Sunday, April 6, 2014

The New American Doctor and The Single Payer

Lost in all the discussion of Obamacare and the direction health care will take in this country is a demographic change which Mad Dog has not seen mentioned yet: The sea change in the make up of the health care work force in the United States.

In today's New York Times "Sunday Review" are two articles about what the future holds for heath care in this country.  The first, by Molly Worthen, a history professor at UNC, Chapel Hill, is an insightful piece about why Canada was able to follow such a different course with respect to fashioning its health care system.
She notes the difference in the political climates of the two countries:
"Canada inherited something else from Britain besides the Westminster system. It retained the full spectrum of English politics. This includes the socialist left and the Tory right--both traditions that, despite their differences, call for a strong central government and the restraint of individual liberty in the interest of the community.
     The United States, by contrast, is a revolutionary state. The founders feared both kingly tyranny and the rule of the mob, and they bequeathed to us a political spectrum that is the narrowest in the Western world."

 And there was something different about the mechanics of politics: 
"American doctors succeeded where Canadian doctors failed (despite multiple doctors' strikes) because the American political system left individual politicians vulnerable to lobbying. They capitalized on the rhetoric of the Cold War, insisting that 'socialized medicine' was on step short of Soviet tyranny."

And there was another factor: Homogeneity in Canada but not in the USA:

"There is also no denying the ugly role that race played in this story: Too many white Americans have rejected reforms for fear that their tax dollars would help black Americans."

She is correct about all three factors, but her most interesting point is about race. Mad Dog would substitute "class" for this idea; here in New Hampshire, where there simply isn't as much race consciousness, because there simply are hardly any non whites here--outside of Manchester.  But you certainly, if you scratch the surface of the white Yankee resistance to Obamacare, find the resistance to the idea that I should help the poor--read that the "lazy"--when I've got problems of my own. 

Europeans cannot understand why Americans reject universal health care, until you ask the Swede, who has universal health care,  whether he'd be willing to support universal health care for all Europe, if that meant his tax dollars would support clinics in Spain, Italy or Greece. The Northern Europeans see themselves much as our New Hampshire Yankees do: We are the hard working, self sacrificing Northerners; they are the lazy, indolent, free-loading Southern Europeans, who sing and dance all night and are too hung over to go to work the next morning. Why should we worker ants support those slackers?

A great deal of the resistance to insuring the uninsured and extending health care to all derives from the resentment of the hard working to the notion of providing for the less enterprising --or less fortunate, depending on how you see the less economically successful.

Ross Douthat notes  we will see:
"A grinding , exhausting argument over how to pay for health care in a society that's growing older, consuming more care, and (especially if current secularizing trends persist) becoming more and more invested in post-poning death."

What neither Douthat nor Worthen focus on is the change in the American medical community, which as been theboiler room of resistance toward movement from a cash and carry system to a government paid system. 

In the 1950's and 1960's, American doctors were, overwhelmingly, white, male and the main if not the sole providers for their families.  Returning from World War II, they rode the post war economic boom, made money easily, built practices by simply hanging up a shingle and enjoyed a dream come true life. 

Even in the early 1970's, when Mad Dog went to London on a medical school rotation, he was struck by the differences in expectations between his American and British medical student friends.  The Brits were younger, just out of high school essentially, about 19 years old, and they expected a life of genteel respectability, but not wealth. They hoped to have a modest car, a flat to start off and, then a house, likely an attached house, in a middle class neighborhood. Their financial prospects were roughly equivalent to what an American kid with a high school education might expect if he were a good machinist and there was work in the factories.  Britain was simply nowhere near as rich as America. Doctors in Britain, if they could successfully emigrate and get past all the hurdles American doctors had erected at the border, could take a leap from modest comfort to dazzling luxury. 

The British students reflected these modest expectations in their modest commitment to patient care. They were out of the hospital at 5 PM, no matter what.  When they became the equivalent of interns and residents (Registrars), they were not up all night the way their American counterparts were. Their days were more contemplative, leisurely and far less filled with effort, management of details. They simply could not order the same range of tests for their patients, so there was less to do for them. They could not command the same range of therapies, so there was less to do.

American students, in those days, thought, "Ah, this is the difference between the rationing and tight budget restrictions in the British system and the more vigorous, incentive driven American system." And that was true, but the implication may not have been true: It may not have been true that the American system, hard driving, piston churning as it was, was better for the patient or for the country. In fact, much of what American doctors and hospitals did for patients may have been worse for patients, and it was most certainly far more expensive for everyone. The Brits, in retrospect, were driving Toyota Camrys and getting where they needed to go, while the Americans were driving fully loaded Mercedes, too fast, and wrecking a lot more often.

But now, decades later, as insurance companies have squeezed the American doctor far harder than Medicare ever did, the nature of the American doctor has changed. And changes have occurred in the demographics:  Virtually half of MD's are now female, and many of these are committed to their families first and their patients second. So, they take time off for pregnancies, choose specialties which allow them to get home early, refuse to take call on nights or weekends, retire in their 40's or 50's and generally spend less time at work. This is not to say they are not good doctors when they are at work; they are simply committed elsewhere.

And just as the Brits realized in the 1950's, it has finally dawned on American payers  that perhaps 50% of visits to doctor's offices for things like sore throats, cough, fever, back pain, injuries can be taken care of by nurses or somebody with far less expensive training than the MD:  a nurse practitioner in a CVS pharmacy, not even a "doc in the box" but a "nurse in the store."  The Brits had GP's doing the screening, referring patients who they had identified with more serious conditions back in the 1950's. Americans would have told you then they would not have tolerated being "pawned off" to a nurse. They wanted to see the doctor.

Now, the American doctor is not paid in the upper 10% any more. The primary care doctor, depending on where in the country she or he practices, makes $80,000 to $160,000.  You can do as well owning a McDonald's franchise. Own two, and you're doing way better than the pediatrician, the family practitioner or the internist.

And 85% of American doctors are not surgeons.  In fact, an increasing number are not MD's--they are "DO's" (doctors of osteopathy.)  The DO's are often among the most business savvy and do as well or better, financially,  than the MD's. They are often masters of marketing.

The surgeons can make $300,000-500,000, and some make millions. But things are changing there. The cardiac surgeons now face a loss of patient volume because angioplasties, stents and other procedures have cut down on the need for the basic heart surgery procedure: The CABG (coronary artery bypass grafting.) Training programs for heart surgeons which once may have had ten residents finishing a year, are now down to two or three. Simply not enough business out there.

So American medicine is now pretty much where British medicine was in 1970--a respectable, relatively secure profession, which promises a middle class life, and can be managed with a family in a decent community. You'll get a house, not a McMansion, and be able to afford a vacation. You'll also likely have significant medical school debt, which will diminish what you can afford for mortgage and you'll expose yourself to significant legal risks the average worker, the McDonald's franchise owner will not have:  Malpractice judgments. 

In short, your mother will be proud. Your father will tell all his friends about his daughter or his son the doctor, but the bloom is off the rose.

And this group of doctors will not, has not objected to the idea of a government salary to replace their commercial insurance company hassles.  Nearly ninety percent of American doctors get W-2 forms now, because they are employees, not the free wheeling, hardy, independent, self-employed doctors of yore.

Single payer?  American doctors now say:  Bring it on. 

And cover my malpractice insurance, while you're at it.


  1. Mad Dog,
    Well at least it would seem Vermont's move to a single payer system, as well as openness on the part of doctors to such a plan, moves us closer to universal healthcare. As Ms. Worthen points out, Canada's move to healthcare for all, also started in the hinterlands-Saskatchewan-before going national. Maybe it will be the same here....

    What do you think the effect of lowering the salaries and perks will mean for the medical profession? Right now medical schools are flooded with the applications of reportedly the "best and brightest", but if the compensation package becomes less than stellar will the applicant pool follow suit? Does that matter? I have to confess if I, or a family member, were facing surgery, I would take some comfort(rightly or wrongly) in the belief it would be performed by a "brilliant" surgeon, rather than a "fairly bright" one. There are few professions that require the years of training, cost, pressure and responsibility of a physician, so in my mind it merits a pay scale well above the average. Doctor's salaries are not the reason for our obscene medical costs, there are instances of over compensation-it's hard to justify a million dollar plastic surgeon-but those are the exceptions. In any case, do England and Canada's medical schools recruit from the top of the class?

  2. Maud,

    This is the subject for a long, long blog post. A quick summary would be that talent following money has operated in medicine, but in more complicated ways than in other fields.
    Clearly, during boom stock market times, bright students in highly competitive colleges rejected medical school and set their sites on Goldman Saks.
    Many in medicine said, "Good riddance to bad rubbish" about the loss of "talent" to Wall Street. "If money's what you are looking for, then don't look to medicine."
    In fact in the 1960's and 1970's at my own medical schools many of the faculty were independently wealthy and clearly had no economic need to do anything at all in the work arena, yet they went through the pre medical boot camp, through medical school, internship and residency because the problems in medicine and surgery fascinated them and because they got a sense of meaning and self worth from medicine they could not find sailing their yachts. I admired them for that--although they were often difficult human beings whose politics were those of the ruling class. That didn't keep them from staying up all night to save the leg of a Bowery bum.
    Now, with the advent of employed physicians and surgeons, with the advent of women and with a entry of more people from less privileged backgrounds one is more apt to see doctors behaving as if medicine is not a calling but a job.
    When your employer judges and rewards or penalizes you for your "productivity" you tend to very quickly see your job as just like any other job, since you are being treated that way.
    I do think the formation of doctors' unions would be a very positive development, just as college players' unions would be, and for many of the same reasons. You may be dealing with talented people, who love what they do, but that doesn't give you the right to profit from their performance and dole out only meager rewards to those who generate the profits.
    From the patient's point of view: It's not the Norman Rockwell doctor any more. But that's not all bad.

    Mad Dog

  3. Mad Dog,
    Your response confirms what I had hoped was the case, but then wasn't sure if I was being naive, that most doctors did not enter the field for the money or status and those willing to move on to greener pastures wouldn't be much of a loss to medicine. However, are you saying you think this will continue to be the case, or will changing pay,working conditions and it becoming more of a job than a calling, attract a different kind of applicant. I hope not-the thought your doctor would be just as happy managing a factory floor doesn't provide much comfort, especially since those motivated by money would most likely be the first to successfully adapt to the "productivity" "churn out the patients" model of medicine. I agree, all the more reason a physicians' union would be a great benefit to both doctors and patients and probably the only way they'll be able to buck the "high volume" model of care pushed by the medical corporations...

  4. Maud,

    It's complicated. The kid who goes to medical school at 22 may go into medicine for all the "right" reasons, but as the years go by, he/she gets jaded and more concerned about income, kids, vacations than about patients. The elders used to guard against burn out and loss of zeal, but now the elders tend to be fat cat rich guys and they are pushing for profit.
    I'm no longer sure I could select out people with "the right stuff."
    I'm not sure the older medical school classes--most students now entering after some years after college doing something else--has really resulted in selecting for people who want more meaningful work.
    The advent of women in medicine, which I thought offered great hope back in the 1970's has not worked out that way. Women, on the whole, tend to be kinder in the exam room but often are missing in action when things get tough--they are committed elsewhere to kids, family etc. Then again, the men, seeing that, have now done the same. It's all shift work now.

    Mad Dog