,
19 tweets,
4 min read
Read on Twitter
I had the privilege of interviewing @EricTopol yesterday about his new book Deep Medicine. Coming out in about a month. He is a delightful person to talk to--insightful, gracious, insightful, humble. One of the themes of the book that we discussed is the transformation of...
medical practice over the last 3-4 decades--how the doctor of today spends minimal time with any one patient, is distracted by the demands of electronic medical records (with little health payoff) and is driven by the business/accounting pressure of modern practice. The result...
is inferior medicine and doctor burnout. Inferior medicine because it seems that the human input into the doctor/patient relationship is powerful medicine. It may be driving the placebo effect and may play a bigger role in healing than we currently understand. Topol argues for...
a future where doctors use AI to do a big chunk of the thinking while spending more time with each patient listening and reading the non-measurable aspects of the patient--the non-verbal cues--while providing that human touch of listening and empathizing. But he worries that...
the improved productivity that AI may push us in the opposite direction--even shorter visits or doctor-free visits. I agreed, suggesting that the incentives simply aren't there in the current system for a human-centered medical encounter between doc and patient. What...
we didn't get to talk about is why the world looks so different today than it did in the past when medicine was slower, more time-intensive, less of a business and more of an art. I want to suggest an answer here with applications beyond medicine. What has changed since, say...
1960 in medicine? A lot of things. But one of them is the rise of third party payments. In 1960, most payments for medical care were paid by the patient to the doctor. A quick internet search says the number was 55% in 1960 and was down to 13% in 2004. Those numbers might not...
be precise but the trend is pretty clear. We've subsidized medical care enormously. You can debate whether this has been a good thing or not on net. Put that to the side. An unavoidable result of this transition is that the patient isn't the customer. The patient has become...
an input into a process that is dramatically more lucrative than it was in the past. It shouldn't be surprising that doctors pay less attention to patients and devote more time to regulatory compliance, through-put, the bottom line and so on. The same thing has happened in...
higher education. I won't bother digging up the numbers but I'm pretty confident that tuition is a smaller part of university revenue than it was 50 years ago. The student isn't the patient. So the romantic image we have of university life--young people exchanging ideas with...
wise mentors and learning how to--the image we have from various movies and maybe something of our own pasts--well that just isn't the way it works. Office hours are minimal. Multiple choice exams with large classes where students spit back what they've been told. Of course...
there are still great teachers and transformative classes in universities. But students aren't the customers, in general. They're inputs into what has become a dramatically more lucrative business, driven as in medicine, by...
enormous subsidies provided by government. As in medicine, these subsidies have had many desirable effects. But an undesirable effect is that they have degraded the face-to-face aspect of the encounter between doctor and patient, teacher and student. Good doctors and...
good teachers still care and may ignore some of the monetary incentives they face in doing their job. But it shouldn't surprise us that the overall effect of killing the feedback loops that would normally exist between customer and provider is to reduce the quality...
of their interaction. Doctors push for shorter patient visits. Professors push for more time to do their research (where the real money is flowing) and spend less time teaching and less time in office hours. And of course there are other effects--therapies and drugs of minimal...
effectiveness can persist because the patient's direct costs are so small. College courses of minimal value can persist because the student isn't paying their full cost. Sure, much of education is signaling, but part of that is endogenous, a result of the heavy subsidies...
Because we have destroyed the feedback loops that usually exist between customer and provider, we have all these other roundabout ways to reduce the wasted resources this kind of system inevitably produces. They don't work very well. The only other point to make is what has...
become too many tweets is that people assume that a private decentralized health care system is "impossible" because fill in the blank--asymmetric info, imperfect competition, etc. Such a system, supplemented by private foundations' aid to the poor would certainly be flawed...
Yet it is so easy to forgot how the current system, mostly the product of the Great Sausage Factory that is the political process comes with a few flaws of its own. We would be wise to remember that as we try to create a system that does better than the current mess.
