How Medical Licensing Laws Harm Patients and Trap Doctors
I am about to commit a professional heresy.
Here it goes: Government licensing of doctors is both morally and economically wrong.
Most organized medical societies including the AMA (American Medical Association) and my own state medical society support government licensing of physicians, on the grounds that it protects the public from incompetent practitioners. But as with all other forms of occupational licensing, medical licensing actually serves primarily to protect the practitioners at the expense of the public. Furthermore, the interaction between current licensing laws and upcoming ObamaCare laws will harm both patients and doctors in unanticipated ways.
Government licensing of physicians is a relatively new phenomenon. Prior to the mid-1800s, there was relatively little regulation over who could or could not practice medicine. But in 1847, the AMA was formed to promote the interests of MD physicians relative to other health practitioners (such as naturopaths and chiropractors). Over the next several decades, the AMA persuaded Congress and state legislators to shut down “substandard” medical schools and impose the current system of state-based medical licensing under licensing boards controlled by physicians. (Some of these other health practitioners eventually survived by forming their own government-sanctioned licensing organizations.)
Nobel Prize winning economist Milton Friedman identified the basic problem with medical licensing in his classic 1962 book Capitalism and Freedom. Friedman observed, “[L]icensure… almost inevitably becomes a tool in the hands of a special producer group to obtain a monopoly position at the expense of the rest of the public.” Licensing laws restrict the supply of practitioners, thus raising prices for patients. Thus, “The public [is] deprived of the medical care it wants to buy and is prevented from buying.”
Nor does licensing ensure professional competence. As a practicing physician, I know first-hand that it’s possible for someone to be a bad doctor yet still hold a state medical license.
I work with many excellent doctors. I also know a few atrocious doctors that I would never let touch me with a 10-foot pole. Yet all of them are licensed by the state of Colorado. In reality, state licensure does not and cannot protect patients from incompetent doctors.
Other private certification agencies provide much better protection for patients than government licensure. For instance, most major medical specialties have private certification boards that set a higher bar than mere state licensure. That’s why doctors typically advise you to seek someone who is “board certified” if you need a specialist such as a pediatrician, neurologist, or orthopedic surgeon.
Similarly, all reputable hospitals have a credentialing committee to oversee which physicians are allowed to practice in their facility. Some of my colleagues are members of these committees at their local hospitals and they work hard to weed out bad doctors. They are motivated by a simple, self-interested reason: the hospital’s reputation can suffer if incompetent doctors practice there. These private entities are much better guarantors of physician competence than mere state licensure.
Government licensure cannot guarantee physician competence. But government licensure can lull patients into a false sense of security. Just as we would never assume that someone possessing a state driver’s license is necessarily a safe driver, patients should never assume that someone possessing a state medical license is necessarily a competent physician. Ultimately, patients should assume primary responsibility for finding a good doctor, using some of the guidelines above, as well as through referrals from friends, family, and trusted physicians. (One good way is to ask your own family doctor, “Who would you send your mother to if she needed to see a specialist in X?”)
More fundamentally, government occupational licensure is morally and economically wrong because it violates individual rights. As Judge Andrew Napolitano recently said, “The state has no moral or lawful authority to restrain A and B from agreeing to exchange a service for a payment, providing that the agreement is voluntary.” Unless there is an issue of force or fraud, the government should leave patients free to seek medical care from willing providers on mutually agreeable terms.
Current medical licensing laws will have an increasingly harmful effect on patients and doctors as ObamaCare is phased in. This will be driven largely by the current shortage of physicians, expected to worsen under ObamaCare. The national shortfall of doctors is projected to reach 60,000 doctors in 2015 and 90,000 doctors by 2020, which amounts to roughly 10-15% of all practicing physicians. This number could climb much higher if a significant fraction of the 34% of doctors who have considering quitting due to ObamaCare actually do so.
ObamaCare also worsens the physician shortage by expanding the number of patients in government medical programs like Medicaid (which is notorious for underpaying physicians). One doctor noted that every time she sees a Medicaid patient, it’s like handing them a $20 bill. Hence, many doctors are choosing to not accept new Medicaid or Medicare patients (although they will likely continue seeing the ones they currently have).
As the New York Times notes, this causes an “invisible shortage” where patients are theoretically covered but have a hard time receiving actual medical care. The NYT notes that in some parts of the country, patients are already “driving long distances to doctors, languishing on waiting lists, overusing emergency rooms and even forgoing care.”
Awesome article. Just like Med insurance, it should cross state lines-why doesn’t med cert travel with the Dr? Is the AMA suggesting that doctors in one state are better than another state? How can that be if the AMA board is the ultimate licencing body?
Life is a racket! There are bad plumbers/carpenters; why not doctors too.
The notion that we’ll suffer a shortage of physicians is patently false because once ObamaCare is fully enacted anybody who can spell “aspirin” with the aid of a spell-checker will be a licensed physician. It’ll be a return, not to the 1800′s, but to the 1600′s. But it’s not all bad, I’ve got a Leech-O-Matic so I’m going to be a Doctor! And I won’t even have to be around sick people. Now if I can just avoid being burned as a witch…
Oh, we won’t have a shortage of physicians under Obamacare. We will have a shortage of competent, motivated physicians. The diploma mills will boom.
Without prescription laws there would be no shortage of primary care physicians because they would no longer be wasting their time on unnecessary (but profitable) office visits and lab tests. People would only see a doctor they decided that they needed to do so, not when the doctor wanted to see them to keep up his or her income. The health insurance companies are in the deal too since higher costs mean higher premiums, and the average private insurance company has a healthy “overhead” of about 20%. So if they can get you to see a doctor more often, they will be also able to convince you to pay a higher premium for your “insurance”. As might be said, “One hand washes the other”, with the public being the loser here.
that someone possessing a state driver’s license is necessarily a safe driver,
OTOH, someone who has a state driver’s license has at least once in his life passed a competency test regarding traffic laws and automobile handling.
That might not be the best analogy for you to use as you raise good points about the dangers of state-mandated regulation. I know someone who was a long-time hospital aide and quite competent at her job but lacked the ability to do well on tests. An enthusiasm for new state regulation cause her to be required to take a test which which she was unable pass and hence she lost her job. The hospital, which was where rubber met the road with regard to accountability, was perfectly happy with her.
The people who proclaim “social justice” really aren’t that interested in social justice.
Hillary Clinton had New York state paid some immense millions of money to NOT accept doctors into medical school. This limited the number of doctors graduating, and thus protecting the pay of the current, licensed doctors.
So, not only will there be fewer doctors in the future, there were active measures to make fewer doctors NOW.
If physician extenders (NPs, PAs) were to remain in their originally intended roles I would have no problem with their practice. However, it seems that in most managed care organizations they are equated with doctors, and their reasoning and orders are only reviewed by physicians after the fact, not in a real time manner. Unfortunnately, they’re NOT doctors and do not have the breadth and depth of training that physicians do.
Regarding state licensing boards is that the ones I’m familiar with tend to enact policies that stifle innovation, especially computer and internet use, under the guise of “protecting patients” when all they are protecting in reality is the status quo.
Hi, fan of good doctors, here. But- and- however- for healthy kids? and mandatory health stuff to get into school and so on? My sons have seen a PA for their whole life. I can probably count the number of times they’ve seen a certified MD on one hand. It’s a multi-staff clinic. The doctors defer to one PA who has been there forever, I think. I could ask for a doctor- but they’ve seen the PA since they were six weeks old. He’s set their bones, diagnosed their flu, treated their boils, treated their warts, checked their growth, diagnosed a nickel reaction, and wrote the orders for their vax, and their chicken pox waiver. He’s pretty sure he’s going to have them as patients until they are 18 and age out to the adult side of the clinic. Other kids have the same continuity.
My own experience is that regardless of how much education you have and/or how much reading you do, your brain only retains the knowledge that you use on a somewhat regular basis. Take for example calculating square root with pencil and paper. I learned this in high school (this was a decade before calculators) and again when I took a course in drafting. The second time I had to relearn how to do it and this was only a matter of a few years. However, the knowledge of how to do it is completely gone again as I have no need (given calculators) to know how to do it. I suspect the exact same thing is true with doctors. Most of what they learned in medical school has been forgotten because they only retain what they use on a somewhat regular basis. Over my lifetime I’ve read many thousands of books on various subjects. But all I retain are “bits and pieces” here and there. Obviously the human brain has a limit on what it holds, and it appears that knowledge that is not used or rarely used eventually gets “deleted”. Of course thanks to the Internet and Google, any knowledge you want to learn or relearn is obtainable for the most part. What this means is that while the medical student did study a lot, how much was actually “retained” a decade later? I suspect the amount that is retained is much less than we expect…
Yeah, for routine stuff? that can be pieced out. I’m not saying doctors shouldn’t. It’s just- there’s a crimp in the pipeline- there aren’t that many doctors coming out of med school. They don’t necessarily need to be seeing kids for shots or boils or even, apparently, broken bones. When the PA set the bone, after 6 weeks we went to the clinic to get an x-ray, right before camp. The doctor was prettty much “Why are you checking in with me? PAforever is the expert.” I had to explain I wasn’t questioning anything, I just wanted an x-ray before camp.
But for complex stuff? Doctors are great. The OB I went to is this really happy, light guy, but when a colleague walked up and asked a complicated question about a pregnancy in danger, it’s like a switch flipped, and he gave him a set of instructions to follow that aren’t in textbooks- really- I looked it up! It was just in research journals! The baby was saved, the mom was fine, everything was good. So I don’t presume to know what he knows. I know midwives surely do not know what he knows. And I know flight-surgeons don’t know- a flight surgeon delivered my friends’ babies, and his techniques were straight out of, oh, the sixties. She looks carved up like a turkey, while I don’t look like anything happened, even though I’d gotten more intense work done to get the babies out.
So, fan of doctors, just not a fan of them doing every little thing. And, again, there’s a crimp in the delivery system- put in place by Hillary Clinton, and presumably others.
Why stop at doctors? How about airline pilots?
I like free markets as well but Medicine is not a box of corn flakes. In this case consumer demand drives the licensing requirement for the same reason that I would not step on an airplane if pilots were not licensed. True, government can get out of hand but what happens is that doctors will go to another state if the Sate gets too restrictive, which is another market check.
In any case medical boards are not the real issue. It is not that hard to get a state license if you completed a qualified school and there is one national exam (3 part) for all the states although regulations differ from there. It is the specialty boards that have the real economic power and those are not government regulated.
When’s the last time you saw a pilot’s license? His point is that there are other people who are much more competent to decide that competency than some examiner who can be bought off one time.
And you also missed his point that absent federal licensing, the airlines themselves would still vigorously attend to the competence of their pilots – maybe even more so becasue they could no longer “blame” the licensing board.
Yes, what about airline pilots? What about car drivers? How about boats?
A license gives the consumer a false sense of security. “He’s a licensed MD, so he must know what he’s doing.”
It’s meaningless. Look at all the horrible, dangerous, stupid drivers on the road. Each one has a license. Someone above stated this means they “at least passed one competency test in their life”. So what? It’s multiple guess and they could have gotten lucky!
So many dumb retorts to this blog post. You could cherry pick a hundred examples of exceptions, but the fact is is most doctors don’t need a license to be good at what they do. It’s purely a system of Trade Unionism meant to protect those with jobs and paying a fee to the union to keep out those seeking jobs who don’t want to pay the union dues.
Just use your brain for 5 minutes to think it through.
In California naturopaths are licensed, which shows you how meaningless a license can be. However, licensing CAN and SHOULD be some measure of competence just like with pilot licenses. I have had three friends die at the hands of ‘alternative healers’ and where I live fakes and con artists abound who promise instant cures from everything from a runny nose to cancer. I live in an almost entirely liberal community, but conservatives often fall into the same trap, fearing vaccinations and fluoridation. People believe that stuff. If you had a free market where anybody could set up a practice without any oversight whatsoever how would the average citizen know who are the real doctors? Most people don’t bother to got to the considerable trouble of informing themselves about the progress of scientific medicine or even understand the basic science (thanks to the lousy science education on public schools).
Private associations are even worse than government licensing; the AMA caved to the chiropractors and thereby proved itself worse than any licensing board. They are really there just to protect the interests of the doctors and have no concern for the welfare of the patients. Some people are all too willing to make a buck of of the fears and anxieties of the sick and the acupuncturists, chiropractors, homeopaths and herbalists are waiting to exploit the unwary.
With or without licenses, there will be people who do it wrong, intentionally or not, and others will be hurt. Whether neurosurgeon trained at the finest hospitals with twenty years of exemplary work, or Bob-who-read-a-book-on-it-while-staying-at-the-I’m-a-smart-person-motel, the idea is not whether or not you were harmed, but whether you were A) MORE harmed by their adive/help/work than by not seeing a doctor, B) MORE harmed by them rather than a regular doctor (cause if a regular doctor would have done it, case closed), and C) intentionally misled or operated without knowledge or training, thereby jeapordizing the life with their negligence. The only deterrence is swift and fair prosecution with VERY harsh punishments for those who risk our lives for their profits, but it should only be for those who KNOWINGLY falsify or cover something up.
Much harm is done by ignorant boobies who think they’re qualified in some form of quackery. I’m reminded of the item I read once in the newspaper about some immigrant family whose infant was sick–they went to some sort of curandero or healer and he wrapped the tot in rags soaked in kerosene. The kid died. You can’t allow such loose cannons to operate freely doing more and more damage just because they didn’t know the harm they were doing. There are many crimes where intent to do harm is not an issue. You do the crime you should do the time.
Because natural selection is a bad instrument?
Idiots need to be weeded out. Progs would establish a board with the power of life and death. They would make lots of mistakes.
Nature would be the alternative. She makes some mistakes, but not nearly as many as a board of power-hungry, self-serving, egotistical idiots.
But then, I often think trial by combat would be far more effective than what we have now as a “legal” system.
I think you are confused about the principle of natural selection and its function in such cases.
IF quacks were subject to summary lynching by outraged patient/victims, THEN there would be some functioning of natural selection, presuming of curse that said quacks took on apprentice quacks to pass on their techniques of fraud.
Of course that would have to also apply to legitimate physicians as well, since there would be no functional way to tell the difference between a quack engaged in general quackery and a physician who made an honest mistake, or just had a patient get to him too late. But hey, you can’t make an omelet without breaking some eggs, so legitimate physicians had best learn to have a 100% success rate or else.
IF however you mean to suggest natural selection is operating among the people choosing a physician over a quack, then it breaks down much faster, as there would be little to enable such distinction without any sort of licensing service, and even a database, if actually legal, would be difficult to properly consult in an emergency situation. Further, the actual victim of an improper choice might not be the person making it, further diluting the actual effect of the selection, particularly with men.
If I were king with unlimited powers for a day I could solve the high cost of medical care in that same day.
- Abolish all federal & state taxes & fees on hospitals, medical equipment manufacturers and inventors, doctors, nurses, and practitioners not directly related to profit or personal income.
- Initiate licensing and oversight through some qualified private concern, siumilar to Underwriters Labs.
- Federal law to over ride all state and federal limitations on interstate insurance competition.
- Forgive federal student loans for persons graduating an accredited US school with an MD who achieve a GPA of 3.5 or higher after nationally standardzing the grading system. Make it a federal felony for medical schools to screw with the grading system with a minimum 10 year sentence.
- Repeal all laws that discourage pharma companies from R&D.
- Encourage & enable primary care w advanced nurse practitioners.
- Encourage competition in every way possible in all aspects of health care. If a private hospital wants to build more rooms than the area can support, that is their problem, not some half-assed state bureaucrat.
- If we concede that we are stuck with Medicare and Medicaid, fund the damn things properly so docs can make a buck, even if that means increasing the payroll tax.
- Find some way to cut down on the time it takes to be a doc. Ten or twelve years is just outrageous.
I’m not king so we’ll just continue to let social engineers and other busybodies screw things up.
You left out the one thing that would make an immediate difference in medical costs and availability: dramatic reform of the legal environment. It is insane that 12 morons with drivers’ licenses can make a determination as to whether a doctor provided appropriate care. The factual determination of malpractice should be made by a special master, a qualified arbitrator, or expert board. Only if a qualified entity made a determination that there was malpractice could the matter go to a jury for a determination of appropriate damages with strict limits on pain and suffering damages and punatives.
Agreed. However, IMHO tort reform must be at the state level to be constitutional. I especially like your expert board idea. Good docs will be harder on their contemporaries than anybody else and the goal should be to get bad docs out of the profession, not to enrich buzzards like trial lawyers. My apology to buzzards.
I don’t trust twelve people with anything but guilt or innocence in a criminal trial, and barely that. For reparations, they will always overdo it oen way or another.
Juries are the reason I don’t support the death penalty. Understand, I don’t have a moral issue with it; if you do something to me or mine, you’d best pray to God the cops find you before I do. But, I’ve used the same rules and tools a prosecutor uses to take lives and liberties to take people’s jobs. I’m as good as any prosecutor and better than most and over 20-odd years of practice as a labor relations advocate I’ve won too many cases I should have lost and lost too many I should have won to have anything like enough faith in the adversarial system to use it to take someone’s life.
I especially abhor the system where the AG or DA is elected and, especially, in death penalty states. Advocates keep score and rank each other and it is intensely competitive. What I liked most about being an advocate was on the front page of the decision it said who the parties, i.e., contestants, were and on the back it said who won. I tried to play it straight and I think I mostly did, but I can’t deny that I took more than a few cases forward without much thought to whether our position was right or wrong but with whether or not I could win. The brass ring for prosecutors is winning a death penalty case. Unfortunately, it causes ambitious prosecutors to over-charge so they can carve the notch in their gun butt or wherever. Casey Anthony would be doing twenty years or so now if they’d just charged her with some involuntary level of homicide or even emphasized the lesser included, but, no, they wanted to strap the little ditz to a gurney. Any fool could see that girl had never formed an intention in her life. And that’s just one very recent and notorious example.
“How about airline pilots?”
I’m not an advocate of doing away with licensure for pilots but from what I’ve seen of the licensure process, it is much like my Captain’s license; an irrelevant barrier to entry. I have a certificate on the wall and a red document that looks like, and works like, a Passport that says I am a “licensed professional mariner” authorized to operate for hire a motor vessel of not more than 100 Tons in coastal waters. If I had actually learned all the stuff the Coast Guard could have asked me about, I could have walked aboard any pre-18th Century sailing ship and so long as I had a sailing master to handle the setting of the sails set out across the oceans or around the World. The reason I limit it to pre-18th Century is that I’m not qualified for true celestial navigation, which began with the development of accurate chronometers and sextants (I’m working on it to extend my license to “Offshore,” but I’m stuggling with math I haven’t used since high school and know I won’t ever have to use in the trade.) The only thing I’ll ever use from the bulk of my studying and testing for my license is the “Rules of the Road,” and you have to know at least the broad strokes and bright colors of that to safely operate a pleasure craft, and there are nice “cheat sheets” for lights and signals that even professionals keep at the helm because you don’t see a lot of things every day. The emphasis in maritime licensure is on dead reckoning navigation working from paper charts. NOBODY DOES THAT ANYMORE! I kept paper charts and kept them up to date because the CG made me. My 30′ boat had redundant GPS, one of which was a chartplotter, and I usually had a handheld GPS aboard as well. I had radar, both a magnetic compass and an electronic compass that talked to the radar, and I had redundant marine VHF radio, one of which had DSC, which talked to the GPS and if I had an emergency would automatically give the CG my position and ID number which they could reference to gather the details of my boat. I also had an AIS receiver that would tell me about any large commercial vessels near me, which eliminates much of the need to know lights. All those electronics can be had for under $5K, considerably less if you can install it yourself. The big commercial vessels are almost totally automated with the “helmsman” making suggestions to the computers with a joystick, yet they require both a unlimited oceans master and a Pilot at the helm in most coastal waters.
What the license doesn’t do is require you to demonstrate any actual ability to operate a vessel, just knowlege about operating one. I know lots of guys, and women, who are a better hand with a boat, especially in close quarters, than I ame, but I take tests really, really well. Consequently, I could charge people to go out on my boat and those without that piece of paper can’t.
A thought, anyone can hang out a shingle to practice medicine, but only licensed physicians can purchase malpractice insurance. Change the bankruptcy code so that unlicensed practitioners cannot have a judgment discharged in a bankruptcy proceeding. Everyone is happy.
I see what you say and agree and would even take it a step further. From the Insurance end, we also have a controlled group similar to the medical field. It has driven up the prices of insurances, (health included), because of requirements under law. What was once just a ‘wise’ decision to buy insurance is now required, (in the instance of medical and auto anyway, and let us remember life is required for loans and mortgages by loan companies). Because the price was controlled by supply and demand the cost was originally low but now driven up by the same kind of special interest monopoly groups. Required health insurance, now driven by similar circumstances can only drive up the cost of health insurance and medical care.
“The state has no moral or lawful authority to restrain A and B from agreeing to exchange a service for a payment, providing that the agreement is voluntary.”
So physician assisted suicide is fine?
Not to mention prescription shopping, or “physician assisted addiction”?
Just to be clear.
You do realize, and I am sure you do, that both of those issues exist already within the framework of our system today?
Yes, I do realize that.
And I take you realize that the particular position they occupy in that framework is as crimes.
Conversely under the framework of that principle they would be perfectly legal, and indeed it would even be illegal to interfere with it.
Your article completely ignores the free-for-all-charlatans situation that predated medical licensure.
I guess you are advocating we return to that?
I am no fan of the way Medical Boards can operate [as any government board can grow intoxicated with their power and self-importance], but they DO censure, limit, and revoke licensure based on quality and protecting the public. Given that a large proportion of patients are minors, it seems important to at least protect kids from their parents who want to take them to a voodoo practitioner for their preventive health care, and insurers (the rest of us) for paying for it.
Thank You For your article. We do need some sort of control to who is a licensed physician and allowed to practice, like proof of education and comprehension. But that agency should be independent. Right now the whole profession is controlled by big pharma including its education of Doctors. I
Eevil Big Pharma. Prove your belief with a few facts, Joan.
When involved as a consultant for SB1720 (Ted Kennedy’s attempt at national health care) I came across a couple articles that I wished I kept, but made such an impression.
The California board of medical quality assurances, was quoted speaking on the quality of doctors practicing in the state and mentioned that 1 in 10 are not qualified and it could be as high as 1 in 5. Very scary thought.
And then the story about the fraud in medical care/billing that was approaching 1 out of every 4 dollars spent was in fraud and abuse.
And as to censure and protecting the public that is laughable.
A few years back I was an expert witness in the death of child at a dental office. The office had 35 malpractice cases in the previous 5 years, and yet they were operating as if no problem, giving the illusion of safety when none existed, and the illusion of quality of care when none existed.
Then there was the health care group, that was involved with billing fraud, quality of care issues and unlicensed people practicing, but the state did nothing until there was a problem with the economic base of this HMO type group, but patients weren’t warned, and in the 5 years of investigating, nobody was being held accountable for the continuous fraud and lack of quality of care.
And the list goes on.
There is a certain component of Darwin here…what you will see are legions of lawyers chasing all these providers and real doctors refusing to bail out the midlevel practitioners to avoid involvement with the quality of medicine being provided. Specialty societies will then become certification agents which will be countered by the formation of mail order medical societies with very fancy names intimating some sort of quality overview…when in fact they are just scams like many of the “self-conferred” specialties which sound impressive but are just charades.
As the New York Times notes, this causes an “invisible shortage” where patients are theoretically covered but have a hard time receiving actual medical care. The NYT notes that in some parts of the country, patients are already “driving long distances to doctors, languishing on waiting lists, overusing emergency rooms and even forgoing care.”
Like the $2 shoes in Russia. No stores currently stock them, but when they have them, they’re only $2.
Dr Hsieh’s historical info is quite misleading. Misleading info often leads to poor or incorrect conclusions.
It was the Flexner report of 1910 that put the kibosh on the many for-profit (repeat: FOR-PROFIT) medical schools, and shifted American medicine toward the science-based model. There was little docs could do for illnesses in the early 20th century, and quacks abounded, per Hsieh’s free market preference.
in 1904 there were 28000 students in 160 med schools. With the closure of the for-profit Doctor mills and the shift to university (i.e., scientific) schools, in 1920 there were 85 schools with 14000 students. The loss of “trained” docs then was no sociobiologic disaster, because so many of them were quacks peddling nostrums.
While founded in 1847, the AMA was incorporated in 1897. Since the 1960s (that rotten decade) it has gradually morphed into a Leftist drift, today counting fewer than 14% of practicing American MDs as members.
Today, the bottom students only enter primary care. We are headed on the path to “barefoot” providers. The toughest specialty to enter now? Plastic Surgery. Hot, because they get to charge market rates for cosmetic surgery, own their own spas. The last vestige for free-market medicine, Dr. Hsieh.
The rest of American medicine is on an inexorable downward slope, and that has precious little to do with State licensing boards. It has to do with economic/demographic insanity brought to us by the Left, which gives Americans many internationals: Bangladeshi, Pakistani, and Chinese medical graduates, inter alia. Some (a few) are great; the rest, not so much.
Yes, you’re correct, but in 1904 a doctor made the same income as a journeyman mechanic, but by 1914 the income of licensed doctors was four times that after riding the progressive reform wave limiting the population of doctors; of course, ethnic minorities and women were basically purged from the surviving training schools, and the progressive Wilson administration had introduced race based hiring/discrimination in the federal civil service, not to mention the defunct/failed League of Nations. I fail to see why state licensing boards should not be separated from training school enrollment decisions, or why federal school loans should be wasted on degrees in the History of Consciousness or critical race theory when the scarce resources could have been dedicated to increasing medical school enrollments.
Dr. Hsieh is partially correct in his recommendation to relax licensing to enable nurse practitioners and the like to “practice medicine” to a greater degree. However his libertarian dogma gets in the way when he starts to advocate elimination of licensing – a total free market – for medical services providers. The “solution” to our health care problems, as articulated by Dr. Hsieh in both his writings here at PJ and in lectures, is a complete free market in medical care with “charity” as the solution for the uninsured and uninsurable. If one measures a successful healthcare system by universal coverage and a high level of outcome, I challenge Dr. Hsieh, or anyone else, to identify a single successful healthcare system, anywhere in the world, based on libertarian claptrap.
Actually, charity was the foundation of most US Hospitals until Medicare and Hill-Burton came along in the 1960s. And docs were charitable at those hospitals too. Medicare’s egalitarian rules PROHIBIT charity to individual patients; if a M’care provider is charitable to one patient, he must make that same charity available to ALL M’care patients. Look it up in your Provider Manual.
Worshippers of systems always ignore individuals.
Actually happened here at the local hospitals. The hospitals were “forgiving” the Medicare deductible (a lot smaller then than now), and they were told by Medicare that it was illegal to do so. Effectively the hospitals were helping the patient, but the government (Medicare is a part of the federal government) was telling the hospitals that they couldn’t do this. Government is truly often more the problem than the solution. Remember too, really smart people don’t become politicians because they can do better in other fields than politics…
Let me get this straight. A physician will no longer be licensed and there will be a cap on medical malpractice. So are you trying to say that even though you completely screwed up and killed my young spouse, your only responsibility will be to maybe give a LITTLE compensation, say around $1,000? This is what we’ve come down to?
I pray none of you have to deal with a doctor destroying TWO young and very productive lives because he didn’t want to take time away from his golf game to play doctor.
We really have become a disposable society.
don: What is the actual total cost to produce an American doctor? It exceeds nominal tuition, BTW.
Inevitably, my comment will be coloured by my being born and raised in Britain. I would not hesitate to say that the best in the USA can equal or outrank the best anywhere else.
Here in England we have had Colleges of Physicians and Surgeons, both incorporated by royal charters, the RCS in 1369 and the RCP in 1517. The idea of a doctor being a medical practitioner is, historically, a late development; the word doctor is derives from the Latin “docere”, which means “to teach”. Only in fairly revcent times has it been applied – and that as a mere courtesy title – to medical practitioners who did not have a doctoral degree.
Here a medical student pursued a course of training and study to first degree level, which would involve AT THE VERY LEAST a Bachelor of Medicine(MB) degree; he would normally also study to obtain a Bachelor of Surgery(ChB) qualification. Further study might lead him to the following levels recognised by the two Colleges, viz. that of Licentiate(LRCP/LRCS), with Membership(MRCP/MRCS) next up the ladder. At, or at least near, the top would be Fellowship(FRCP/FRCS). A curious survival from those olden times is that an FRCS is referred to as Mr So-and-So and not Dostor So-and-so; here “Mister” is to be understood as a by-form of “Master”.
Do we have something akin to your AMA? Yes, we have the General Medical Council(BMC) which serves as a disciplinary body to deal with those who abuse their position in relationship to a patient. If some aspects may sound arcane and a mite quaint to US ears, well, it seems to work!
I disagree with several of your points. I am a doctor.
Hospitals do not do a very good job of policing bad doctors. To the contrary. The more money a doctor makes for a hospital, the more the hospital protects them. In addition, as more doctors have become employed, their allegiance turns to doing the hospital’s bidding. I have been a victim of sham peer review…maligning a doctor’s personal or professional medical credentials… for economic reasons, not quality of care reasons. This is especially the case in smaller hospitals, or communities with just one hospital.
As more hospitals are employing doctors and driving private practice doctors out of the community…oh, yes, this happens, see above…hospitals are become de facto medical cartels in their communities. If the hospital doesn’t want you to practice in the community and you need a hospital for your specialty…too bad. Hospitals sign exclusive contracts which grant a monopoly to certain doctors, and shield them from competition. Hospitals are also making doctors sign non compete clauses so that they cannot stay in the community if they decide they don’t want to work for the hospital anymore. This is a bad practice, especially for so called not for profit hospitals.
Employed physicians do not work for a patient. They work for the hospital and the hospital board and CEO, which do not have a patient care duty. Theirs is a fiduciary duty, and when a doctor has his or her paycheck signed by a hospital CEO, the fiduciary duty takes precedence. I see it every day in our local community hospital.
Finally, regarding mid level providers. Granting them additional responsibility seems to be a popular idea in Obamacare and with the hard left academics who promote Nurse practitioners, who often argue their care is ” just as good” as a doctor, across the board. In my practice, I see mid level providers practicing on the backs of other doctors…soliciting them for advice…or Googling. I also take issue with your assertion that all midlevels know their limits. I have had NP’s tell me I have to do certain things because the law allows it…not that I think they are in over their heads. Also, in some states, NP’s do not have to have physician supervision, and doctors have no say over what an NP does, because technically NP’s are not practicing medicine.
There is a reason doctors go through the training they do. If it is true, as you seem to think, that midlevels can do it just as well, then we should close down the medical schools right away. I think that’s absurd, but the arguments being put forth that midlevels are just as equivalent to physicians is equally absurd.
Midlevels tend to order far more tests and as their practices are expanded based on political concerns, that bill will become due. But the real reason the government likes midlevels is that they follow protocols to a T…the centerpiece of the Electronic Medical Record is also having all diagnostic and therapeutic orders judged by a population based computer protocol and allowed or disallowed as the government sees fit. Midlevels don’t know what they don’t know…ideal for following orders.
The ipad will bury you.
Just kidding. But you need to embrace technology, and be the leader mentor to the new class of practitioners. Face it, there aren’t enough of you, but much of what you learned in medical school can be canned and spat out by computers, especially if you have smart folks working with those computers, under your guidance.
Adapt, or the ipad will bury you.
“Government licensing of physicians is a relatively new phenomenon. Prior to the mid-1800s, there was relatively little regulation over who could or could not practice medicine.”
Not subjecting criminal suspects to judicial torture is a relatively new phenomenon. Prior to the mid-1600s, most criminal suspects were tortured into admitting guilt.
I am a physician and this has been a topic of discussion recently in the medical community, but not for the reasons mentioned in this article. The truth is that medical licensing in America is handled by state boards who are powerful, capricious, unsupervised and unaccountable to ANYONE! In recent years many of them have flagrantly abused this power, and violated the civil rights of innocent doctors, often destroying their careers and their lives! This is totally unacceptable in the USA. But, has received virtually no press.
But, another reason that medical licensing will not go the way of the dodo, is that the fees (which are EXORBITANT) collected from physicians are a major “cash cow” for state treasuries, to the point that they constitute a dramatically unfair TAX on doctors.
Physicians long ago gave up the idea that they/we would ever be treated fairly. Politicians and lawyers just too much enjoy bashing us, criminalizing us, and blaming us for all the problems in health care, all while threatening our livelihoods and stealing from us!! The reality is that the ship is sinking and we have been bailing as hard as we can. But, not much longer.
licensing is just another tax. taxation without consent of the governed == slavery. this is true no matter what tyranny the government commits outside the Constitution.
if doctors want to impose a “tax” on themselves in private association for the purposes of licensing, no problem.
when non-doctors impose such a tax, big problem.
I’m not hearing the elephant in the room (nor seeing it in this article – but I can feel it). Its the FDA. Its not medical licensing that is limiting medicine in the US, its the FDA that limits doctors from using tools that have been a boon to engineers for the last 30 years. Yeah, computers are starting to peak into the medical practice. But the real help will be diagnostic databases, which are smarter and faster than even MIT graduates. But the FDA has blocked them for over a decade, and now it wants to even block med devices that are tied to ipad/smart phone tech.
Additionally, doctors should work to get undergraduate degrees in medicine. Are you telling me that medicine is more complicated than engineering, physics, or chemistry? As a PhD who has education in nuclear engineering and has used and worked on Physiologically-Based Pharmacokinetic (PBPK) Modeling, I’ll tell you its not. Pace the medical profession, its the knowledge that makes the difference (and of course, the human touch). Medical diagnostic databases have that knowledge. And computers are starting to take over even at surgery.
We still need doctors. But they need to re-imagine themselves, and become team leaders for a new emerging class of medical techs, who use technology like their engineering cousins. The sooner they overthrow the old order, the faster prices will drop…
Prices for medical care will not drop unless and until medical care is recognized to be what it is…an service for which a consumer will pay money.
Doctors don’t set their fees anymore. Fees are established by fiat, generally by the government and insurance companies. The fee is more often than not, totally irrational…I spend a good deal of time trying to game the system. Insurance company A pays 100 percent of the fee I set by Ingenix. What do I do? I raise my fee, because I don’t charge enough.
When there are ten or twenty reimbursements for the same medical procedure or bill…and for which the provider has no input as to his pricing based on the actual cost and value of the procedure as determined by the provider…then the game is to get as much as you can, regardless.
Only when prices can be set by the providers…and modified by true competitive forces in which the actual cost of the procedure is related to the actual cost, and not a theoretical cost imposed by the government…will prices come down.
As it is,everyone seems to believe the government knows best, and so the game is to maximize revenue from the patient, and to hell with the theoretical cost.
As to Ipads deadite…well, the filtering capacity of the internet is not there yet with regards to discrimination functions of the complexity of medical care no matter what you think. But by all means, go ahead and try. Doesn’t affect me…it’s your life.
Well said and thank you.
Medicine in this country has devolved into a complete SCAM. It’s all about doctors trying to squeeze the most amount of money from the smallest amount of work.
Paul Hsieh’s idea to end licensing is a good one, but it will NEVER happen. Doctors would much rather have a “doctor shortage” where they are in high-demand and able to financially rape the patient, rather than one where medical care is cheap and available.
“Do no harm?” That’s the biggest crock of all.
Behind every great fortune is a great crime. Doctors are no exception to this.
Go Galt brethren, Go Galt.