Archive for the ‘health reform’ Category

Medicine and Obama’s Third Term.

Friday, June 4th, 2021

Obamacare changed American Medicine forever. I am becoming convinced that was a major purpose. Since 1978, Medicine and doctors have become the most regulated sector of the American economy.

Five years ago, I predicted one consequence. A doctor shortage. Why ?

A few years ago, it was reported that 10,000 doctors were leaving UK every year. How has the NHS dealt with this shortage?

By importing third world doctors.

The UK’s National Health Service (NHS) will soon begin a major campaign to recruit health workers from other countries to meet growing staff shortages.

Reports suggest a strategy has been drawn up to target a number of countries around the world, including poorer nations outside Europe.

One estimate in March this year said the NHS will need 5,000 extra nurses every year – three times the figure it currently recruits annually.

But what about the countries that it will recruit from – what impact will it have on them?

Where do non-UK staff come from?
The NHS already recruits globally to meet its staffing needs.

More than 12% of the workforce reported their nationality as not British, according to a report published last year.

How are we dealing with our doctor shortage ? By adding “Practitioners” instead of doctors.

How did this begin? In 1978, a new federal program was created called “Professional Standards Review Organizations.”

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It is time to start the economy again.

Saturday, March 21st, 2020

UPDATE: Here is a pretty good discussion of the economy right now.

I have previously described the COVID 19 virus, which is also referred to as Wuhan virus, to the annoyance of the China friendly US Media. The consequences for the US economy have been severe. The most affected states, New York, California, Illinois and Washington, have virtually shut down their population. Arizona is less affected with 78 positives cases as of today, and no deaths.

Italy and China have had the most deaths. There are a number of factors that probably affect these cases. China is notorious for air pollution and smoking, especially men smoking. There has been a dearth, so far, of listing comorbidities but age has been a major one.

One study lists mortality at age 80+ at 15%. The overall death rate in China was listed at 2.3%, which may reflect smoking and air pollution. South Korea, which has had a big spike as testing progressed much more rapidly than in the US, has a case mortality of less than 1%

South Korea has the dubious distinction of suffering the second-highest number of Covid-19 infections after China – but can also boast the lowest death ratio among countries with significant numbers of cases.

According to the WHO on March 6, the crude mortality ratio for Covid-19 – that is, the number of reported deaths divided by the number of reported cases – is between 3-4%. In Korea, as of March 9, that figure was a mere 0.7%.

AS US testing finally gets going, after the FDA and CDC delayed matters for a month, we will see a big spike in number of cases but, I am convinced, a big drop in mortality rate.

Telephone consulting services, drive-through test centers and thermal cameras – which, set up in buildings and public places to detect fever, swiftly came online. South Korea has undertaken approximately 190,000 tests thus far, according to KCDC Deputy Director General Kwon Jun-wook, and has the capacity to undertake 20,000 per day. Turnaround times are six-24 hours.

Tests are highly affordable. “The test kit is about $130, and about half is covered by insurance the other half by individual,” Kwon said. Those who test positive get the test free, “So there is no reason for suspected cases to hide their symptoms,” he said.

We should be doing the same.

At the same time, we are risking severe economic damage to the country by shutting down business activity. I believe that much of the drastic steps taken by governors, especially in New York and California, is unnecessary. High density cities like New York City and Chicago may have more reason to fear spread of the virus. Most of the country, a source of annoyance to left wing politicians, is of low population density.

Another failure of the US response is the absence of masks, which may play a role in limiting transmission in densely populated areas, as in Asia cities. There are reports that China has controlled most of the manufacturing and resists export.

China made half the world’s masks before the coronavirus emerged there, and it has expanded production nearly 12-fold since then. But it has claimed mask factory output for itself. Purchases and donations also brought China a big chunk of the world’s supply from elsewhere.

Now, worries about mask supplies are rising. As the virus’s global spread escalates, governments around the world are restricting exports of protective gear, which experts say could worsen the pandemic.

Also, there is now evidence that treatment of the infected may not require new drugs but be available with known drugs like chloroquine and its analog, hydroxychloroquine

Israeli pharmaceutical company Teva is donating millions of doses of a malaria drug that is believed to be effective in fighting the symptoms of the coronavirus.

The Jerusalem Post reports that the six million doses of hydroxychloroquine sulfate will be shipped to US hospitals started March 31. By the end of next month, 10 million will be shipped.

It is uncertain how effective the malaria treatment will be against coronavirus, but research is currently ongoing.

In fact, there is good evidence that it is effective.

The in vitro antiviral activity of chloroquine has been identified since the late 1960’s (Inglot, 1969; Miller and Lenard, 1981; Shimizu et al., 1972) and the growth of many different viruses can be inhibited in cell culture by both chloroquine and hydroxychloroquine, including the SARS coronavirus (Keyaerts et al., 2004). Some evidence for activity in mice has been found for a variety of viruses, including human coronavirus OC43 (Keyaerts et al., 2009), enterovirus EV-A71 (Tan et al., 2018), Zika virus (Li et al., 2017) and influenza A H5N1 (Yan et al., 2013). However, chloroquine did not prevent influenza infection in a randomized, double-blind, placebo-controlled clinical trial (Paton et al., 2011), and had no effect on dengue-infecteds patient in a randomized controlled trial in Vietnam.

I had speculated that they might be effective in Influenza but this appears to not be the case.

Clinical trials have already shown effectiveness.

According to Sun, patients treated with chloroquine demonstrated a better drop in fever, improvement of lung CT images, and required a shorter time to recover compared to parallel groups.

The percentage of patients with negative viral nucleic acid tests was also higher with the anti-malarial drug.

Chloroquine has so far showed no obvious serious adverse reactions in the more than 100 participants in the trials.

The first case report using remdesivir was dramatic.

The drug is now in clinical trial but the chloroquine evidence reduces the urgency of the study.

What do we do now ?

My wife and I are at high risk but it is easy for us to self isolate. The mortality rate for those under age 50 is about equal to that of influenza. For those between 50 and 70, only those with pre-existing morbidities have a serious risk.

It is time to reopen the economy certainly by next week. The damage done by unemployment and bankruptcy will far exceed that of the disease.

Healthcare as an election issue in 2020.

Wednesday, February 26th, 2020

There is a good deal of talk about healthcare among Democrats in the coming election. The latest is a Washington state Congresswoman telling us that American healthcare is causing people to die.

“Well if you did it on Wall Street speculation and obviously on the people who invest on the stock market who make enormous amounts of money would be paying that tiny financial transactions tax on their financial transactions. And I think the thing here to think about is we have a health care system that literally causes people to die.
… the system as a whole will cost us $55 trillion over the next ten years, so the question becomes, why would you protect the status quo? How do we make sure that every person has universal care?”

“Medicare for All” is a slogan, not a plan. I am a Medicare beneficiary and paid both halves of the Social Security tax since 1972 and Social Security tax since I was 16 years old. Ten years ago, I wrote a series of posts about what I considered a good choice of alternatives.

Since then, the American health care system was partially destroyed by Obamacare. I published a number of posts on those changes when it was introduced.

The net effects, in my opinion, were to destroy the small group plans (To the consternation of many Obama supporters in big cities.) while employer plans were left alone. The original intent was to roll those plans into Obamacare but the Democrats recognized that the electoral result would be catastrophic for their union support.

The Obamacare plans were approved by most hospital administrators who believed that the result would be greatly to the advantage of “vertically integrated” health care systems. As a result, many hospitals bought doctors’ practices and groups to control utilization and increase revenues. The failure to roll employer plans into Obamacare has limited the success of these plans but the control of doctors has proceeded apace. The hospital, where I spent 20 years in practice has now required staff members, some of whom have been on the staff 25 years, to get “permission” from salaried ER doctors before they are allowed to admit ill patients.

The Trauma surgery team I organized in 1979, was eventually fired and replaced by an anonymous group of surgeons from elsewhere.

At present, from the best I can discern, Obamacare consisted of an expanded Medicaid with intensified cost controls, applied through intrusive Electronic Health Record software, which is resulting in physician burnout.

While aimed at improving the quality of healthcare, CMS quality measures have had two unintended side effects:

Increasing data-entry demands on clinicians.
Creating a focus on fulfilling measures for reimbursement versus quality of care.

I was an enthusiast on electronic systems in the 1980s and 90s. I thought they would add quality and convenience. That has not happened.

Reevaluation of documentation to change policies to reduce regulatory burden. In a letter to CMS in February 2018, the American Association of Family Practitioners (AAFP) described its principles for reducing administrative burden on clinicians. The AAFP’s proposals included minimizing health IT utilization measures and implementing medical record documentation guidelines, data exchange policies, standard representation of clinical data models, prior authorization guidelines, measures harmonization, and certification and documentation procedures.

These are suggestions which are likely to be ignored unless the political situation changes.

What are the probable changes to come ? It depends on the election. The status quo ante was actually satisfactory to 85% of Americans. The poor was eligible for Medicaid which provided a baseline but was widely abused. Choices of insurance options were available. Young people could buy cheap catastrophic plans that protected them from accidents. Those are all gone. More young people are actually uninsured since the Obama administration shrank from enforcing mandates. Costs are higher as insurance companies make their money from processing claims. Bernie Sanders is actually correct on this topic. The solution would be to go back to an indemnity system of coverage and allow cash discounts by providers. There is no reason to spend $75 to process a $100 claim.

The French system would still be an option but the chance for real reform was lost with Obama care and the political will to try again is just not there.

Some thoughts on what reform in healthcare would look like.

Monday, April 1st, 2019

I have previously posted some articles on the French healthcare system, which is the best in Europe.

Here is an article on the French system.

The French citizen or resident joins Caisse Nationale d’Assurance Maladie deTravailleurs Salariés (CNAMTS)—health insurance organisation for salaried workers. That covers about 80% of the population now and it pays 80% (often more like 70%) of a fee schedule for the doctor visit although specialists are allowed to charge more. French doctors are divided for payment and fee schedule purposes into three “sectors” after 1980. Sector 1 doctors agreed to abide by the fee schedule established in 1960, modified for inflaton and technological changes. They are mostly primary care doctors although some had waivers from the fee schedule prior to 1971 because they were more experienced or had great reputations. Few are still practicing. Sector 2 doctors could set their own fees but reimbursement was still determined by the fee schedule. These two categories correspond roughly to Medicare assignment in the US. If you accept assignment, you agree to accept Medicare payment as the full payment (or 80% of it plus the Medi-Gap payment).

The French have private insurance companies that provide what we call “Medi-Gap policies for Medicare. Theirs cover everyone.

It seems unlikely to me that Democrats would accept a health plan that allowed balance billing, which is the only way to control costs, short of pure rationing. The French basically provide a fee schedule that is the same for everyone but which allows doctors to charge more if the patient is willing to pay. For example, I called the office of a new internist last week to schedule an appointment. The clerk required that I submit all my insurance information, not my health status, and the doctor would decide if he would see me. If he is that busy, perhaps he could justify charging more.

Here is another article from that series explaining the French system.

French primary care physicians are paid less than American but medical school in France does not require a college degree and is free. I suspect that system might be more attractive in the US than many realize.

Unfortunately, such a radical reform is unlikely. There are other options under consideration.

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From Russia to healthcare in one day.

Saturday, March 30th, 2019

Last Friday, the Mueller report was submitted to the DOJ. Monday, left wing media saw ratings collapse.

What next ? Why Healthcare, of course.

Obamacare, which is a form of expanded Medicaid, costs too much and provides too little care (high deductibles) unless you are a Medicaid recipient. It was designed to shift costs to the insured from the poor. It also was a gift to certain sectors of the healthcare industry. Ted Kennedy criticized healthcare as a “cottage industry” with lots of independent doctors doing their own thing as small businesspeople. That is why doctors have traditionally been conservative. Obamacare changed that. Healthcare is now an industry with doctors mostly on salary and controlled by administrators.

I talked to a young ophthalmologist last week, who had treated a mild eye disorder. He told me he moved to Tucson to work at U of Arizona medical center, which used to be called “UMC” by everybody in Arizona. He explained that the UMC administrators had gotten deeply into debt installing a new “Electronic Health Record” system and sold the UMC to Banner Health. This is a chain that runs the former UMC and has seen an exodus of university faculty physicians. Even my barber noticed. He told me several weeks ago that his surgeon, who had operated on him, got tired of constantly being told he only had 15 minutes to see each patient and left for the VA. The ophthalmologist was disappointed as he had looked forward to working at the academic center.

Traditionally, administrators hated doctors. We made their lives more difficult by advocating for patients. I once told an administrator that if the hospital did not reduce the markup on pacemakers, I would testify for the patient if they sued him for the balance of the bill. They didn’t like it but knew I could go elsewhere,and take my patients there. If I had been an employee, I would not have that choice. Several years ago, I explained how we started a trauma center in our hospital. Since then, the hospital has been sold to a non-profit run by nuns. The surgical group that ran the trauma center for 35 years was fired two years ago. They had declined to sell the group to the hospital. They were replaced by six female surgeons no one had ever heard of and who had never applied for privileges at the hospital or been evaluated by the Surgery Department. No one knew anything about them except one member of this new group had applied for a job at the trauma group and been turned down.

There were a few comments about some less satisfactory results on trauma cases but that has quickly gotten quiet.

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The Revenge of John McCain.

Saturday, December 1st, 2018

John McCain Was elected to Congress in 1982 and elected to the Senate in 1986 taking the seat previously held by Barry Goldwater. In 1989, he was involved in the “Keating Five Scandal.

The five senators—Alan Cranston (Democrat of California), Dennis DeConcini (Democrat of Arizona), John Glenn (Democrat of Ohio), John McCain (Republican of Arizona), and Donald W. Riegle, Jr. (Democrat of Michigan)—were accused of improperly intervening in 1987 on behalf of Charles H. Keating, Jr., Chairman of the Lincoln Savings and Loan Association, which was the target of a regulatory investigation by the Federal Home Loan Bank Board (FHLBB). The FHLBB subsequently backed off taking action against Lincoln.

The late 1980s were the era of the Savings and Loan scandals.

The Federal Home Loan Bank Act of 1932 created the S&L system to promote homeownership for the working class. The S&Ls paid lower-than-average interest rates on deposits. In return, they offered lower-than-average mortgage rates. S&Ls couldn’t lend money for commercial real estate, business expansion, or education. They didn’t even provide checking accounts.

In 1934, Congress created the FSLIC to insure the S&L deposits. It provided the same protection that the Federal Deposit Insurance Corporation does for commercial banks. By 1980, the FSLIC insured 4,000 S&Ls with total assets of $604 billion. State-sponsored insurance programs insured 590 S&Ls with assets of $12.2 billion.

Inflation in the late 1970s and early 1980s led to pressure on Savings and Loan institutions that had been lending money at 6% to home buyers but savers were demanding higher interest rates to compensate for inflation. The S&Ls were caught in the “Borrow high and Lend low” vise that led to their demise.

My review of Nicole Gelinas’ book on the 2008 economic crisis includes some discussion of the 1986 problems.

The story of the 2008 collapse begins in 1984 with the rescue of the Continental Illinois Bank. Here began the “too big to fail” story. Two things happened here that led to the crisis. One was the decision to bail out all depositors, including those whose deposits exceeded the FDIC maximum. Secondly, the FDIC guaranteed the bond holders, as well. Thus began the problem of moral hazard. Another feature of this story was the role of Penn Square Bank, which had gone under two years earlier in the wake of the oil price collapse, which devastated many of its poorly collateralized loans in the oil industry. Both banks had been caught seeking higher returns through risky investments. Penn Square, however, had been allowed to collapse. Continental was rescued and that began a trend that the author lays out in detail through most of the rest of the book.

The 1986 crisis and the 1989 scandal affected McCain deeply. He was a freshman Senator and was probably included in the group for two reasons. First he was the only Republican and Second, Keating, a Phoenix developer, was a constituent. McCain was humiliated and his ego was as big as all outdoors.

His reaction to his humiliation was once of the worst pieces of legislation in the 20th century, The McCain-Feingold Act.

In 1995, Senators John McCain (R-AZ) and Russ Feingold (D-WI) jointly published an op-ed calling for campaign finance reform, and began working on their own bill. In 1998, the Senate voted on the bill, but the bill failed to meet the 60 vote threshold to defeat a filibuster. All 45 Senate Democrats and 6 Senate Republicans voted to invoke cloture, but the remaining 49 Republicans voted against invoking cloture. This effectively killed the bill for the remainder of the 105th Congress.

McCain, still in his “Maverick mode and still running on ego, persisted.

McCain’s 2000 campaign for president and a series of scandals (including the Enron scandal) brought the issue of campaign finance to the fore of public consciousness in 2001. McCain and Feingold pushed the bill in the Senate, while Chris Shays (R-CT) and Marty Meehan (D-MA) led the effort to pass the bill in the House. In just the second successful use of the discharge petition since the 1980s, a mixture of Democrats and Republicans defied Speaker Dennis Hastert and passed a campaign finance reform bill. The House approved the bill with a 240–189 vote, sending the bill to the Senate. The bill passed the Senate in a 60–40 vote, the bare minimum required to overcome the filibuster. Throughout the Congressional battle on the bill, President Bush declined to take a strong position, but Bush signed the law in March 2002 after it cleared both houses of Congress.

The results have been disastrous. Congressmen have spent most of their time “dialing for dollars,” as fundraising is referred to and staff members write legislation. The result is monster bills, like Obamacare and Dodd-Frank, that have devastated the economy and destroyed healthcare in this country. Now another consequence is developing. Congress members are quitting.

Only once since 1930 has the number of voluntary departures been higher than it was this cycle. Members choosing to walk away from the legislative branch include eight Republican committee chairs, as well as House Speaker Paul Ryan (R-WI), who became the second speaker in a row to voluntarily give up the gavel of the most powerful position in the House.

Interviews with more than half a dozen departing members and some recently retired members revealed three major drivers behind the surge of retirements: a legislative process dominated by party leaders, the constant pressure to raise money, and political dysfunction plaguing Congress from top to bottom. The picture painted by these departing Republicans and Democrats lays bare a disturbing reality: Congress is fast becoming a place that repels, rather than attracts, public servants who want to get things done.

Committee chairs are expected to raise more money even than regular members.

Rep. Thomas Massie (R-KY), who was first elected to Congress in 2012, has said that party leaders’ efforts to get him to pay his dues went so far as reminders being “stuffed in my pocket during votes” on the House floor.

Asked what happens when member don’t pay their party dues, retiring Rep. Jimmy Duncan (R-TN) bluntly said “You don’t get these chairmanships.”

Outgoing Rep. Lynn Jenkins (R-KS), likewise, acknowledged fundraising frustrations and even joked, “My mom had taught me not to talk a lot about myself and never ask strangers for money, and then, that’s all I’ve done for the last ten years.”

Many soon-to-be retirees also look forward to walking away from the hostile culture that pervades Capitol Hill.

The recent decision by the Supreme Court on “Citizens United vs FEC has brought the issue into focus.

The United States Supreme Court held (5–4) on January 21, 2010, that the free speech clause of the First Amendment to the Constitution prohibits the government from restricting independent expenditures for communications by nonprofit corporations, for-profit corporations, labor unions, and other associations.

In the case, the conservative non-profit organization Citizens United sought to air a film critical of Hillary Clinton and to advertise the film during television broadcasts shortly before the 2008 Democratic primary election in which Clinton was running for U.S. President.

Outrage by Democrats followed and Obama even berated the Supreme Court majority during his State of the Union speech.

On January 27, 2010, Obama further condemned the decision during the 2010 State of the Union Address, stating that, “Last week, the Supreme Court reversed a century of law to open the floodgates for special interests – including foreign corporations – to spend without limit in our elections.

The statement about “foreign corporations” is a lie. He should know better since his campaign in 2008 disabled credit card verification to allow foreign donations, which are illegal.

Ultimately, John McCain did what he could in person to get revenge on the voters when he killed Obamacare repeal with his vote in the Senate in spite of his promise in the 2016 campaign to vote for repeal.

Why Importing Foreign Doctors may not fix the shortage.

Sunday, April 17th, 2016

MoS2 Template Master

The coming doctor shortage that I have previously written about might be dealt with as Canada did with theirs some years ago, by importing foreign medical graduates. Britain has adopted a similar plan as thousands of younger doctors plan to leave Britain.

How is the plan to import foreign doctors working out ?

Not very well.

Nearly three-quarters of doctors struck off the medical register in Britain are foreign, according to shocking figures uncovered in a Mail on Sunday investigation.
Medics who trained overseas have been banned from practising for a series of shocking blunders and misdemeanours.
Cases include an Indian GP who ran an immigration scam from his surgery, a Ghanaian neurosurgeon who pretended he had removed a patient’s brain tumour, and a Malaysian doctor who used 007-style watches to secretly film intimate examinations with his female patients.

First of all, foreign medical schools are often limited in real experience and students often graduate with nothing beyond classroom lectures.

This was the case with Mexican medical schools, like that in Guadalajara where many American students attended. A program was devised to provide them with a year of clinical training before they could be licensed.

The revelations come just a week after it emerged health bosses want to lure 400 trainee GPs here from India, to help ease short-staffing in the NHS.
Last night Julie Manning, chief executive of think-tank 2020 Health, said: ‘The NHS has thrived on many international doctors coming to work in the UK – but the public needs reassuring they are all truly fit to practise in the first place.’

Of course, the foreign doctors have their defenders.

Dr Ramesh Mehta, president of the British Association of Physicians of Indian Origin, admitted ‘there is a problem’ with the high strike-off rate among foreign doctors. But he claimed racism played a part.

We have a similar problem with affirmative action medical graduates but the figures are not available about their rates of license revocation. For example, the The Alan Bakke case went to the US Supreme Court, which eventually ruled in his favor. By the time the court ruled, years had gone by and Bakke eventually did gradate from medical school and has practiced quietly ever since.

However, a black student admitted by the program that denied Bakke a place was subsequently prosecuted for gross negligence and his license removed. Affirmative Action has been vigorously defended.

An admissions process that allows for ethnicity and other special characteristics to be used heavily in admission decisions yields powerful effects on the diversity of the student population and shows no evidence of diluting the quality of the graduates.

However, the conclusion does not match the findings in the study.

Regular admission students had higher scores on Parts I and II of the National Board of Medical Examiners examination, and special consideration students were more likely to repeat the examination to receive a passing grade.

The article goes on to explain that There was no difference in completion of residency training or evaluation of performance by residency directors.

A friend of mine was the Chairman of the Department of Surgery at a UC medical school who decided to fire a black female resident for incompetence. He was advised by the UC system and the other department heads that he would lose a lawsuit if she filed one. She did, in fact, file such a lawsuit alleging racial prejudice (of course). The department chair was able to successfully defend his decision but the fact that no one else was willing to try explains the finding that There was no difference in completion of residency training or evaluation of performance by residency directors.

I have had the experience of being a Surgery Department Chair in a community hospital confronted with the application of a known incompetent surgeon. The same factors apply to those known to be dishonest. A request for a letter of reference from the department in which the applicant trained usually results in a response that states, “The applicant completed the residency from X date to Y date.” No other information is provided and a further request is usually answered by “The matter is in litigation,” or words to that effect. This applies to all such applicants but affirmative action individuals are almost impossible to find negative information on even if the “grapevine” has provided warnings.

The general concern can be found, but details are thin on the ground.

A quick scan of the documents reveals that white students applying to medical school with a GPA in the 3.40-3.59 range and with an MCAT score in the 21-23 range (a below-average score on a test with a maximal score of 45) had an 11.5% acceptance rate (total of 1,500 applicants meeting these criteria). Meanwhile, a review of minority students (black, Latino, and Native American) with the same GPA and MCAT range had a 42.6% acceptance rate (total of 745 applicants meeting these criteria). Thus, as a minority student with a GPA and MCAT in the aforementioned ranges, you are more than 30% more likely to gain acceptance to a medical school.

There are other sources of the facts, but they don’t appear in mainstream publications. Social Justice keeps most of these concerns underground.

A friend of mine, who is Cuban born and an immigrant as a child, applied to UC, San Francisco medical school. This was in the 1970s. Affirmative Action was well underway. He waited several weeks, then months, to hear if he had been accepted. Finally, he drove to San Francisco and asked someone in the Admissions Office what had happened to his application. He was told that it was in the “Hispanic Applicant Committee.” Having no idea what criteria such a committee might be using to determine who should be admitted, he asked if his application could just be considered as a “white” applicant. This was done and he received a letter approving his admission a few days later.

The pressure is now on medical education to provide the hundreds of thousands of new doctors this society believes it needs. Productivity of the present graduates is well below that of my generation. Some of that is the disappearance of fee-for-service practice which motivates work ethic. Some of it is a result of the 60% female medical school classes.

The female doctor population is acknowledged to work less.

Today, however, increasing numbers of doctors — mostly women — decide to work part time or leave the profession. Since 2005 the part-time physician workforce has expanded by 62 percent, according to recent survey data from the American Medical Group Association, with nearly 4 in 10 female doctors between the ages of 35 and 44 reporting in 2010 that they worked part time.

This was the reason why medical school admissions committees “discriminated” against female applicants in the 1960s when I was a medical student. They were concerned, even then, about a doctor shortage and assumed women would stop working to have children or practice part-time.

They were absolutely correct.

Canada is finding some productivity issues and even some explanation.

a fee for service model, and its inherent encouragement of increased productivity through increased volume of patients, a significant shift away from this single model is taking hold.

This, of course, will not deter the Social Justice types as more doctors with less productivity is somehow more efficient than paying doctors more to encourage higher work loads. Socialism is the aim, productivity will have to take care of itself.

In the meantime, PHYSICIANS WHO DID not attend medical schools in the United States or Canada, referred to as “international medical graduates (IMGs)”, play an integral role in the U.S. health care system. Such physicians now represent approximately 25 percent of practicing doctors nationwide.

It’s going to increase.

The Doctor Shortage, discovered once more.

Friday, April 1st, 2016

33 - Lister

I have previously written posts about a coming doctor shortage.

They assume that primary care will be delivered by nurse practitioners and physician assistants. They are probably correct as we see with the new Wal Mart primary care clinics.

The company has opened five primary care locations in South Carolina and Texas, and plans to open a sixth clinic in Palestine, Tex., on Friday and another six by the end of the year. The clinics, it says, can offer a broader range of services, like chronic disease management, than the 100 or so acute care clinics leased by hospital operators at Walmarts across the country. Unlike CVS or Walgreens, which also offer some similar services, or Costco, which offers eye care, Walmart is marketing itself as a primary medical provider.

This is all well and good. What happens when a patient comes in with a serious condition ?

The health policy “experts” have been concerned to train “lesser licensed practitioners” and have pretty much ignored primary care MDs except to burden them with clumsy electronic medical record systems that take up time and make life miserable.

I repeatedly ask medical students if they would choose a career in primary care if it would completely erase their student loan debt. A few hands go up, but not many. In fact, for a while now, the federal government has dedicated millions of dollars to repaying loans for students who choose primary care. Yet residency match numbers show that the percentage of students choosing primary care is not increasing. Though loan forgiveness is a step in the right direction, medical students realize that by choosing a more lucrative specialty, they can pay off their loans just fine.

I proposed years ago, a health reform that resembled that of France where medical school is free. It could be arranged that service in primary care, low income clinics would give credit against student loans. Nothing happened. Except physician income has declined. And tuition has increased.

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Another update on the NHS, Bernie’s favorite health plan.

Friday, February 12th, 2016

NHS

I have mentioned problems with the NHS here before.

That was about emergency care.

Last fall there was a concern about junior doctors emigrating to other countries.

Britain is already suffering from a serious, and unprecedented, shortage of GPs, on a scale that doctors’ leaders say is fast becoming a crisis.

According to figures released last week, a staggering 10.2 per cent of full-time GP positions across the UK are currently vacant, a figure that has quadrupled in the past three years.

Two-thirds of practices are now finding it ‘difficult’ or ‘very difficult’ to find locums — freelance medics — to cover the shortfall.
As our population gets steadily older, and sicker, frontline surgeries are becoming increasingly swamped.
‘We are in dire straits if we do not act to address the GP recruitment crisis immediately,’ the Royal College of GPs warned last week.

In standard government medicine fashion, the British Health Minister imposed a new employment contract that ignored doctors complaints.

The result ?

Junior doctors are threatening a mass exodus to Australia after Jeremy Hunt forced through his controversial new contract yesterday.
There has been a huge surge in the numbers seeking certificates to practise abroad and some have already lined up jobs.
Almost 760 doctors were issued with documents by the General Medical Council in the first four weeks of this year – nearly 200 a week and almost double the usual number. Although they include some older GPs and consultants, the vast majority were disillusioned younger doctors.

Becoming a doctor is a classic middle class occupational choice. Few doctors become rich and almost none do so from actual practice. There was a phase in the 1960s when doctors suddenly became much more prosperous as Medicare was introduced, providing payment for care that had been done for no charge mostly. With time, the US government has reduced compensation and imposed rules designed to reduce costs. With the imposition of Obamacare, many older doctors who do not have heavy student loan balances and whose own children are educated, are choosing to drop all insurance, including Medicare, and practice for cash.

Obamacare has resulted in many hospitals consolidating and buying up medical practices to develop a vertically integrated system of health care delivery that resembles old industrial models. The result for physicians is a trend to salary jobs and dissatisfaction with their careers.

I met a woman geriatrician, the only fellowship trained geriatric specialist in central Iowa. She had quit Medicare. That sounds a bit suicidal if all your patients are Medicare age. What had happened was she was being harassed by Medicare because she was seeing patients too often. Many of them were frail elderly living at home. She dropped out and began charging her patients cash for services. She was making a decent living after a year and was happy with her decision. I don’t know how many realize that geriatrics, as a specialty, is a university subsidized field. There is no private geriatric practice because the doctor can’t survive on what Medicare pays. She tried and had to quit. She is doing it on her own now.

That was about Medicare. The same is happening with Obamacare and the medical conglomerates that have been assembled in anticipation of the “Industrial Model” of medical care. How is that working out in Britain ?

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2015 is gone, thank God.

Friday, January 1st, 2016

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I am content to see the year 2015 gone. I can remember as a college student thinking that 1960 would never come. That was a good year. I didn’t graduate from USC as planned but I did get married and I did get accepted to medical school.

Some of the story is here in my short biography. More of it is here in my “stream of consciousness.” The next installment is here as I describe Basic Training.

When I got back from Basic Training in December 1959, I had my first date with Irene Lynch. A year later to the day, we were married and a week later, I got a letter from SC Medical School telling I had been accepted to the class beginning in September 1961. So, 1960 was a pretty good year.

In 2015 I spent what I think will be my last year teaching medical students at what is now named “Keck School of Medicine of USC” and is where I attended from 1962 to 1966. I went back to teaching there in 1998 in a program called Introduction to Clinical Medicine, which seems to be disappearing into the “Family Medicine” Department which is a shame.

I now have a book of memoirs called “War Stories: 50 years in Medicine” and which is a Kindle book only so far. Much of my medical school experience is included along with stories from my years as a surgeon. It started to be “40 years a surgeon” but I decided to include the rest and changed to 50. In June 2016, it will 50 years since I graduated from Medical School and that seemed a appropriate.

I enjoyed my time with students and I am quitting only because of frustrations with the Electronic Medical Record, about which I used to be enthusiastic, and with changes in the County Hospital which used to be a wonderful teaching institution. The Electronic Medical Record, now more often called The Electronic Health Record, probably because much of it is not about medicine, is a big problem.

The EHR, as it is called, has acquired a bad reputation.

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