From: nyeda@cnsvax.uwec.edu (David Nye)
Newsgroups: sci.med
Subject: Re: Reliability in medicine and engineering  (was: ... incomes)
Date: 24 Dec 92 23:00:08 GMT
Organization: University of Wisconsin Eau Claire

[reply to hrubin@pop.stat.purdue.edu]
 
>>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.
 
I'm not saying that I like any of this.  As a doctor, I would much
prefer to practice medicine the way it is, if only someone would pay for
all the patients who currently can't afford insurance.  This of course
will never happen.  I think the changes I have outlined are unavoidable
and that the current system is doomed to collapse under its own weight
in a few years.  The US being what it is, I'm sure it will always be
possible for those with money to buy premium care.  For the rest, I
think the quality of medicine will suffer to some extent as it does
already under Medicare and Medicaid, but at least it will be accessible
to all.
 
I share your concern about the loss of thinkers in medicine.  The
average GPA of applicants to medical school has fallen almost every year
for over a decade.  This of course doesn't mean that we aren't getting
many good people, but some that would have been great physicians are
choosing other careers.  It could get a lot worse, depending on what
happens politically.  Add to this the increasing complexity of medicine.
 
The only way I can see for doctors of the future to be able to cope with
all this information is with computers.  The medical record will be
entirely electronic before long.  It already may be cheaper than paper.
Once the history and exam are in a computer, a decision support system
will use natural language processing techniques to extract the pertinent
clinical information (or perhaps the traditional record will be replaced
with a database format).  The computer will then present the doctor with
a differential diagnosis and suggestions for further workup and
treatment generated from those algorithms I mentioned earlier.  All of
the elements of this system are already developed, although natural
language processing techmology still needs more work.  The Internist
project at U. Pitt. with which Gordon has been involved has been
downsized and is available to run on a PC or Mac (Randy Miller's QMR).
It does a surprisingly good job on a limited domain (internal medicine).
The reason everyone isn't using it yet is because of the time that it
takes to enter the clinical information into the computer.  If it were
already in the computer and the expert system's advice were available
for free, everyone would use it.
 
I suspect the quality of medicine as practiced by the average
practitioner would be markedly better under such a system.  perhaps it
would even be reasonable to have nurses provide all community-based
primary care.  Most physicians would be involved in research, sorting
out the information needed to update the expert system and doing basic
research.

David Nye
nyeda@cnsvax.uwec.edu