A Brief Look At The Criticism Of Professional Labor Organizations

from the building-the-foundation dept

In my initial piece on professional organizations like the AMA and the Bar, I laid out the general case for thinking of these groups as unions, whose primary purpose is to protect the interest of their members. The basic argument is that these organizations preserve high barriers to entry for their professions for the purpose of keeping profits high for their existing members. The organizations are able to do this because they've been granted the right to regulate their own industry, so that their rules are, for all purposes, laws. This is an issue and a problem because as an economy, we're spending more and more on legal and medical services, which means that efforts to reduce our expenses in these areas are bound to intensify. The upshot is that these efforts will be in direct contradiction with the interests of doctors and lawyers, which, in turn, will mobilize their professional organizations. As I stated at the outset, this itself isn't a particularly new argument, though the urgency of these matters is not something that's been discussed very much. In the mean time, it would be a good idea to briefly touch on some of the established thought on the subject.

As mentioned last time, one of the chief agitators on this issue was Milton Friedman. In his seminal book Capitalism & Freedom, he devoted a whole chapter to occupational licensure, in which he wrote:
A story about lawyers will perhaps illustrate the point. At a meeting of lawyers at which problems of admission were being discussed, a colleague of mine, arguing against restrictive admission standards, used an analogy from the automobile industry. Would it not, he said, be absurd if the automobile industry were to argue that no one should drive a low quality car and therefore that no automobile manufacturer should be permitted to produce a car that did not come up to the Cadillac standard. One member of the audience rose and approved the analogy, saying that, of course, the country cannot afford any thing but Cadillac lawyers! This tends to be the professional attitude. The members look solely at technical standards of performance, and argue in effect that we must have only first-rate physicians even if this means that some people get no medical service -- though of course they never put it that way. Nonetheless, the view that people should get only the "optimum" medical service always lead to a restrictive policy, a policy that keeps down the number of physicians. I would not, of course, want to argue that this is the only force at work, but only that this kind of consideration leads many well-meaning physicians to go along with policies that they would reject out-of-hand if they did not have this kind of comforting rationalization.
The analogy to Cadillacs is a good one because it anticipates the natural rebuttal to all of these concerns, which is that these groups look out for the public interest by ensuring that members of their trade are all highly skilled. But if you carry this logic over to cars, and say that nobody should drive unless they can afford a Cadillac (or whatever the safest car is deemed to be), you'd soon realize that the practical effect is to cut a lot of buyers out of the market. Either that or you'd wind up with the situation we have today, whereby people don't have the luxury of opting out of the market, and so (due to the supply & demand imbalance) the price of professional services spirals up enormously. Since Friedman, other economists have explored the same issue and have concluded that these groups are primarily in the business of reducing competition, not protecting the public good.

Criticisms of these groups isn't, however, limited strictly to academic arguments made by economists. Later on in the series we'll dive into more specifics, but there a number of complaints, from a variety of perspectives, about the power that these groups wield. To take a simple example, doctors weren't always the gatekeepers to medicine, and in many developed countries (in Europe, for example), they still aren't. In the US, however, the AMA has fought hard to ensure that doctors stand between patients and pills, even when a drug is deemed to be safe enough for over-the-counter distribution. This system, which is ostensibly for the benefit of patients, has the practical effect of making drugs much less affordable. As for the Bar, even many lawyers recognize problems with the way it operates. The practice of state-by-state exams, for example, has the effect of reducing the mobility of lawyers, since they can't easily practice in any state. Also, by demanding that lawyers are well-versed in a wide variety of legal subjects, the Bar prevents the emergence of legal "technicians", narrowly-trained professionals that could offer cut-rate legal services in areas specific to their training. While you do have medical technicians and paralegals, they're only there to support a doctor or a lawyer, and are rarely in a position to offer services to patients directly.

So clearly there's nothing in itself novel about criticizing these groups. There have been a lot of theoretical and practical complaints leveled against them, and the above examples only scratch the service. The coming posts in this series will drill down deeper into how these groups actually operate, the practical effects of their actions and, importantly, why this is not just a matter of theoretical concern.


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  1.  
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    Sanguine Dream, May 23rd, 2007 @ 2:14pm

    I would say...

    that this is not just a theoretical concern. Most labor organizations, espcially medicine and law, would like the idea of tightening the reigns and broadening the reach of its influence.

    I know someone will eventually do I'll just relate this to the recent activity of the RIAA.

    The AMA and RIAA both want tighter control over the industry they operate in.

    They both wish to raise the bar of admission under the guise to inproving quality.

    It's almost as if the RIAA and AMA (among sever others) want to create a monopoly in their industry.

    This looks to be an intersting series. Are you going to (if only briefly and in a small way) tie this series in with your series on economics and scarcity?

     

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    IronChef, May 23rd, 2007 @ 2:20pm

    Interesting Perspectives

    Good analysis, Joe.

    In professional ranks, where downstream effects can be very severe, the subject matter needs to be fully understood, and professional licensure seems to work the best. Schools require teachers with certification, Doctors with AMA certification and the like.

    I don't know if I totally grasped the direction of the article... But I do question, if this level of formailty and licensure is required for positions with lesser educational requirement. For example, State responsibility to manage the process around licensing hair stylists, and to some degree, the Realtor Asssn... Look forward to your next analysis

     

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    MissingFrame, May 23rd, 2007 @ 2:25pm

    Far from being Cadillac

    A licensed lawyer or doctor is not a Cadillac, because they just meet the minimum requirements, so the analogy could be easily changed. It is not absurd because the automobile industry does argue that no one should drive an unsafe car and therefore that no automobile manufacturer should be permitted to produce a car that did not come up to the U.S. safety standards.

    You cannot bring some random Chinese vehicle in without seatbelts, bumpers but with an exploding gastank and then complain that the evil automobile industry is preventing you from a legitimate business.

    People want to be assured that the person they are hiring to do a job is at least minimally qualified for that job.

    Obviously these organizations and their codes can be corrupted, but that doesn't invalidate the necessity of having them.

     

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    Jo Mamma, May 23rd, 2007 @ 2:41pm

    Re: Far from being Cadillac

    Well said missingFrame! I couldn't have said it better myself.

    Already you have people complaining about how the medical care of the rich is of lower quality than that of the poor (and who can blame them?), what do you think letting a few "Yugo" doctors in is going to do?

    Lowering standards is definitely NOT the way to improve access to essential services.

    (But I do credit you greatly on quoting Friedman)

     

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    Joe, May 23rd, 2007 @ 2:45pm

    Professional Organizations and Branding

    As Missingframe notes, there are safety standards enforced by the government for cars. The government has largely abdicated regulation of safety standards for doctors to the AMA. This could be because the government is not a very good entity for deciding medical safety standards, most lawmakers are not doctors, and some of the one who are doctors are quacks.

    Even if you thought about a world where the government was capable of defining (more basic) safety standards for doctors, you would have a problem where people would not know if they were getting a Cadillac or a Pinto. Because doctors can't be well inspected by the laity, you would still need professional organizations to endorse doctors. You might initially find a situation where you had competing 'brands' of doctors, and those organizations would have their own standards. You would see lots of advertising to build the brands, with doctors signing up to multiple organizations in some cases.

    I am not a medical historian, but it is my guess that the medical profession looked precisely so in the days before regulatory control was given over to the AMA. So we're back where we started.

     

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    Jo Mamma, May 23rd, 2007 @ 2:49pm

    Licensed by state

    Oh, and as far as keeping mobility down among lawyers by requiring different state licensure... states make their own laws. Anyone practicing law should be familiar with that state's laws.

    Your two options are 1) Allow non-knowledgeable lawyers in to practice law in any state 2) Eliminate states -- or at least their ability to make their own laws. Which one sounds reasonable to you?

     

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    Beefcake, May 23rd, 2007 @ 3:28pm

    Definitions

    I think your definition of "brief" and mine are a little out of synch. Good article though.

     

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    Confused, May 23rd, 2007 @ 3:32pm

    Mike? Is that you?
    Do we really need another blowhard article "series"?

    And Mike, if you did put Joe up to this, they why isn't it about patents?

     

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    Headlights and Bumpers, May 23rd, 2007 @ 3:37pm

    Automobile Analogy

    As mentioned above, the automobile analogy does fall apart if you correlate legal restrictions on medical and legal practice to our requirements that all automobiles have a number of safety features for them to be road legal, even though all of those features might not be necessary for all drivers.

    Like driving, medicine and legal work are areas that an underqualified practitioner can be dangerous to others. The phrase 'everything looks like a nail when you're only tool is a hammer' comes to mind when I think of specialized practitioners. Highly specialized technitions in either law or medicine are likely to misdiagnose and mishandle cases that include problems outside of their area of expertise. The practice of diagnosing a patient or choosing a legal strategy both require people with some kind of understanding of legal or medical practice as a whole.

    Areas of medicine and law where the ramifications are fairly constrained might lend themselves to cut rate practitioners who can provide instruction and do-it-yourself documentation, but it seems to me that the bulk of the work done in either field has a range of outcomes which can be improved on, or an uncertain outcome that can be made increasingly likely by a highly skilled practictioner.

    If you need one, there's no such thing as a lawyer or a doctor who is too good.

     

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    mac84, May 23rd, 2007 @ 3:42pm

    Bad Analogy

    Friedman's assertion is that the Bar association requires all lawyers that pass to be Cadillacs but he offers no evidence to back that up. To the contrary there appear to be many public defenders out there who have passed the bar but who I would not want to represent me in court.

    Likewise I wouldn't mind a structural engineer without professional registration to design my garage, but if he's going to design a suspension bridge I drive my car over, he better have a PE registration.

    There may be a degree of the abuse that Friedman talks about within the system but the alternative would be much worse.

     

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    Blowhard, May 23rd, 2007 @ 3:53pm

    I smell several laywers. Can you not see what the minimum requirements are and why they are set? Also,why is there a lack of real punishment of members in the ranks of the BAR or the AMA that are found to be breaking their own organizational codes and laws. Because the organizations are only there to protect the membership and their respective industry and not to insure that the public is provided the best possible service.
    Passing an exam does not equal future quality work

     

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    William, May 23rd, 2007 @ 4:15pm

    The real limiting Factor

    My brother is a Doctor and he could tell you that the hardest part of becoming a Doctor is getting into Medical School. 97% of all the people in his first year graduated with him. I think the AMA are more against foreign doctors and those who didn't go to medical school pretending to be doctors. And yes we do have higher standards in the US than in say Mexico so we probably shouldn't let Mexican Doctors practice in the US without taking a look at their credentials first. Just to ensure that they aren't incompetent.
    Maybe we should start the American Information Technology Association or (AITA) to prevent substandard foreign IT workers form entering this country with H1B visa's and driving down the salaries i mean standards of American work.

     

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    dorpus, May 23rd, 2007 @ 4:21pm

    Lengthening Articles

    As Techdirt becomes more self-indulgent, will we see more pages-long soapbox rantings?

     

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    Automobile Analogy, May 23rd, 2007 @ 4:34pm

    No Lawyers Here

    I work in product development for an SEM company myself. I doubt that many lawyers frequent techdirt.

     

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    Jackson, May 23rd, 2007 @ 4:36pm

    When do poor people need lawyers?

    If someone is tried for a crime, they get a free public defender WHO PASSED THE BAR. If someone wants to sue in tort, the lawyers work on a contingency fee basis and are only paid if they win. In what situation would a poor person not be able to afford a lawyer? Generally only if someone sued them. People usually avoid suing people who don't have money.

    The bar is not as much of a barrier to entry as you're making it seem. A bad bar passage rate (percentage of people who pass after their first try) is like 70%. There are only a handful of schools that are below 50%. You can take it as many times as you want.

    What would the benefit be of allowing unlicensed attorneys? Poor people would be able to get a cheap defense attorney who doesn't know the law enough to pass the bar. Doesn't seem to me that there would be any benefit in that.

    Also, another thing you didn't mention is that the bar association helps keep people who are unethical from practicing the law.

    I'm starting a licensing organization called the American Blog Association. It is going to require bloggers to understand what they are talking about before posting. Don't even bother trying to join.

    Blowhard says that passing an exam does not equal future quality work. This is true, but it is also irrelevant. It is a minimum standard. Failing equals not knowing the law, and guarantees poor quality work.

     

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    MW, May 23rd, 2007 @ 4:51pm

    Say No to Pills

    Yes, a physician standing between a patient and pill theoretically drives up the cost of obtaining the pill (as the patient has to pay the physician's fees). However the pill is not the solution to the patient's problem. There is no such thing as a safe pill, and it would be dangerous to have unlimited access to powerful drugs. Having a physician intermediary gives the patient access to a lot more resources that helps him/her make an informed decision whether to take that pill. Should that be mandatory? Considering the serious personal and societal consequences that adverse drug reactions cause, I vote yes.

    An extreme analogy would be access to guns - the public can buy a gun relatively easily, many still use them irresponsibly. If you were mandated to consult with a policeman prior to being allowed to purchase a gun, as is in many developed countries (in Europe, for example), would that be better?

     

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    Dick Harriff, May 23rd, 2007 @ 5:27pm

    Licensing doctors, lawyers et.al.

    When professional organizations claim they are necessary for quality, they should consistently seek quality. How many lawyers are disbarred and how many docs are stripped of their licenses for malpractice each year? Very few. California doctors seem to fight transparency whether it is through a state run web site listing doctors who have experienced malpractice actions, or hospital infection rates, or education and training credentials, or a host of other indicators of quality. The same kind of thing applies to lawyers.

     

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    Michael Long, May 23rd, 2007 @ 6:30pm

    Training

    Becoming a doctor takes about 11 years of very expensive training. And even 11 years of training isn't enough, since we demand not trained doctors but perfect ones. Which which means that doctors now not only have to repay student loans but also cover malpractice insurnace. And make enough to live on to boot.

    We could subsidize training, but that has drawbacks. We could reduce grounds for lawsuits and reduce potential payouts, but again, with the associated drawbacks.

    And I think if you look, you'll find plenty of people in the medical system who aren't as expensive as doctors. Technicians of every type, a veritable army of nurses, administrators, paramedics and so on.

    Bottom line, I think your series will once again be pointing fingers in the wrong direction. Talk about the insane number of lawsuits or the lack of oversight in medicare billing practices or equipment that costs millions of dollars (MRI) or anything else.

    And above all, unlike your copyright series, how about proposing a set of specific, scalable solutions?

     

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    Anonymous Coward, May 23rd, 2007 @ 6:36pm

    I work for a computer programmer at a medical billing firm. I recently attended a meeting about a new dashboard service we were rolling out to our doctors so they could track where their money was coming from. The meeting used live data, and it quickly became apparent that we have at least three doctors that gross $1Million per month. Not year: month. Our company takes a small percent, Uncle Sam takes a big chunk (these doctors have to pay self-employment tax, plus are I'm sure in a high bracket), and malpractice insurance takes another chunk. But after that they have no overhead- all equipment and offices are provided by their hospitals. After all is said and done they net at least $200K to $300K per month. Again- that month, not year. And they are radiologists whose only job is to look at and annotate XRays and MRIs - a job which can now be and, and done better, by a computer.

     

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    |333173|3|_||3, May 23rd, 2007 @ 6:37pm

    Govt. ombudmaen (using the police if necessary) can investigate cliams of malpractice, for professionals, like they do for other industries.
    Someone's educational level should provide enough nformation for the public to decide wether to trust them. If someone only has a Third-class BEng (Civ & Struc) from some sh*thole university, you would not want tehm building a bridge over the Chesapeake, but would probably not mind them designing a culvert on a back lane. OTOH, If somoen has a PhD, Fist-class degree from a good university, or other excellent qualifications, as well as plenty of experience, then they might be considered for a amjor work. The same applies to Lawyers adn doctors. The professional associations are not required for people to know the standards fo professionals.

     

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    Chris Beck, May 23rd, 2007 @ 8:01pm

    Friedman?

    Given that his ideas were proven inapplicable in the real world even before he died I am not sure why you think that quoting him proves anything.

     

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    RandomThoughts, May 23rd, 2007 @ 8:42pm

    You guys sound more and more like Steven Cobert every day, except without the humor. Tonight he did a bit on FDA regulation and the current meat recall and I swear that he got his material for you.

    We don't need regulation, just let the market decide. If their products kill people, they will lose in the marketplace because they will have fewer customers to sell their products to.

    He had to get that from here. Too bad he is going for laughs and you are not.

     

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    Anonymous Coward, May 23rd, 2007 @ 10:05pm

    Re: Friedman?

    > Given that his ideas were proven inapplicable in the real world even before he died I am not sure why you think that quoting him proves anything.

    Stunning reading comprehension there Chris. Joe wasn't quoting him to "prove" anything. As he very clearly states (if you read what he wrote) he was just examining some of what others had said on the issue. If you want to attack the ideas, go ahead, but attacking Joe for who he quoted is really weak.

    Besides, I'm not sure which of Friedman's ideas were proven inapplicable in the real world. In fact, if you look around, a lot of what's happened in the last 40 to 50 years has been the triumph of Friedman's ideas. Which ones were proven inapplicable?

     

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    jesse, May 23rd, 2007 @ 11:02pm

    maybe...but then again, in canada and the states even cars have minimum standards...like I don't know, brakes..or more seriously just general safety standards. with the system you have now, you still have great doctors and mediocre doctors, and a minimum required standard of care.

    it would be funny to see the world where any moron could become a doctor. you don't have to go far to imagine it, look at the medical systems of some developping countries, where some people think that having sex with a virgin will cure you of aids. could you imagine the guy that thinks that becoming a doctor?

     

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    Anonymous Coward, May 23rd, 2007 @ 11:26pm

    Re: Training

    Michael Long,

    > And above all, unlike your copyright series, how about proposing a set of specific, scalable solutions?

    I'm guessing you missed this:

    http://www.techdirt.com/articles/20070503/012939.shtml

     

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    Derek Kerton (profile), May 24th, 2007 @ 3:01am

    Off Target

    A lot of the commenters are missing the lion's share of the point. We are not just talking about good and crappy doctors and lawyers, but about technicians and specialists.

    For example, if you want to buy some real estate, do you need a lawyer who is fully trained in IP law, tort, divorce, etc? Or does your lawyer just need to know the laws around real estate? But if a non-lawyer who is highly trained in those areas gives you quality legal advice for a fee (see NoLo), the Bar will go after him for practicing without a license. If I'm the customer, I have to "pay" for every bit of training my lawyer got, why do I want to waste my money training them in areas of expertise that have no use for me?

    Similarly, I had warts that I wanted professionally removed, but I was required to see a primary physician, and be referred to a dermatologist to treat them. The dermatologist uses liquid nitrogen to freeze and kill the wart tissue. How much money is spent on a few warts including copay and insurance benefits? $400? Ridiculous! The whole process is also a waste of my time. Treatment actually takes about 3 minutes. A cosmetologist or my barber could offer the service for $20. As it turns out, I got a shipment of steaks from Omaha Steaks, and used the dry ice in the box to do it myself.

    Why does the system force me to choose between two doctors, two hours wasted, and $400 in costs, or Omaha Steaks? It's a racket. A happy medium would seem reasonable.

     

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    Chronno S. Trigger, May 24th, 2007 @ 5:35am

    Re: Off Target

    You make a vary valid point. Joe isn't talking about letting under-qualified people be Doctors or Lawyers. He's talking about letting people specialise in one part of their field.

    This would allow them to offer a better service to a smaller portion of the market than someone who has no specific expertise. This would also allow a property lawyer to study and master property law without getting caught up in traffic or malpractice law.

     

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    Ferin, May 24th, 2007 @ 6:09am

    Two thoughts

    One, as to the idea of doctors standing between patients and pills, not all of that is based on trying to make people dependant on doctors. Firstly, while many nurse practioners and physicians assistants are qualified to asses medical conditions and give out drugs, they are not always properly trained in the assesment of contrindicators or dangerous interactions.

    Case in point: A friend of mine has a sister who works at a major New Jersey hospital as a doctor. She observed a PCA (patient care or physician care) Assistant, running about the floor checking on pain levels of patients. When somebody siad they had pain, he promptly dosed them with dilodid (SP?).

    The problem was, he started asking patients who were on antidepressants if they needed some pain medication. Administering dilodid to those patients could have caused a significant harmful interaction, which includes a 10% fatality rate. When told not to, the PCA simply moved on to the next patient and tried again. My friend's sister literally had to have the man thrown out of the hospital to keep him from endangering patients.

    This may seem an isolated case that could be treated by better education. That training takes time, and needs to be assesed to some standard.

    The other facet of the rpescription issue is the regulations around many drugs, and the concerns about over use of certain medications. A large part of my medical expenses are for the visits to the office ever three months that are required by law so that my doctor can continue to prescribe me the schedule 2 medication psychoactive medication I take for my disabilities. The drugs laws themselves create some of the barriers that lock people out of treatment, not just the doctors.

    And a word on overuse of drugs: Allowing people to buy anitbiotics over the counter would be a fantasically bad idea.

    Too many people take them now when they don't need them, and even more did so in the last half of the nineteenth century, when food producers and doctors handed them out like candy. We are now reaping the benefit of such practices in the form of drug resistant super bugs that are quiickly rendering our antibiotics useless. There need to be some barriers to prevent the general population from needlessly using certain drugs into obsolesence.

    The system sucks right now, I agree, but there are some significantly good reasons for certain parts of it, and not all the bad things are the direct result of the system.

    Another thought on the idea of specialist legal technicians, as you call them. I would assume that you might logically extend this idea into the realm of medicine. I can't speak for the legal realm, but I can tell you what that idea has done to some of the medical realm.

    In medicine such technicians usually take the form of so called doctor owned hospitals. These are usually speicialist hospitals where several doctors in one field pool their resources create an environment specially devoted to their field. In theory this creates competition with larger general hospitals, which should be healthy.

    The problem that keeps cropping up is that in many cases, these specialist hospitals don't set up to compete with hospitals in every area. They simply cherry pick the most profitable fields and procedures, the ones that hospitals use to make up for money sinks like open ERs. Without those ERs, we would all be a lot worse off, but they often cost an enormous amount more money to run than they generate. When specialty hospitals start taking away revenue generating procedures, the general hospitals with start having to cut back in their ERs, which does significantly harm the public good.

    Lastly in the same vein, those specialist hospitals aren't always a good idea. In many cases they don't have the expertise outside their area to deal with complications that can arise from the procedures they practice. Often, they don't have 24 doctor coverage, and they may not even have the equipment needed to deal with serious complications.

    Reference the case this year of a woman in a texas specialty hospital who stayed overnight after surgery. She developed complications, but no doctor was on call, and the specialty hospital staff couldn't deal with her symptoms. She had to be rushed by ambulance to an ER at a general hospital, where she died.

    I'm not saying that these ideas don't have merit, but their are some very deep and complex reasons the systems works the way it does right now, and applying simply economic concepts in these areas and expecting a good result will not get you very far.

     

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    MW, May 24th, 2007 @ 6:10am

    Re: Licensing doctors, lawyers et.al.

    The "transparency" debate is much bigger than what you summarize. Hospital infection rates, malpractice actions, etc. have little to do with the "quality" of the physician. Take something more "obvious," like operative mortality. It seems intuitive that a surgeon whose patients die more is worse than a surgeon whose patients survive. However perhaps surgeon #1 was taking on all the patients who were sick to begin with, had complicated surgeries, etc - the patients who nobody else would touch? Now this surgeon's mortality data is open for anybody to interpret, his insurance company reduces his reimbursement, his hospital pressures him to improve his outcomes - and he decides to not take on any more high-risk patients.

    So who will help the sick patient?

     

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    Unknowledgeable Geek, May 24th, 2007 @ 9:15am

    Laws get written

    That is a greatly written article, which i would think, few can find fault with. The best part is that you didn't even mention the fact that the constitution specifically prohibits these "special interest groups".

     

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    reed, May 24th, 2007 @ 11:37am

    Some other points

    How about AMA's war against any form of socializing medicine? While I am not always a fan of government involvement just about every other first world country has put there foot down to control costs. Here in the US we have no such luxury and often end up subsidizing prescriptions costs for the rest of the world. Is this fair?

    Also because of HMO's most doctors have ceased to be advocates for their patients and have instead been forced to become advocates for insurance companies. Things like capitation has forced doctors to accept low payments for all their patients forcing many doctors to stop working with HMO's altogether.

    Where does the AMA ring in on all this stuff? Well they don't really because they are not truly an organization that has socieites best interests at heart.

    With over 50 million people from the US uninsured and with that number growing over a million a year one begins to wonder if the AMA is an effective organization at all. If their only creed is to look out for doctors and corporations they have failed miserably to uphold the Hippocratic Oath.

    Giving so much power to private organization like this without oversight of any form seems to be detrimental to our ability to provide effective health care.

    Those who actually believe Americans are incapable of prescribing themselves the majority of available medication are fooling themselves. Sure there are drugs that should be by prescription only due to extreme narcotic effects or side effects, but this is not true for a lot of prescriptions out there. If I am sick in the same way I have always been why can't I go get some good cough syrup?

    Professionalism has had a disempowering effect in our society and we need to keep this effect in check so people can realize that they are capable of taking care of the majority of their problems themselves. Our systems should b e designed to empower individuals in order to keep costs down.

    This to me means making the law clearer and more simple to understand so the average lay-person can manage most of their own legal issues. It mean giving more power to the individual for their own health care and arming them with the knowledge they really need to make those decisions. For those who would argue that everyone would "over-prescribe" themselves things like antibiotics I would like to remind you that doctors already do this and they are trained NOT to.

    Professionalism is only as worthwhile as it does good for society. Once we see that the laws and rules have become counterproductive it is time to make a change.

    The time for change has come and gone, now we need to take a long hard look at our state of affairs and do some action. We can't learn if we don't make mistakes so let's not be afraid to try some new ideas.

     

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  32.  
    identicon
    Anonymous Coward, May 24th, 2007 @ 1:53pm

    "For example, if you want to buy some real estate, do you need a lawyer who is fully trained in IP law, tort, divorce, etc? Or does your lawyer just need to know the laws around real estate? But if a non-lawyer who is highly trained in those areas gives you quality legal advice for a fee (see NoLo), the Bar will go after him for practicing without a license. If I'm the customer, I have to "pay" for every bit of training my lawyer got, why do I want to waste my money training them in areas of expertise that have no use for me?"

    Yeah, he used really bad examples by going for doctors. The original examples were better - why the hell do appraisers and real-estate agents need special protection? Other than a mandated monopoly?

     

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  33.  
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    RandomThoughts, May 24th, 2007 @ 7:26pm

    If you are not talking about doctors and lawyers, then don't mention them. Of course you do, because you know that will drive traffic. No one really cares about hair care and other professions.

    There is one very good reason why a doctor that is fully trained should stand between you and your perscription. A good example of this is Lipitor. It is a very safe drug, has very few side effects and has been run through many clinical trials. It could be over the counter. It isn't and shouldn't ever be. Regular checkups are a good thing. Sure, you could have gotten the Lipitor over the counter, but without seeing a doctor, you might not find out something that you need to know. Something that may be causing that problem or others.

    Seeing someone who has all around knowledge, not just specialized, picks up those things.

     

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  34.  
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    Joe, May 25th, 2007 @ 6:55am

    criticiscm of the criticism of the criticism

    Judging from the comments, it's clear that a lot of people understand the problems with professional groups, but still view doctors and lawyers as special cases, where traditional market logic doesn't apply. Somehow, in people's minds, those professions, unlike say locksmiths or or real estate professionals, really should require an exceptionally high hurdle to gain licensure. But in both of those areas, many tasks could be broken down into jobs that could be done with much less training. Nurses, for example, can perform a lot of the care that a patient needs, but it's very hard to just go to a nurse for something routine. Instead, the nurse is there to serve the doctor, so you end up paying the doctor toll on top of the nurse fees. As a number of people have pointed out, in the legal profession a number of tasks (like drawing up wills) could be done via a will specialist (or a piece of software), but you can't get trained in just wills. You have to study constitutional law as well (and torts and criminal law and environmental law...).

    People also seem to assume that a technician wouldn't be able to recognize when something is above there pay grade. But I see no reason to think that people couldn't be trained to say "this is not something that I have expertise in, here's the number of someone with more training that you should go see". After all, generalist doctors do that all the time, when they encounter an issue that needs to be dealt with by a specialist.

    The main detractors of my original post seem mainly interested in setting up straw men by arguing that without high hurdles, these professions would become populated by quacks. But quacks don't survive in the market very long, and there are ways of ascertaining the reputation of a service provider before going with them. The goal isn't to make life easier for quacks, the goal (as subsequent pots will delve into more fully), is to broaden the range of expertise and skills that professionals have, so that people can go to someone that adequately meets there needs without wasting a ton of money.

     

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  35.  
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    MW, May 25th, 2007 @ 8:30am

    Re: criticiscm of the criticism of the criticism

    Nurses do not just serve the doctor - they have specific roles that a doctor will not get involved in. Medication administration comes to mind - while doctors screen for drug interactions, it is up to the nurse to determine whether the two medications can be given in the same IV or do they need two separate IVs. The nurses skills in starting IVs, addressing the patient's non-medical needs, etc. are best handled by nurses alone, without involving the doctor.

    What exactly is "something routine" that a patient can go to a nurse for? Or, for that matter, say a nurse specializes in "fever management" - while a lot of patients could go to that nurse and get treated for fever, it would take a lot of training (say, that given to a doctor) for the nurse to do a good job managing the fever and considering all the possibilities.

    Medicine, in particular, is all about pattern recognition. A patient's symptoms, exam finding, labs, tests, etc, fit a pattern, and that combined with disease trends and epidemiology and best available evidence help formulate a plan. Medicine cannot be broken down into separate unrelated tasks, at least not now, when our understanding of the complicated human organism is minimal at best.

    Generalist doctors have tremendous amounts of training to screen patients, and determine WHICH specialist they need to go to. They need to determine what the disease is, what the overall plan would be, then refer to a specialist for fine-tuning the plan. The referral is never "I don't know what you have, how about you go to the heart doctor and let him figure it out."

    When the public asks for a will to be made, he or she needs a will to be made. When a patient goes to the generalist, he says "I have chest pain when I mow the lawn" - and not "I need angioplasty for my heart." And you can't get just trained in doing angioplasty without learning grassroots medicine first. Thank heavens for that.

     

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  36.  
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    Derek Kerton (profile), May 25th, 2007 @ 12:31pm

    More Criticism

    RE: #35, man think a little.

    Your second paragraph, "What exactly is "something routine" that a patient can go to a nurse for?" You seem to think it would be hard to come up with a good example. How about my my example in #26, wart treatment? Or say, athlete's foot, corns, sprained ankle... We're not talking rocket science here, sometimes the diagnosis is just plain simple, and we don't need Marcus Welby.

    Sometimes it's as simple as when you have a nail sticking out the side of your car's tire. Do you need to go to a licensed mechanic who understands the finer details of how the nail is related to the engine, or to look for a "pattern" that is related to a specific carburetor disease? I'm just thinking that for me, a tire guy would do fine.

    To agree in part, when I have unidentified chest pain, I'm not going to ask my hairdresser about it. There's a lot of cases where doctor knows best.

    But you are WAY to complimentary to doctors. You say, "The referral is never 'I don't know what you have, how about you go to the heart doctor and let him figure it out.'" Are you kidding me? That's an excellent paraphrase of what GPs or primary care physician's say almost every time I've ever seen one, but they're not quite so humble or honest.

     

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  37.  
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    Chris Beck, May 25th, 2007 @ 7:56pm

    Re: Re: Friedman?

    Joe wasn't quoting him to prove anything? So the quote taking up 20-30% of the article was there for filler? The paragraph of analysis of the Cadillac analogy was decorative? I do not understand how attacking who Joe quotes is weak. Joe obviously selected the quote and its place in the article is prominent and is therefore deserving of analysis and criticism.

    As for Friedman, shall I mention Monetarism which he himself rejected in a June 6, 2006 interview in the Financial Times? His laissez-fair absolutism that despite rising market prices has resulted in a disproportionate growth in income disparity? Natural unemployment rates? Chile is perhaps outside the scope of this discussion.

    You are right, however, that if I addressed Joe's own text then my rejection of the Friedman quote would have had more weight. Joe said 'by demanding that lawyers are well-verse in a wide variety of legal subjects, the Bar prevents the emergence of legal "technicians", narrowly-trained professionals that could offer cut-rate legal services in areas specific to their training' I find this statement to be false. We can already hire divorce lawyers or tax lawyers or contract lawyers, in general the field is too broad to be mastered by any one individual. To imply that we need lawyers more narrowly trained is to imagine that court cases rarely proceed beyond the bounds expected by one party. It is also a flawed premise that a specialist would charge less than a generalist, this is certainly not the case in other fields such as programming, medicine, or construction.

    As for the AMA, to imply that American drug prices are drastically higher because of their interference is to ignore the evidence of prices in other western countries that also have professional medical associations and that have much lower drug costs - e.g. Canada, France, the UK. The single largest factor in drug costs in the US is the poorly organized medical insurance industry and the lack of a single-payer drug system with authority to negotiate.

    Please do not imagine that I imagine these organizations to be without flaws. I do hold the position that we would be better of with well run versions of them than without.

     

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  38.  
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    RandomThoughts, May 25th, 2007 @ 9:46pm

    Joe, it sounds like you have the series already written and are not really interested in discussion, so why don't you just post them all at once?

    Anything that get people in to see a doctor is a good thing. Go in to get a wart treated by a specialist? OK, thats great, but what happens when a wart specialist sees something that a doctor would recognize as a problem goes over the wart specialist. Hey, they took care of the wart, right? Too bad you had that stroke, that that wasn't their area.

     

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  39.  
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    MW, May 26th, 2007 @ 11:07am

    Re: More Criticism

    Yes, a less trained person can remove a wart, but would that person be able to recognize whether the wart is a precursor for cancer in the same spot? Could that athlete's foot signal an underlying diabetes that the patient has? Could the sprained ankle actually be a broken bone?

    My point is that the human body is not a car. A tire guy would be fine for a nail in the tire, but a "wart guy" is not the best person for the wart.

    The mere fact that the GP is referring you to a heart doctor (and not, say, a gastro doctor) indicates that he has made a decision that your chest pain comes from the heart, and not any of the HUGE list of things that could cause the pain. The GP did not pick a doctor's name/specialty out of a hat, there was a reason why he/she sent him to that doctor.

     

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  40.  
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    MW, May 26th, 2007 @ 11:22am

    Re: Re: Off Target

    Medicine is all about specialization, these days. There are heart specialists, heart specialists who deal with abnormal EKGs, abnormal EKG specialists who deal with a particular type of abnormality.

    Letting the patient directly go to a "specialist" without determining what specialist he/she should go to is fraught with danger. It's a common practice these days though, patients will come in to their general practitioner asking to be sent to a heart doctor for their chest pain. They see the GP as an unnecessary hurdle put in place by the greedy AMA, insurance company, etc. to prevent them from accessing the service they need.

    The problem is that a patient's self-diagnosis is often off-the-mark, especially in the US where health literacy is abysmal. And going to a specialist (as other people have pointed out in these comments) will almost certainly lead to a diagnosis that falls under the purview of the specialist, even though it may not be the answer to the patient's problem - reasons being many, including the fact that a specialist will concentrate on finding abnormalities that he/she deals with routinely and may overlook others.

    The patient who came in seeking a heart doctor will see one, who will likely have the patient undergo an angiogram to "make sure" this is not a heart problem. After all, the GP sent this patient to him, clearly the GP was concerned about heart issues and this "must" be settled. The angiogram (hopefully goes well) shows some minor abnormalities, which the heart doc will quickly blame for the patient's chest pain. The patient's pain may or may not get better, but at least there is a reason (is there?). But now everybody else stops looking for an alternate reason for the chest pain.

    Though we would very much like it to be so, medicine does not work by cause-and-effect. We simply do not understand the human body like we do, say, a car.

     

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  41.  
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    MW, May 26th, 2007 @ 11:35am

    Of warts

    Why did the GP refer you to the dermatologist? So the derm doc could look at the wart, determine if it needed a biopsy to check for cancer, and then remove it.

    Could the GP have done this himself? Consider your GP giving you "full disclosure" - "This seems like an ordinary wart. However there is a very small chance that this could be a cancer, one that can rapidly become incurable. You have three options:

    1. Remove it yourself and take that small risk
    2. GP can remove it and biopsy it, which means it will cost you more, and you will have some discomfort along with a small chance of procedural complications (scarring, bleeding, infection), but we can ensure this is not cancer.
    3. GP can send you to a dermatologist who can make an expert determination of whether a biopsy is needed at all, thus you have to pay more but are saved the risk of procedural complications.

    You picked option #1. Your GP recommended option #3, perhaps because HE didn't want to take the chance that you later develop a cancer and blame him, also your GP would probably not get paid at all for removing your wart, so he has no incentive to spend his resources for free.

    An average American demands health care that is painless, complication-free and infallible. That is clearly the goal, but that average American has to realize that medical science is not there yet.

     

    reply to this | link to this | view in thread ]


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