I have spent a lot of time recently thinking about and discussing the problems with lawyer licensing and regulation and how it unnecessarily increases the costs and decreases the utility of legal services (e.g., here).
I often wonder, and get asked, what about medicine? Like why are there not enough doctors or other medical practitioners? Why don’t doctors use modern technology to interact with patients (e.g, even email??). Of course part of the reason, as with everything else in the world, is regulation, for doctors particularly including privacy regs.
But part of the reason is the same as for lawyers: the straitjacketing effect of licensing and ethical rules. For a great little snapshot of the problem, see Jay Parkinson, (HT MR).
Parkinson starts his story by outline an idea for the new kind of medical practice he was going to start after his residency:
- Patients would visit my website
- See my Google calendar
- Choose a time and input their symptoms
- My iphone would alert me
- I would make a house call
- They’d pay me via paypal
- We’d follow up by email, IM, videochat, or in person
Well he did it. And “my patients loved the experience— I was an accessible, affordable doctor in their neighborhood who communicated just like them.”
And then he stopped practicing, and hasn’t seen a private patient in three years. Because after he did it he got a scary letter from the New York State Office of Professional Conduct asking for his records for drug prescriptions, obviously trying to nail him on a narcotics charge. Dr. Parkinson points out that
someone didn’t like me. I knew I had plenty of haters given the heated debate in the medical blogs and news stories about my practice. * * * The only criticism I’ve ever received came from within the medical community. So someone, somewhere called the state and complained…and given the online discussion I can only assume the complaint was made by a doctor. You see, anyone, anywhere, can call the state anonymously and report any doctor they want. The state then takes action by sending a startling letter to that doctor asking for records. You are then asked to produce those records and appear in front of their board with or without your lawyer at your expense (lawyer’s fees and lost revenue from time not practicing…thousands of dollars).
He survived that experience because he wasn’t doing anything wrong. But it was scary enough that it soured him on the whole idea of practice. Then he adds:
Medical education and residency is pretty militaristic. You fall in line or you’re out. Trust me, I’ve been there. If you are an “outside the box” thinker, this doesn’t last long in medical school or residency. The egos of your superiors are too threatened. This is an important fact. Doctors have such a preoccupation with being right, they can’t tolerate being wrong. This is of course needed because who wants to go to a doctor known for being wrong all the time? Questioning the status quo is threatening.* * *
Doctors fall in line with the system they’re given. Don’t question it because you, your family, your finances, and the profession will suffer. That’s why innovations like my practice are so few and far between.
Technology won’t solve complex human politics and culture. Real change won’t happen until our medical institutions and the American public want change to happen.
The first step is realizing that our current medical culture doesn’t foster innovation and creativity. In fact, at almost every level, it actively and legally stifles innovation
You can easily substitute “law” and “law practice” for the medical references in this post. Incumbent doctors and lawyers don’t want to change because they don’t like the idea of competition. Those who want change are met by impermeable barriers. This hurts everybody. Vast areas of our economy are immune from innovation. It’s time for change.
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Coincidentally, I was discussing just this issue with my family today, because I was showing my parents the smartphone app used by the academic medical center where I received care recently. But “regulation, for doctors particularly including privacy regs” and “the straitjacketing effect of licensing and ethical rules” didn’t really come up, except that I showed how the app protects my info through a password.
Unsurprisingly, Dr. T is far more accurate than a non-doctor about “Why don’t doctors use modern technology to interact with patients (e.g, even email??).” However, a few doctors DO, and they’re not just mavericks like Parkinson. They tend to be physicians in academic practice (yup, just those folks who “have such a preoccupation with being right”), like the ones training my little sister to be a radiologist who welcome emails and texts messages from their patients and interns/residents. Or physicians who have a short patient list comprised mostly of educated, technologically-literate, well-off people who would only spend time on sending an email if they’re looking for a terse answer to an immediate concern. (Say, the kind of folks who live in Williamsburg, are young with infrequent health issues, and can afford to pay for house calls.)
In contrast, physicians like my dad — practitioner in a rural area, in a mostly geriatric specialty, who sees dozens of patients a day and gets reimbursed by Medicare and Blue Cross/Blue Shield (the insurer for the town’s main employers: chicken plant, paper plant, Super Wal-Mart) — are not interested in using email because they don’t get a penny for the time they spend on it. If he gave patients his email address, he’d be getting rambling messages of the type they send to their grandchildren, *maybe* with an actual medical concern that he could address buried somewhere in it. And it’s not that he doesn’t get along with his patients. He’ll cross a restaurant to say hi anytime he sees them, and their families thank him for his care (and even ask him to be a pallbearer when a longtime patient passes). But he doesn’t want to be emailing with them because it would eat up a lot of time for which he’d go unreimbursed, and without providing a benefit to the patient anywhere near the cost to himself.
This is not an issue faced by lawyers who bill for their time, and who if they receive a call that never gets to the point can still charge for staying on the line. (It is an issue for public interest lawyers, which is why they limit what their clients can contact them about. E.g. the cellphone is to be called only when it’s an immediate concern like “My ex-husband is banging on the door” or “I’m going to be late to court because immigration just picked up my mom.”) If lawyers got paid for the equivalent of procedures — only for face-to-face meetings, paperwork filed, time spent in court — they’d suddenly become a lot less receptive to calls and emails.
And there’s been technological innovation in medicine probably to a greater extent than in law. I have to sleep with my ears pricked for my Blackberry going off because I need to hop up and cover something for a client. My little sister can be “on call” while at home because she can look at scans on her computer, and even have radiologists in Australia reading scans that come in the middle of the night US time but during the workday Australia time. And those awful regulations by the Obama Administration… well, one of them (https://www.cms.gov/ehrincentiveprograms) is to incentivize the use of EHR (what Parkinson now makes a living selling to physicians still in practice) by paying practitioners to do it, which is why my parents were interested in my app in the first place.
The key point here is that ALL professions and trades in the United States must focus on how to reduce their income so that the billionaire plunder may continue unabated!
This is our future! Celebrate it!
I’m a clinical pathologist who doesn’t see patients, so I have no ax to grind about patient care methods and reimbursement types.
“Why don’t doctors use modern technology to interact with patients (e.g, even email??).”
Because Medicare, Medicaid, and most health care insurance companies will not reimburse physicians for the time they spend communicating with patients remotely (by telephone or internet). Physicians also (except under rare circustances) do not get reimbursed for travel time related to house calls.
Dr. Parkinson’s criticisms of medical education and residency training are correct. The situation is worse than he portrays, because both environments not only stifle innovation, they support memorization and pattern-recognition over deep understanding of disease (pathophysiology) and logical approaches to making diagnoses (that would greatly benefit from the computer-based tools that were developed in the 1980s and 1990s but died because stick-in-the-mud physicians refused to use them).
Quite right, Larry. Lawyers are most resistant to change: http://kowalskiandassociatesblog.com/2010/06/18/meeting-and-overcoming-lawyers-resistance-to-change-how-are-changes-required-by-the-new-era-effectively-adopted-and-incorporated-within-the-law-firm/