From: hrubin@pop.stat.purdue.edu (Herman Rubin)
Subject: Re: Reliability in medicine and engineering  (was: ... incomes)
Organization: Purdue University Statistics Department
Date: Thu, 24 Dec 1992 14:15:13 GMT

In article <1992Dec23.172610.2996@cnsvax.uwec.edu> nyeda@cnsvax.uwec.edu (David Nye) writes:

			....................

>The big question of how to cut costs without cutting quality depends on
>what you mean by quality.  If we continue to insist that quality means
>unlimited access when we want it to all health care resources, then it
>can't be done.  If instead we decide that we really just want reasonable
>care for everyone, we can have it for much less than we currently spend.
>It will mean that some die who could have been saved.  It will mean
>rationing, such as no CPR for patients over 60 in an out-of-hospital
>arrest, (but less than 5% of those patients make it back, and at an
>exorbitant cost).  It will mean either eliminating medical malpractice
>or never finding against the physician when he follows standard approved
>algorithms for diagnosis and treatment (since nothing short of these
>will stop physicians from practicing defensive medicine).  It will mean
>that the insurance and legal industries will be cut out, which will put
>many lawyers and insurance industry people out of work.  It will mean
>that some physicians will lose their houses, and fewer qualified people
>will be attracted to medicine.

This is a typical totalitarian bureaucratic attitude toward what is 
reasonable, and it means poor care and little progress in any situation
which requires thinking and innovation.  If the rationers decide that
only 2% of our national income can be spent on medicine, that is what
will happen.  

According to the "following standard approved algorithms" approach, 
we would stagnate.  We are now frittering much medical research funding
on attempting to find cures by throwing money at a problem, such as
cancer chemotherapy, rather that by using much smaller amounts to find
out the basic information, and certainly most of that money will end 
up "wasted"; if we knew which methods would work, we do not have to
do research.  All research would have to be approved by bean counters,
and innovation would be even more stifled than it is now.

We need thinkers, and unfortunately the great bulk of today's physicians
already have it knocked out of them.  Now Mr. (Dr.?) Nye's proposal would
tell physicians that if they go by the book and refuse to think that they
are safe, but they are at risk if they deviate from it.  But we have had
cases posted to sci.med in which many overspecialists failed to see what
someone who could think found obvious.  Right now I am seeing several
physicians.  I cannot find one who can put things together; it is like
building a house where one cannot find an architect to even discuss the
overall design.

It will mean that a hack who completes the mandated medical training will
be secure for life, and that the already too small number of thinkers in
medical practice will almost vanish.

On the contrary, we must get the bureaucrats and bean counters out of the
process, and encourage thinkers to enter.  We should have far more medical
students, and not have the extremely low failure rate; nobody can evaluate
the candidates THAT well.
-- 
Herman Rubin, Dept. of Statistics, Purdue Univ., West Lafayette IN47907-1399
Phone: (317)494-6054
hrubin@snap.stat.purdue.edu (Internet, bitnet)  
{purdue,pur-ee}!snap.stat!hrubin(UUCP)