Health Care, Medical Care and Managers

Several articles have appeared, conveniently, raising the question of the possible shortage of medical personnel in the next years. Some state that disaffected medical people will leave the profession, some that the increase of patients will overwhelm a stable physician population. One article suggests the rise of "physician extenders" (PA's, nurse practitioners) to make up the deficit.

The physician problem is already here. Every office offers anecdotal reports with significant declines in insurance reimbursement. Inefficient offices will be collapse; physicians who are already burdened because of time demands, age detriments or simple morale fatigue will likely leave. This new health scheme was created with little input from anyone (it would be interesting to know who wrote the bill) but physicians had the least input of any involved group (other than patients.) The reason, of course, is that this plan is not concerned with medical care, it is concerned with health costs. When confronting costs, as Wal-mart can testify, quality is the first to go.

A generation ago I spent some time in what was then East Germany and met a number of medical students. They were all in a two year program out of high school. All were women. When I asked where the male students were I was told, "The men here go into engineering. Medicine is women's work." This is the product of one of government's fondest wishes: The belief in incrementalism. If there are varying levels of expertise in any system, there must be a very high and a very low quality that is necessary. Thus much of the routine medical work can be done by low quality personnel. After all, medics are superficially educated and they see a lot of serious injuries first. So do EMT's. Consequently the belief that the lower rung of medical complexity can be managed by lower rung personnel. The problem in medicine is that the first encounter usually determines the complexity. And stabilization is a lot different than management.

We are entering a very different time in medicine, the time of the manager. Medicine is extremely complex. It is a true profession; its foundation is vows. It is only incidentally a product. It now will become primarily a product, subject to all the stresses and pressures of others. That will solve a problem for the managers as a profession will not allow compromise in quality or motive. If the profession is destroyed or diminished, everything is negotiable. Soon medicine will be less available; then good medicine will be less available.

Finally real medicine will be scarce and available only to our betters.