Sunday, July 12, 2009
The Future of Medicine as Perceived by a Working Neurosurgeon
Health-care reform has taken center stage in the national political debate in America. In truth, it has been center stage for years. I recall when I completed my residency in neurosurgery in Washington, D.C. in 1984 the talk was all about the escalating and out-of-control health-care costs. Government had to control medicare costs, limiting expenditures with the assistance and complicity of physicians. The government gained support of physicians by a monetery redistribution, taking money form "proceduralists" who were the minority and giving more to "cognitive" specialists, physicians in the majority. In other words, they took money from surgeons and gave more to internists, general practioners and the like. In the end, of course, everyone got less. The "cognitive" specialists had to see many more patients to make ends meet and the "proceduralists" could never make enough with the reimbursements the government provides. In the end, private insurance had to subsidize the medicare system to keep "proceduralists" in the medicare program. Surgeons, unless they are employed by a hospital, make their living from private insurance reimbursement. If the government begins to provide a medicare-type insurance policy to the currently uninsured at reimbursement rates similar to medicare rates, "proceduralists" will drop like flies. They will simply be unable to remain in business. The truth is that we already have a shortage of "proceduralists" and we will have a major crisis in access to care if the number of "proceduralists" drops further. As the population grows and ages, more people require craniotomies for subdural evacuations, hip and knee replacements, laminectomies, thoracotomies, abdominal operations, prostectomies, organ transplants, mastectomies, colonoscopies, arterial stenting procedures, etc, etc.. Though much is being spoken of primary care shortages, the solution lies not in more primary care physicians but in more physicians extenders. It does not make fiscal sense to pay highly trained physicians to provide well-patient care. In truth, one physician can oversee several nurse practioners and physician assistants. These physician extenders can provide care for many routine medical problems ranging from colds to diabetes management. More complex disorders which require more expertise and more time can then be managed by internists and medical specialists such as cardiologists, neurologists, endocrinologists, oncologists and the list keeps expanding because medicine keeps becoming more complex as more is learned about each medical disorder and treatments become more refined and diverse. It has become nearly impossible for one physician to know all the crucial management issues for every medical disorder. Furthermore, individuals are becoming more involved in their health-care and as information becomes more abundant on the internet, the majority of Americans will be playing a significant role in their health-care. In fact, patients may be required to become more active in "doctoring" themselves. It will improve the quality of health-care and save a substantial amount of money. Patients will be required to fill out forms on-line that ask questions about their medical history and symptoms of illness. Based on these answers a differential diagnosis will be generated. Patients can then review these diagnoses to understand more about their illness and also review possible treatments. When they then go to their health-care provider a differential diagnosis will already have been generated saving the health professional a considerable amount of time. It will also reduce errors of diagnosis and treatment because the health-care provider can choose a treatment course based on the recommendations the program generates. If the treatment plan does not match an option, the health professional will need to provide a justification/explanation for why they have choosen this particular approach over another. The patient can review the treatment plan to whatever depth they wish in order to feel comfortable with the plan that has been recommended. In the end, the quality will have been maximized. This type of program could be created now (and probably is being created by some clever health-care organization) and patients who are willing to complete it before seeing their health-care provider should be offered a discount since they are saving their health-care professional and the health-care system time and, as they say, time is money. More ruminations on health-care to come.