From: jlove@ivrit.ra.itd.umich.edu (Jack Love)
Newsgroups: talk.politics.medicine
Subject: Re: The future of medicine
Date: 11 Jan 1993 15:34:00 GMT
Organization: /usr/local/trn/lib/organization
NNTP-Posting-Host: ivrit.ra.itd.umich.edu

In article <1993Jan11.021922.3067@cnsvax.uwec.edu> nyeda@cnsvax.uwec.edu (David Nye) writes:
>[reply to jlove@ivrit.ra.itd.umich.edu]
> 
>>I found this to a remarkably well-reasoned brief article
> 
>Gee, thanks. :)

You're welcome.

>>>When the inevitable rationing begins, we are going to have many
>>>dissatisfied customers.
> 
>>My quibble here is that I think we already have rationing.
> 
>True, but I think it is going to become much more overt.  Few carriers
>now deny treatment unless it is experimental or of no proven utility.
>What I meant by rationing is what was attempted in Oregon, or the rules
>in the Brittish system that no one over a certain age is eligible for a
>transplant or gets recussitated after an arrest.

We need more of that "public discussion" you're promoting. I'm not
sure I wouldn't rather have the Oregon or Brittish way of doing
things. And I mean "I'm not sure." So far, I think the data are
incomplete or inconclusive. 

>The most common situation in which an unnecessary test is ordered is
>when the physician is confident that he can exclude some diagnosis based
>on his history and examination, but knows that a negative test will
>carry more weight in court than his own observations.  This is the
>rational behind ordering a brain imaging study in a patient with a
>migraine.  If the patient's headaches are not present every day, they
>can't be due to a brain tumor (the tumor doesn't come and go once a week
>or month).  What happens if the patient is found to have an unrelated
>brain tumor or a ruptured aneurysm 5 years later?  I've seen physicians
>successfully sued in this situation.  Most physicians just figure they
>will avoid the potential hassle and get the study, even if it isn't
>indicated.  Some physicians will get any study a patient asks for, even
>when they know it isn't indicated, just to avoid antagonizing the
>patient.

The above statement was true before we ever worried about "defensive
medicine." I don't think I'm competent to judge the merits of the
other sorts of examples. The last time this matter came up in the
general press, I recall seeing an article by a physician who said
that if the malpractice industry dried up tomorrow, most doctors
would continue doing many of the tests that are now included in
this category.

>>While my suggestions are not quite as radical as shooting all the
>>lawyers and destroying all the insurance companies, they would result
>>in some additional unemployment in both professions. :-)
> 
>If they contribute nothing to the quality of health care, they have no
>right a slice of the pie.  

But they do contribute something. Insurance companies represent 
a source of knowledge about claims-handling, office automation
technology, etc. As long as they are bidding for business in
a competitive environment, the public has much to be gained by
availing themselves (lousy grammar but this is UseNet) of the
resources. Lawyers can serve as a vital check on abuse, either
individual or systemic. Once again, the key is to stack the 
deck as well as possible to serve public and individual interests.
The book I made reference to, Tobias, "The Invisible Bankers"
considers these issues far better than I can suggest in the 
space of a brief reply.

>>>quality control maintained by professional societies, not the
>>>courts.  I won't hold my breath waiting for this to happen, though.
> 
>>For one reason or another, the members are never held to appropriate
>>standards.
> 
>True.  Well, perhaps a panel of experts, physicians employed by the
>state?

I'm not sure why you are specifying that the panel be composed
of physicians. Any such panel would have to have the public's
trust, and this would seem to me to mandate a more diverse
composition.
-- 
________________________________________
Jack F. Love	| 	Opinions expressed are mine alone.
		|	(Unless you happen to agree.)
Newsgroups: talk.politics.medicine