for such innovative approaches. That's a problem.
Some people might argue that other ACA initiatives, like ACOs or value-based purchasing, simply haven't had enough time to prove their worth. That may be valid, but I'm still not seeing the where-did-that-come-from aspects of either.
All those ACOs and other integrated health systems aspire to be Kaiser, but, as I wrote about previously, the Kaiser model may be more the past than the future. After 70 years, they hold dominant market position in California, but it is their only market where that is true. Their enrollment growth since 2004 averages a paltry 1.5% per year, and, for all their integration, their costs and cost increases really aren't any lower than competitors.
If in ten years we're all getting care through integrated delivery systems like Kaiser, that might be better for us, but it wouldn't be a breakthrough.
I've made some predictions about the future previously (Living in a Jetson's World), but what I really hope for is a system that doesn't just look like today's health care system modestly improved. I'm hoping for changes that seemingly come out of nowhere to radically reshape the system. Maybe that's gene therapy or nanotechnology (or, better yet, nanotechnology delivering gene therapy -- as is already being piloted). I don't know what they'll be, but someone is already working on them.
Whatever the changes are going to be, I worry that if they go through our existing delivery and financing mechanisms, they'll suffer the same fate as telemedicine -- slow, halting, incremental adoption that at best integrates with instead of reshaping.
As I wrote in Getting Our Piece of the Pie, I want to see health care's versions of Napster: innovations that are willing to wreck the system in order to reshape it. I want to see something that connects us to our health in the way that Facebook has connected us with our social circle, that democratizes health information and even treatments like Wikipedia has done for reference, or that untethers us in the way smartphones and YouTube have.
Let's not wait ten years.
Tuesday, November 4, 2014
Stay Off of My Turf!
The obvious thing to write about would be the announcement of Microsoft Health, but I thought I'd switch gears by focusing on a seemingly unrelated topic: America's slow yet expensive Internet.
Bear with me and I promise to loop this back to health care.
The Open Technology Institute just released its Cost of Connectivity report for 2014. It concludes that "customers in the U.S. still tend to pay more than their peers in Asia and Europe for comparable broadband Internet service." Put even more simply, OTI asserts that we're "paying more money for slower Internet access."
Sadly, their conclusions are neither new nor surprising; the problem is well-understood. The OTI report includes an extensive literature documentation, but here are some similar findings:
There is widespread agreement about the reason why we're getting such a poor product: lack of competition. As Tim Wu, a Columbia law professor and antitrust expert, told The New York Times: “It’s just very simple economics. The average market has one or two serious Internet providers, and they set their prices at monopoly or duopoly pricing.”
In the early days of the Internet, before broadband, we got by through using cable or telephone lines. Now that we have moved into broadband, fiber optic is the technology of choice. But it is expensive to lay fiber optic cables, and monopoly or duopoly providers haven't seen much reason to make that investment.
Sure, maybe we can squeeze more speed out of copper wires -- as Bell Labs has demonstrated -- but technology isn't standing still; at some point, even current fiber cables will be outdated. It is a technological arms race that we are falling behind on.
ReadWrite's Adriana Lee contrasted concerted efforts to build out broadband infrastructure in South Korea and Romania versus our rather more laissez-faire attitude approach. The results? Well, as FCC Chairman Tom Wheeler said in September, "...three-quarters of American homes have no competitive choice for the essential infrastructure for 21st century economics and democracy."
The OTI report noted that the U.S. cities with the fastest service tended to either have municipal high-speed networks, or were pilot markets for Google's fiber-optic efforts. Susan Crawford, a former technology and science advisor to President Obama, told BBC last year:
You could rephrase the OTI quote above by saying that, when it comes to health care, we're paying more money for worse outcomes. If you don't believe that, check out OECD or Commonwealth Fund statistics.
The increasingly lack of competition is coming from provider consolidation, with health systems merging or acquiring rival systems, and also buying up physician practices. I've written on provider consolidation before, as have numerous others (e.g., Delbanco or AHIP). Much of the consolidation is done in the name of "clinical integration," but there is some pretty good empirical evidence that the main effect is to raise costs (for example, see Robinson and Miller). It is something that should worry anyone concerned about cost, quality, or innovation.
The aspect of our health care system that most obviously intersects with Internet speed is perhaps telemedicine, which has been fighting an uphill battle for mainstream recognition for much of this century. It is making progress, but the barriers to more widespread adoption are not technological but rather issues with our 20th century mechanisms for reimbursement and for provider licensing.
The common thread between provider consolidation and provider licensing is, of course, protecting turf. Providers vow that both are done in the best interests of patients, but that rings hollow to me.
The turf issue reached ridiculous new heights recently when the Supreme Court agreed to hear North Carolina Board of Dental Examiners vs FTC. Essentially, the Board tried to prevent anyone but dentists from doing teeth whitening. They claim they were simply protecting their (would-be) patients' oral health, but it sure looks like cartel activity to me. And I don't think either North Carolina nor dentists are unique in this kind of protective behavior.
George Will says these occupational licensure laws are "...residues of the mercantilist mentality, which was a residue of the feudal guild system, which was crony capitalism before there was capitalism." Ouch.
I've written previously on both state medical boards and medical education, which control who can do what to us for our health care. The Supreme Court has already previewed that it has a strong desire that such appropriate health care experts decide health care issues, rather than "bureaucrats," but I just wish I felt more confident that these various professional organizations were, in fact, acting in the public's best interest rather than that of their profession.
If they were, they'd be leading the charge for better performance monitoring and increased focus on patient safety. Instead, they're being dragging kicking & screaming,
It's not about the patient. It's about the money.
Rates for long distance calls plummeted in the 1980's, due to telephone companies being required to offer equal access to other long distance providers. That's the kind of innovation we should be looking for. It may be easier to see how that might apply to the Internet than to health care, but that's the fun challenge.
We need to be radically rethinking where we receive care; how and from whom we receive that care; how the people giving care get trained, licensed, and overseen; even what "care" is. Hey, in China they are working hard to integrate Traditional Chinese Medicine with so-called Western medicine; maybe nothing will come of it, but it is far too early for us to have closed minds about what works and what doesn't.
What I'm pretty sure won't work is anything aimed at artificially protecting someone's turf.
Bear with me and I promise to loop this back to health care.
The Open Technology Institute just released its Cost of Connectivity report for 2014. It concludes that "customers in the U.S. still tend to pay more than their peers in Asia and Europe for comparable broadband Internet service." Put even more simply, OTI asserts that we're "paying more money for slower Internet access."
Sadly, their conclusions are neither new nor surprising; the problem is well-understood. The OTI report includes an extensive literature documentation, but here are some similar findings:
- Akamai's State of the Internet report has the U.S. slipping to 14th place for average connection speed. Our average speed is less than half of South Korea's.
- The Ookla download speedtest puts us in 27th place, right between Finland and the U.K. South Korea is 3x faster, and they're only 2nd best in the world.
- Ookla puts us at a dismal 34th place for cost per Megabit per second (MBPS), paying $3.50/MBPS versus only $0.47 in Bulgaria. At least if measured by relative cost (calculated as cost divided by GDP per capita), we jump all the way to 19th place.
There is widespread agreement about the reason why we're getting such a poor product: lack of competition. As Tim Wu, a Columbia law professor and antitrust expert, told The New York Times: “It’s just very simple economics. The average market has one or two serious Internet providers, and they set their prices at monopoly or duopoly pricing.”
In the early days of the Internet, before broadband, we got by through using cable or telephone lines. Now that we have moved into broadband, fiber optic is the technology of choice. But it is expensive to lay fiber optic cables, and monopoly or duopoly providers haven't seen much reason to make that investment.
Sure, maybe we can squeeze more speed out of copper wires -- as Bell Labs has demonstrated -- but technology isn't standing still; at some point, even current fiber cables will be outdated. It is a technological arms race that we are falling behind on.
ReadWrite's Adriana Lee contrasted concerted efforts to build out broadband infrastructure in South Korea and Romania versus our rather more laissez-faire attitude approach. The results? Well, as FCC Chairman Tom Wheeler said in September, "...three-quarters of American homes have no competitive choice for the essential infrastructure for 21st century economics and democracy."
The OTI report noted that the U.S. cities with the fastest service tended to either have municipal high-speed networks, or were pilot markets for Google's fiber-optic efforts. Susan Crawford, a former technology and science advisor to President Obama, told BBC last year:
We deregulated high-speed internet access 10 years ago and since then we've seen enormous consolidation and monopolies, so left to their own devices, companies that supply internet access will charge high prices, because they face neither competition nor oversight.Hmm, a capital-intensive industry that has rapidly consolidated, to the point most markets have only one or two service providers, and those providers take advantage of their cozy market positions to charge high prices and innovate very cautiously. It may very well describe ISPs, but it sure as hell also characterizes much of our health care system, especially when it comes to health systems.
You could rephrase the OTI quote above by saying that, when it comes to health care, we're paying more money for worse outcomes. If you don't believe that, check out OECD or Commonwealth Fund statistics.
The increasingly lack of competition is coming from provider consolidation, with health systems merging or acquiring rival systems, and also buying up physician practices. I've written on provider consolidation before, as have numerous others (e.g., Delbanco or AHIP). Much of the consolidation is done in the name of "clinical integration," but there is some pretty good empirical evidence that the main effect is to raise costs (for example, see Robinson and Miller). It is something that should worry anyone concerned about cost, quality, or innovation.
The aspect of our health care system that most obviously intersects with Internet speed is perhaps telemedicine, which has been fighting an uphill battle for mainstream recognition for much of this century. It is making progress, but the barriers to more widespread adoption are not technological but rather issues with our 20th century mechanisms for reimbursement and for provider licensing.
The common thread between provider consolidation and provider licensing is, of course, protecting turf. Providers vow that both are done in the best interests of patients, but that rings hollow to me.
The turf issue reached ridiculous new heights recently when the Supreme Court agreed to hear North Carolina Board of Dental Examiners vs FTC. Essentially, the Board tried to prevent anyone but dentists from doing teeth whitening. They claim they were simply protecting their (would-be) patients' oral health, but it sure looks like cartel activity to me. And I don't think either North Carolina nor dentists are unique in this kind of protective behavior.
George Will says these occupational licensure laws are "...residues of the mercantilist mentality, which was a residue of the feudal guild system, which was crony capitalism before there was capitalism." Ouch.
I've written previously on both state medical boards and medical education, which control who can do what to us for our health care. The Supreme Court has already previewed that it has a strong desire that such appropriate health care experts decide health care issues, rather than "bureaucrats," but I just wish I felt more confident that these various professional organizations were, in fact, acting in the public's best interest rather than that of their profession.
If they were, they'd be leading the charge for better performance monitoring and increased focus on patient safety. Instead, they're being dragging kicking & screaming,
It's not about the patient. It's about the money.
Rates for long distance calls plummeted in the 1980's, due to telephone companies being required to offer equal access to other long distance providers. That's the kind of innovation we should be looking for. It may be easier to see how that might apply to the Internet than to health care, but that's the fun challenge.
We need to be radically rethinking where we receive care; how and from whom we receive that care; how the people giving care get trained, licensed, and overseen; even what "care" is. Hey, in China they are working hard to integrate Traditional Chinese Medicine with so-called Western medicine; maybe nothing will come of it, but it is far too early for us to have closed minds about what works and what doesn't.
What I'm pretty sure won't work is anything aimed at artificially protecting someone's turf.
Tuesday, October 28, 2014
Living in a Jetsons World
The quote of the week has to go to Deloitte's Harry Greenspun, M.D.. Speaking at WEDI's annual conference, FierceHealth IT reports he said: "We live in a Jetsons world, but when you go to the doctor's office it's like an episode of The Flintstones."
Millennials, you're going to have to look up those references.
To be fair, we're not quite in a Jetsons world yet -- anyone driving a flying car? -- but, on the other hand, I haven't seen a tablet at a doctor's office that is literally a stone tablet either. Still, I wouldn't at all be surprised to find doctors' offices that don't yet have computers, much less tablets, and the number of providers who can easily share patient data with other providers is low enough to remind one of the pre-Internet days. So, all in all, most of us know exactly what Dr. Greenspun was getting at.
Dr. Greenspun noted that the vast amount of health-related data that is, or soon will be, available challenges both providers and patients about how to best make use of it in a way that will positively impact patients' health. It's a good problem to have -- we've muddled along too long with only intermittent and incomplete data about what is happening with people's health -- but it is a problem nonetheless.
After all, about one-in-five Americans own a wearable device, according to PwC's The Wearable Future with one-in-ten wearing it daily. Two-thirds of Americans say would use one in exchange for discounts on their health insurance. Forty-four percent of those without wearables claim that better advice from their provider would be an incentive to use one. Analysts are predicting crazy growth rates for wearables -- 43.4% CAGR over the next 5 years -- and even if they're off it is clear there is going to be a heck of a lot more tracking.
That's potentially a lot of data, but it's as the old expression says: be careful what you wish for...
The other great point Dr. Greenspun made was that people are only patients in health care settings but are healthcare consumers all the time (or they should be, at least). I believe Dr. Greenspun was pointing out that there is a lot about people's health that happens outside health care settings -- which is certainly true -- but I'm also struck by the implicit duality in his characterization. Aren't they always consumers?
I've suggested before (Mistaking Success for Failure) that perhaps continuing to use the term "patient" is part of the problem. It fosters the illness-versus-health, dependent-versus-responsible, passive-versus-proactive attitude that pervades our health care system. We need a new word, something that recognizes that we're responsible for our own health, although sometimes we need help -- often a lot of it -- from others.
I'm open to suggestions.
What would care look like in a Jetson's world, hopefully one in which we've decided to really put patients/consumers/people first? Here are a few thoughts:
Millennials, you're going to have to look up those references.
To be fair, we're not quite in a Jetsons world yet -- anyone driving a flying car? -- but, on the other hand, I haven't seen a tablet at a doctor's office that is literally a stone tablet either. Still, I wouldn't at all be surprised to find doctors' offices that don't yet have computers, much less tablets, and the number of providers who can easily share patient data with other providers is low enough to remind one of the pre-Internet days. So, all in all, most of us know exactly what Dr. Greenspun was getting at.
Dr. Greenspun noted that the vast amount of health-related data that is, or soon will be, available challenges both providers and patients about how to best make use of it in a way that will positively impact patients' health. It's a good problem to have -- we've muddled along too long with only intermittent and incomplete data about what is happening with people's health -- but it is a problem nonetheless.
After all, about one-in-five Americans own a wearable device, according to PwC's The Wearable Future with one-in-ten wearing it daily. Two-thirds of Americans say would use one in exchange for discounts on their health insurance. Forty-four percent of those without wearables claim that better advice from their provider would be an incentive to use one. Analysts are predicting crazy growth rates for wearables -- 43.4% CAGR over the next 5 years -- and even if they're off it is clear there is going to be a heck of a lot more tracking.
That's potentially a lot of data, but it's as the old expression says: be careful what you wish for...
The other great point Dr. Greenspun made was that people are only patients in health care settings but are healthcare consumers all the time (or they should be, at least). I believe Dr. Greenspun was pointing out that there is a lot about people's health that happens outside health care settings -- which is certainly true -- but I'm also struck by the implicit duality in his characterization. Aren't they always consumers?
I've suggested before (Mistaking Success for Failure) that perhaps continuing to use the term "patient" is part of the problem. It fosters the illness-versus-health, dependent-versus-responsible, passive-versus-proactive attitude that pervades our health care system. We need a new word, something that recognizes that we're responsible for our own health, although sometimes we need help -- often a lot of it -- from others.
I'm open to suggestions.
What would care look like in a Jetson's world, hopefully one in which we've decided to really put patients/consumers/people first? Here are a few thoughts:
- For one thing, I wouldn't expect to get too much of that care in a doctor's office. As I wrote in I'll Take My Care To Go, we increasingly expect services to be ubiquitous, and health care is tracking in that direction. Yes, many people -- especially doctors -- firmly believe in a physician needing to see and touch patients, but with even today's optics and with steadily improving virtual reality for touch (e.g., Nimble VR), physical presence becomes much less important.
- I also wouldn't expect that you'll be seeing as much of doctors, or, in fact, actual humans for your care, at least for E&M. I wrote about the use of AI in May I Speak to the Doctor's Computer, and in a Jetsons world I fully expect a large percent of things that currently would require a physician could be dealt with via an expert system using AI. You wouldn't ever have to wait for them to call back. Of course, the system would need to know when to triage issues off to human experts (usually but not necessarily always physicians).
- Care will become much more proactive. All that monitoring will create massive amounts of data about what is going on with you and your health, analyzed real-time and producing targeted feedback. I see much of that feedback coming from -- again -- AI, in the form of a virtual health assistant or avatar. We've already got Alme from NextIT and Molly from Sense-ly. These avatars are only going to get better -- not only able to deal with more kinds of problems, but also more tailored to your needs and personality (e.g., some people need to be nagged, some rebel against nagging). They're not going to wait for you to notice or complain about a problem.
- We're not only going to get virtual replacements for caregivers. The Jetsons had a housekeeping robot named Rosie; maybe that will happen, but someone is going to make a fortune by developing a personal care robot. Hospitals, nursing homes, and assisted living centers struggle to staff their aides now, and the impending aging Baby Boomer demographics will demand we solve the staffing shortfall through technology. Toyota, for example, is already working on what they call "personal assist robots" for this very purpose. These will allow people to stay home longer/go home sooner and reshape our concept of "care," not to mention many of our institutional settings.
- Your health record will, indeed, be yours, in a graphic, easy-to-understand, actionable form that is available on-demand 24/7. Rather than worrying about providers trying to connect their various versions of your record, which they may or may not let you notate or even view, they will annotate your record, downloading whatever they need from it for their business needs.
- We're going to know what care costs in advance. These shell games that are being used to hide and disguise health care costs (e.g., absurd charge structures, out-of-network billing in in-network settings, after-the-fact medical necessity decisions) are evidence of a very dysfunctional market. We shouldn't be paying blindly for piecework that may or may not produce good results; we should be paying for actual results. Frankly, I'm not sure anything we're even testing now will resemble the payment and financing mechanisms we'll find in a Jetsons health care system.
Monday, October 20, 2014
Google Wants to Helpout Your Health
I suppose it was inevitable that I'd end up writing something about Google's interest in health, since recent posts have focused on efforts from Facebook and Amazon, as well as the general gold rush for health IT. Fortunately Google has obliged me by introducing a neat health-related wrinkle on their Helpouts service.
Google's new service pops up an offer to do a video chat with one of their Helpouts physicians when you are doing health-related searches, in case you want more expert opinions and advice. It certainly beats getting an ad for a pill or a health aid (although I don't imagine Google will stop presenting those as well).
Let's back up. For those of you not previously familiar with it (and count me among those), Helpouts is a Google service, launched last November, that allows consumers to connect with applicable experts via live video chats. Right from the start, they made sure it was HIPAA-compliant and included some physician experts.
The new feature connects the service to search results. You may not have Google Helpouts top-of-mind when looking for health information, but it's a pretty safe bet that you might use Google search in doing your research. Pew says 72% of Internet users searched for health information within the past year, with 77% of them starting with a search engine. Since Google commands about two-thirds of U.S. search results, they undoubtedly answer a lot of health requests -- thus giving them a potentially big market for Helpouts telemedicine feature. Those Helpouts doctors could be very busy.
"Google Docs" takes on a whole new meaning now, doesn't it?
The telemedicine aspect of Helpouts is not strikingly new. I've written on telemedicine before, especially about the painfully slow regulatory progress, but it continues to become more mainstream. According to a recent report by U.S. News & World Report, about a million patients a year use video services to talk to physicians, and half of U.S. hospitals use some sort of telemedicine, such as video visits or remote monitoring. There are starting to be plenty of telemedicine options, with more jumping in every day (including a new "virtual health concierge" approach by PlushCare).
What distinguishes Google's effort, of course, that it is pro-active. It doesn't wait for you to decide things are serious enough to seek out a doctor, but, rather, uses your search activity to trigger the offer of a consult. I think this will be an important part of our health system's future -- not merely reacting but being proactive. All these remote monitoring devices are pretty pointless if we don't use them to try to intervene early, instead of waiting for an acute event or an office visit to trigger care.
You have to figure that online content sites like WebMD or Mayo Clinic are kicking themselves for not thinking of this first, or at least not getting their versions in the market earlier. After all, plenty of shopping sites feature real time chat support, and Amazon offers its cool Mayday feature that connects Fire users to a real person via video. Surely getting the right health information is more important than picking the right pair of jeans, right?
I have a couple of suggestions, or at least questions, on the new Helpouts feature:
Of course, Google's health interests don't end with the current Helpouts approach. They are already pushing Google Fit as a way for Android developers to connect their health apps, and it'd be a great next step if Google could tie Helpouts to those apps, using the data mined from them to trigger an offer of a consult -- or an intervention, depending on the urgency of the need (e.g., it could trigger a 911 call if your heart monitor indicated a heart attack).
It'd be even better if you could opt-in your own physician(s) and health system to the Helpouts service instead of relying on Google's set of physicians. That would assume that your providers have the right capabilities, which some might and others will soon develop. Providing those capabilities might even open a new business opportunity for Google.
As long as I'm already trying to come up with more things Google could do in health, I might as well add that I'd love to see them get into the transparency business. They try to help consumers find the best prices for other goods, and certainly health care can use all the help it can get in this regard. There's no shortage of companies already working on the problem, but if any of them aren't worried about what a Google or an Amazon could do if they devoted resources to it, they're being myopic. At some point the market opportunity will simply be too big to pass up.
Whether Google buys one of the major transparency players or develops their own approach will be interesting to watch.
Google is thinking bigger than these more modest expansions, like their "moonshot" to genetically map a healthy human body, or their new health and well-being company Calico, which has already announced the building of a major research facility. I like that they are taking the long view, focusing on prevention and cures rather than simply more treatments, but there's still plenty of ways they can help the health care system in the short term as well.
Hmm, Google loves robots: maybe robotic surgery -- or doctors -- is next.
Google's new service pops up an offer to do a video chat with one of their Helpouts physicians when you are doing health-related searches, in case you want more expert opinions and advice. It certainly beats getting an ad for a pill or a health aid (although I don't imagine Google will stop presenting those as well).
Let's back up. For those of you not previously familiar with it (and count me among those), Helpouts is a Google service, launched last November, that allows consumers to connect with applicable experts via live video chats. Right from the start, they made sure it was HIPAA-compliant and included some physician experts.
The new feature connects the service to search results. You may not have Google Helpouts top-of-mind when looking for health information, but it's a pretty safe bet that you might use Google search in doing your research. Pew says 72% of Internet users searched for health information within the past year, with 77% of them starting with a search engine. Since Google commands about two-thirds of U.S. search results, they undoubtedly answer a lot of health requests -- thus giving them a potentially big market for Helpouts telemedicine feature. Those Helpouts doctors could be very busy.
"Google Docs" takes on a whole new meaning now, doesn't it?
The telemedicine aspect of Helpouts is not strikingly new. I've written on telemedicine before, especially about the painfully slow regulatory progress, but it continues to become more mainstream. According to a recent report by U.S. News & World Report, about a million patients a year use video services to talk to physicians, and half of U.S. hospitals use some sort of telemedicine, such as video visits or remote monitoring. There are starting to be plenty of telemedicine options, with more jumping in every day (including a new "virtual health concierge" approach by PlushCare).
What distinguishes Google's effort, of course, that it is pro-active. It doesn't wait for you to decide things are serious enough to seek out a doctor, but, rather, uses your search activity to trigger the offer of a consult. I think this will be an important part of our health system's future -- not merely reacting but being proactive. All these remote monitoring devices are pretty pointless if we don't use them to try to intervene early, instead of waiting for an acute event or an office visit to trigger care.
You have to figure that online content sites like WebMD or Mayo Clinic are kicking themselves for not thinking of this first, or at least not getting their versions in the market earlier. After all, plenty of shopping sites feature real time chat support, and Amazon offers its cool Mayday feature that connects Fire users to a real person via video. Surely getting the right health information is more important than picking the right pair of jeans, right?
I have a couple of suggestions, or at least questions, on the new Helpouts feature:
- It's not clear to me how specific the type of physician available is to the search request. If you are searching on angina, for example, it'd be nice if you got a cardiologist to talk with rather than a dermatologist.
- It's not clear to me if the experts are always physicians, or if they triage the experts based on the severity of the information being searched for. We have this problem that we tend to see physicians as the only authoritative source of information, and that may not always be true. Rather than starting with the most expensive, least available type of expert, perhaps Google could use their fancy algorithms to match search requests with the most appropriate type of expert, including nurses, nurse practitioners, physician assistants, or pharmacists.
Of course, Google's health interests don't end with the current Helpouts approach. They are already pushing Google Fit as a way for Android developers to connect their health apps, and it'd be a great next step if Google could tie Helpouts to those apps, using the data mined from them to trigger an offer of a consult -- or an intervention, depending on the urgency of the need (e.g., it could trigger a 911 call if your heart monitor indicated a heart attack).
It'd be even better if you could opt-in your own physician(s) and health system to the Helpouts service instead of relying on Google's set of physicians. That would assume that your providers have the right capabilities, which some might and others will soon develop. Providing those capabilities might even open a new business opportunity for Google.
As long as I'm already trying to come up with more things Google could do in health, I might as well add that I'd love to see them get into the transparency business. They try to help consumers find the best prices for other goods, and certainly health care can use all the help it can get in this regard. There's no shortage of companies already working on the problem, but if any of them aren't worried about what a Google or an Amazon could do if they devoted resources to it, they're being myopic. At some point the market opportunity will simply be too big to pass up.
Whether Google buys one of the major transparency players or develops their own approach will be interesting to watch.
Google is thinking bigger than these more modest expansions, like their "moonshot" to genetically map a healthy human body, or their new health and well-being company Calico, which has already announced the building of a major research facility. I like that they are taking the long view, focusing on prevention and cures rather than simply more treatments, but there's still plenty of ways they can help the health care system in the short term as well.
Hmm, Google loves robots: maybe robotic surgery -- or doctors -- is next.
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.
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.
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