From: rkaplan@netcom.com (Richard Kaplan)
Subject: Re: Repealing medical licensure laws
Organization: Netcom - Online Communication Services  (408 241-9760 guest) 
Distribution: usa
Date: Tue, 24 Nov 1992 02:02:48 GMT

In article <By6sCH.Bvp@mentor.cc.purdue.edu> hrubin@pop.stat.purdue.edu
 (Herman Rubin) writes:

>So what is the present situation?  At this time, I have no way of knowing
>if the doctor is a clod who can handle routine situations, or if he can
>think and do something sensible in a non-routine situation.  I suspect
>that at the present time most cannot.  

No system is perfect.  Yes, there are some incompetent
physicians in our current system.  But before changing to
some other system, we should assess if the new system is
likely to be better or worse.  Currently you at least know
that your physician graduated from an accredited medical
school, internship, and (in most cases) residency program
and that he passed appropriate licensing examinations and
that for a period of years during his training,his performance
treating patients was closely supervised and judged to
be acceptable by a large number of other physicians.

Under a pure free market system, apparently anyone could 
hang a shingle and practice medicine and there would be
no regulation of his training.  There would be only the word
of some private rating agency, whose qualifications
would be equally unclear.   

Then there is the problem I debated at length with
Tim Starr of the unconscious emergency room patient who
cannot make a true free market decision.  How would you 
solve that problem?

Why do you think your system would be better than the
current system?
  

>You are right that a patient cannot know how good the doctor is.  This is
>the situation WITH licensing.  In a free market situation, there might very
>well be an attempt to provide better information.  Fraud should be a far
>more serious crime than it is now, and interpreted so as to include much
>of the current hype.

As I have mentioned several times before, the laws
of a free market do not apply to patients with 
serious illnesses or to patients with emergency
conditions.  These patients do not have the ability
to research doctor ratings and thus some minimum standard
for physicians must exist.  If some agency wishes
to comparatively rate *LICENSED* physicians, that would
be fine (but see next paragraph for a problem).

May I also point out that in order to properly evaluate
a doctor's performance a private rating agency would
need to have access to a doctor's clinical files.  Surely
as a Libertarian (as I presume from your postings) you
would object to your private medical data being made
available to rating agencies.

Regarding fraud, that will be a problem under 
any system.  Address it with appropriate laws.
Don't change the system as a result of it.

>>2.  Acutely ill patients may not be able to rationally
>>make decisions, further exacerbating # 1 above.  If you
>>drive into a tiny town in Idaho with an acute appendicitis,
>>how will you know if your "surgeon" has appropriate training? 
>
>How do you know that the surgeon has not lost his skills?  How do
>you know that your surgeon has kept up with the increased knowledge
>about the dangers of anesthetics?  

No system is perfect.  I am open to suggestions on 
improving our current licensing system.  However, there
needs to be at least some minimum standard for a 
practicing physician.  Under the current system, I
know that a doctor treating me in an emergency situation
passed some objective standards for physician competency
and attended an accredited medical school in the past.
Under a free market system, there would be nothing
to stop a teenager who watches Doogie Howser, M.D.
from attempting brain surgery on a patient brought
into an emergency room with an alcohol overdose.

In a completely free market system, who decides who
is permitted to medically treat an unstable patient
who does not have family to speak for him?  We
can discuss the details of physician credentialing
if you wish, but clearly there has to be SOME such
system in place.  This cannot be left to anarchy.  

>Until we recognize that competence is not a 0/1 quality, we 
>cannot correct this.  Also, competence should be evaluated as
>such.  NO requirements of degrees, time spent in residence, 
>and such other idiocies associated with licensure.  It is what

There is no doubt that significant reform of medical
education and postgraduate medical training is sorely
needed.  I can list dozens of problems in addition to the
ones you mentioned.  However, none of this negates
the situation that *SOME* regulation is necessary.  See
above -- This cannot be left to anarchy.


-- 
Richard Kaplan M.D.           Medical Software Exchange BBS
806 2nd St. SW # 104          (507) 281-1989 14,400 HST
Rochester, MN  55902          (507) 281-1689 Voice
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