From: hrubin@pop.stat.purdue.edu (Herman Rubin)
Subject: Re: Repealing medical licensure laws
Organization: Purdue University Statistics Department
Distribution: usa
Date: Mon, 23 Nov 1992 20:45:52 GMT

In article <1992Nov21.020336.4390@netcom.com> rkaplan@netcom.com (Richard Kaplan) writes:
>In article <1992Nov20.104503.636@genie.slhs.udel.edu>
> starr@genie.slhs.udel.edu (Tim Starr) writes:

>>I see no reason why the State should be any better at determining the
>>quality of medical practitioners than the private sector, and plenty of
>>reasons why it should be worse.  A medical license is no guarantee against
>>pseudo-science.  Why shouldn't opening up the market for this form of
>>highly skilled labor induce competition (assuming the absence of State
>>financing) which would reduce prices and improve quality?

>I agree wholeheartedly that MAJOR reform in medical education
>and in policing quality of care by licensed physicians
>is sorely needed.  That said, however, repealing medical
>licensure laws (and reverting said authority to a free 
>market) would be a tragic disaster because:

>1.  For the overwhelming majority of citizens, the public 
>does not have sufficient understanding of physiology to make
>an informed decision regarding the quality of care of a 
>doctor.  Yes, a patient can decide if he likes a given 
>doctor's beside manner, availability, etc. but he cannot
>reliably know how good the doctor is.  You might say
>we should publish information on doctors' effectiveness
>in treating patients, but this data would be horribly
>distorted by confounding variables, such as discrepancies
>in the acuity of various doctors' practices.

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.  

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.

>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?  

>3.  If we repeal medical licensing laws, who will regulate
>narcotics and other controlled substances?  Or should
>all medications be legal for over the counter sale?

As long as they do not directly pose a danger to others, yes.
But far more information should be provided.  Concealing known
information about the dangers of a substance should be far more
actively prosecuted.  

>4.  The potential for pseudo "doctors" to take advantage
>of terminally ill patients with high-priced "cures"
>would be tremendous.  Such patients would be at a disadvantage
>due to # 2 above.

There are still the laws against fraud.  The civil consequences should
be unlimited.  

>Again, there are serious problems currently regarding 
>the competency of some licensed physicians..... we should
>work on correcting this.   However, to open up the
>practice of medicine to the public at large would be 
>a grave mistake.

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
the person can do.  I can visualize doctors who can take the
information gathered by others and come up with intelligent
diagnoses and putative diagnoses, but could not personally carry
out an examination nor conduct a treatment requiring physical
skills.  Others may be skilled surgeons, but atrocious at doing
any diagnoses.  The present training of physicians is quite good
at eliminating those who can think but should not do routine.
-- 
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)
Newsgroups: talk.politics.medicine