highest acceptance rate

afan · September 4, 2006, 11:46am

For a more reasoned view on the medical errors question, see NEJM 2000, v 342, p 1123. This is an editorial by the author of the studies on which the IOM estimate of national medical errors was based. The author takes exception to the fundamental methodology of the IOM extrapolation as so oversimplifield as to be meaningless. I cannot post the entire article, but anyone who goes to the NEJM site can get free access to past articles. This one is non-technical and readable by everyone.

A few samples of the problems

In other words, the most prominent “result” of the study, the one that gets trumpetted around the world, was not supported by actually determining whether the so-called errors were errors at all.

in other words, if you don’t know the current rate of errors (and we don’t) then you cannot measure a change.

sakky · September 6, 2006, 8:56pm

I never argued for high standards. I am arguing (as is the article I cited) for USEFUL and VOLUNTARY standards.

In short, I am not thoroughly convinced that we need to maintain mandatory standards for physician health-care, not when the alternative for some poor rural people is to get no physician-provided health-care at all.

That’s not the same thing. What is being argued is that continuing doctors and new doctors should be forced to pass the SAME exams with the SAME passing thresholds. Things should not be made easier for you just because you are a practicing physician. That is, if you are actually trying to enforce quality. For example, if new physicians have to pass the USMLE, then continuing physicians should also have to prove that they can pass the USMLE.

Or, more importantly, if it is becoming increasingly more difficult to get into medical school, as evidenced by higher GPA’s and MCAT scores of incoming students, then it should also be made more difficult for existing doctors to maintain their license. The truth is, the hardest part about becoming a doctor is just getting into medical school. Furthermore, the truth is, a lot of current doctors would not have gotten into med-school if subjected to today’s admissions competition. So if the difficulty of the premed path is rising, then so should the difficulty of the relicensing exams. What’s fair is fair.

What are you talking about? This question was specifically dealt with by the article. Like the article stated, you can have a voluntary certification process, acting as a seal of approval. Hospitals may enforce a rule that stipulates that they will only hire doctors who have this seal of approval. HMO’s can market their plan as being ‘purely certified’. But the point is, you don’t have to prevent others who are ‘unlicensed’ from practicing medicine.

Now, you may say that this sounds dangerous, in that I am exposing people to ‘unlicensed practitioners’. But let me put it to you this way. Right now, many Americans choose to fly to foreign countries to get cheap LASIK or cheap plastic surgery, often times from “unlicensed” doctors (in the sense that they don’t have US medical degrees). In fact, the whole industry of medical tourism is based on this notion. Honestly, how is it any worse for a guy to fly to Costa Rica to get cheap unlicensed liposuction from a foreign doctor, than it is for a guy to get liposuction in the US from an ‘unlicensed’ doctor? At the end of the day, isn’t that the same thing? Either way, you’re getting a medical procedure from somebody who is not licensed by an American accreditation board.

So I propose that we start off with elective surgery in the US. Let unlicensed operators operate. You as an individual can choose not to patronize such establishments by only getting your surgery from an “approved” doctor, just like you can choose not to fly to Costa Rica or India or the Dominican Republic or wherever it is to get cheap elective surgery via medical tourism. But the point is, if Americans right now have the choice to travel to another country to get cheap unlicensed medical care, why can’t they have the choice to get that same cheap unlicensed care without having to travel?

To give you another example, the state of California allows people who have never been to law school to still qualify for a license to practice law. You have to pass a battery of state-run tests and a bunch of other things. But the point is, if you can prove that you know California state law, you can qualify for a license to practice law in California even if you’ve never been to law school. You will probably find it very difficult to get hired by a respectable law firm because you don’t have an actual law degree. You will probably also find it difficult to start your own firm and get clients, because most clients want to hire a lawyer who has actually been to law school. But the point is, the ABA cannot prevent these people from practicing law.

Yes, lots of people are killed by medical errors. Whether that points to a low or high level of quality depends on the alternatives. What are the comparable figures elsewhere? What would be the comparable figure if admission to medical school were easier? If it were harder? If there were more or fewer training slots? If training were longer and more demanding, or shorter and less detailed? If ongoing assessment of physician skills were more common and demanding or less? This point estimate, without something to compare it to tells us only that this is the outcome of the totality of our economic and political healthcare system. By the way, there are no reliable estimates on the numbers injured by medical mistakes. Any attempt to get that figure is dominated by the assumptions used in the modelling. The real number could be very different. Statisticians and epidemiologists debate this quite a bit. That the number is large- no question. How large? No one knows.

But you basically proved the point of the article. The AMA would have you believe that the reason why medical licensing is so tough is because they are attempting to uphold standards of high quality. But you just stated that nobody really knows if quality really is high. Hence, there is no basis for the AMA’s assertions.

bluedevilmike · September 6, 2006, 9:05pm

Part of the problem would be asymmetric information - plenty of data at the moment suggest patients currently do an inadequate job of doctor/hospital shopping, and that shopping that they do do is done using poor metrics (“my neighbor said he was a nice guy”) rather than, say, controlled mortality rates, for example - which probably don’t exist anyway.

In an asymmetric information, case, then, there exists valid reasoning for gov’t intervention.

Notice a few things.
1.) I have not argued in favor of what kind of government intervention I would require, and in fact have no idea.
2.) Your argument about double standards for admission/continuing to practice is clearly valid.
3.) I actually wonder whether your suggestion would hurt DO’s and NP’s - non-MD’s who currently do have licenses to practice medicine. With insurance plans under pressure to declare their programs “MD-only”, or “Top-50-Medical-School Only”, then the expansion of supply - since search is performed using proxies due to the difficulty of acquiring good information - might actually end up restricting practice, not expanding it (basic game theory: current licensing requirements “signal” that all practitioners are qualified; expansion would force people to turn to other proxies, which might be less legally restrictive but more restrictive thanks to the advertising needs of third-party payers and employers like hospitals or hospital systems).

4.) How would malpractice work in your proposal? Would less qualified people (say, NP’s performing a hip transplant) be held to the same standards? (“The person with the knife is the surgeon, period.”) Lower? (“Caveat emptor”/“You get what you pay for.”) De facto higher? (“The MD’s proved they were good by getting into Penn Med, so their fatalities must just be bad luck. The NP’s never proved anything, so their fatalities are probably because they’re lower-quality.”)

5.) The best solution, obviously, is improved metrics (assuming that that can happen without adverse incentivizing) followed by loosened market restrictions. I can’t think of how one would do this.

afan · September 6, 2006, 11:35pm

Medical school admissions are no more difficult now than in the past. In the late 70’s, for example, there were three times as many people applying as there were slots in med school. The current ratio is closer to 2:1. Scores and GPA’s bounce around, but the basic bar to getting in is about the same as ever.

I believe this is wrong.

It is way harder to get through medical school and training than it is to get in. College premed is MUCH easier, different world, different universe from medical school and medical training.

Theory aside, there is excellent evidence that increasing the number of physicians does not correct the maldistribution, inaccessibility for low income or rural people, or lower cost. It clearly increases costs.

USMLE is largely irrelevant to practicing medicine. No one should be required to take it as it is. Perhaps they could come up with a worthwhile test, but USMLE is not it. Well known that scores on it tell you nothing about clinical performance. That it is still used is a monument to institutional inertia. Does not even serve to restrict supply, since everyone passes anyway. Certainly a waste of time to make practicing docs take it. On the other hand, the recertification exams for specialty certification are realistic exams that test what one needs to know, and practicing docs do take those.

I hardly would trust insurance companies to enforce quality. It is the last thing on their minds. They would be only too happy to have the LPN do your bypass. Death during surgery is pretty cheap-no post op care.

Get serious

you don’t have to prevent others who are ‘unlicensed’ from flying airplanes

How many people get to choose their practitioner when brought to the ER? How many can interpret the information they are given even for elective care? Most people cannot understand the nutrition label on a box of cereal. Leaving them defenseless against quacks would be immoral.

Right now, malpractice would be close to “the knife-wielder is the surgeon”, but that can be redefined down. Label a procedure as appropriately performed by a high school dropout, pay them for doing it, and that becomes the standard of care.

I’m still waiting for evidence that increasing the number of physicians would solve any of these problems. Not even persuaded there is a shortage, as opposed to stable maldistribution, let alone that increasing numbers would alleviate the so called shortage. See for example Goodman in the March/April issue of Health Affairs, and Starfield from May/June of 2005.

No. Citing a figure for the medical error rate, in isolation, does not tell anyone whether quality would be higher or lower with different admission and training standards. At best it tells us an error rate under the totality of the current system, but nothing more.

sakky · September 7, 2006, 11:35am

Uh, no, this is not a case of ‘bouncing around’. MCAT scores for matriculated students in particular have been clearly trending upwards over the last decade.

Huh? How does it increase cost? If you are referring to medical training, then one way to correct that is to simply start charging the true price of that training to those extra ancillary students who couldn’t get admitted as a normal student (but who are still good enough to be doctors). I’m sure there are quite a students who come from very rich families who wouldn’t mind paying 250k a year for medical training. Hence, you could make the training aspect cost-neutral.

I also don’t see why increasing the number of doctors wouldn’t inevitably alleviate the maldistribution problem. Simple supply and demand would work. As more doctors enter the big cities to practice, their competition would either drive down prices or take up all of the available hospital/clinic spots in those cities. After all, there are only X number of people in those cities who demand Y amount of medical services. Eventually, the extra doctors would inevitably have to move to the underserved areas in order to practice, simply because there would be no space for them in the cities.

The same thing could be said for the MCAT. It would certainly be a waste of time to get practicing doctors to take the MCAT, as they would almost certainly all get low scores (without re-studying the material), as the truth is, much of the material on the MCAT is simply not highly relevant to the day-to-day life of a physician.

But you bring up the point of specialty recertification. But the fact is, you don’t need to recertify yourself in a specialty in order to practice as a doctor. For the most part, this sort of specialization is a voluntary process for marketing purposes (i.e. you as a doctor can now say that you are certified in X). Hence, it exists basically as a voluntary ‘seal of approval’ - which is similar to what I proposed (and the article proposed) regarding a seal of approval that identifies who have graduated from ‘approved’ medical schools. But there is no legal requirement that I as a patient will be served by a certified specialist. There are plenty of uncertified specialists practicing today.

I am not saying that I “trust” insurance companies. What I am saying is that I don’t trust the AMA, and I don’t trust the other physician lobbying groups either. After all, let’s face it, they aren’t always exactly looking out for the best interests of patients either. In short, I don’t trust any of them.

The answer to this is that you then go to the ER that has only ‘approved’ physicians. Or, municipalities vote to have their paramedics bring patients to only hospitals that hire ‘approved’ physicians.

And that’s why I would like to start small. Take all of the elective surgery out there for which medical tourism exists, and let the free market decide. Right now, plenty of Americans have decided that they don’t really want to pay for a licensed American plastic surgeon and would rather get cheap plastic surgery in a foreign country. This is a case of the free market deciding. I therefore see no reason why we can’t have ‘unlicensed’ plastic surgeons operating here, at least as a pilot study.

Look, I’m not saying that I want to change the entire system willy-nilly. Why not just start small, and in particular, start with optional cosmetic procedures? If it works, then we can see whether we can apply the same principles to other medical services. If not, then allright, we can go back to the old system. You’re using a strawman in saying that I want to change the entire system overnight. I want to tinker with some things on the edge to start with. For example, what’s so bad about letting unlicensed people inject Botox into people’s foreheads? Americans right now are getting Botox injections in foreign countries.

You did it again. Basically, what you keep showing is what I keep saying, which is that the AMA has no basis for stating that it stands for high quality, because there is no statistical proof that the standard of US medical care is really high. Hence, the AMA should withdraw any statements to the effect of quality. There may be high quality. But the point is, as you have shown, we just don’t know. Hence, the AMA should not be acting as if it is a known fact, when it is not.

afan · September 7, 2006, 6:31pm

There is a very large literature on the relationship between physician supply and medical costs. You may want to read some of it before you declare you know the answer. If you think the answer is “increasing physician supply would reduce costs” you are wrong, and demonstrably so. In fact, a quick read through Health Affairs (the most important journal in the field) will show you just how wrong this notion is. It has nothing to do with the cost of medical training. So charging people for training would be completely beside the point. Read the literature. You will probably find it interesting.

This is why is it worth reading the literature. This is simply wrong. And well documented to be wrong. In fact, what happens is that amount of medical services in the regions with high physician supply continues to go up as the physician supply goes up. So the cost of care goes up. You obviously did not read the articles by Goodman and Starfield, which could serve as a very brief introduction to the hundreds of studies of this effect. As far as I know, there is no responsible expert who disagrees with this observation.

I almost agree. The MCAT has nothing to do with practicing medicine, but it is an excellent predictor of academic performance in medical school. So, as an admissions test, it does have some merit.

Difficult to manage when you are unconscious.

Statist
Assumes such hospitals would exist when barriers to entry have been dropped, and per procedure reimbusement has fallen to reflect the larger number of “qualified” providers.
Assumes that a municipality could do this. What about transport across city/county/state lines?

But of course cosmetic surgery is not practicing medicine, it is simply dangerous and unethical beautician work. No doctor with a shred of self-respect would do it. They should have given up their med school slots to those who wanted to provide health care.

You are conflating “quality” with “standards”. Standards are an attempt to establish a level of quality. However, measuring quality is difficult. So one uses standards that seem to have content validity. To return to the pilot example, we know the current rate at which planes crash. We know current requirements for pilot’s licenses. We (or at least I) believe that the crash rate would be higher if there were no license requirements. How much higher? I don’t know. Would the rate be lower if it were harder to get a license than it is now? Again, I don’t know. Would probably depend on how many crashes now are caused by unqualified pilots making errors that more qualified pilots would not- as opposed to equipment problems, weather, etc. Does the fact that we do not know exactly how much one would lose in safety by reducing pilot requirements mean that we should permit unlicensed people to fly?

afan · September 7, 2006, 6:57pm

As for MCAT, you have to take a longer view. If you look at the last 10 years, you are using an unusually low interest in medicine as the starting point. In fact, leading up to the late 90’s there was a lot of worry about the falling applications to medical school. They have come back, partially, but med school admissions on the basis of the percent of applicants who end up with at least one admission, are still easier than the long term norm. It has been difficult for a very long time. Recent trends are reverting toward the mean.

bluedevilmike · September 8, 2006, 12:09am

This could in fact imply that the supply of physicians is too low even in large cities - which would be consistent with the inability of market saturation to push physicians into rural areas (i.e. we’re not saturated yet), and would imply that we simply haven’t increased quantity nearly enough.

In other words, you’d expect quantity of medical care to increase some and cost to decrease some if the markets were already clearing; if there’s currently a shortage, then you’d expect total expenditure to increase considerably and quantity of medical care to increase even more. You seem to be arguing that this is the case.

my_0.02 · September 8, 2006, 3:57am

Some hospitals and many insurance companies require board certification as a condition of staff membership or panel participation. While board certification doesn’t guarantee competence, lack of board certification should raise questions from the intelligent health care consumer.

sakky · September 8, 2006, 10:27pm

I am not saying that I always know the answer, but what I would say is that if what you are saying is true, this violates practically every single law of economics, and would therefore be an EXTREMELY INTERESTING (in fact, probably Nobel-Prize caliber) area of economics research. Greater supply = greater cost? That implies an perpetually upward sloping demand curve, a perpetually downward sloping supply curve , or both, something that is as rare as a unicorn.

Now I agree with bluedevilmike that there may be short-run and short-impact factors at work, and that specifically, we may be nowhere near the market equilibrium point such that costs may indeed increase with a relatively small increase in supply. But increasing the supply still more, it’s hard to see how costs would continue to increase, as perpetually downward sloping supply curves have never been found, and medical care is almost certainly not a luxury good (which would impkly a perpetually upward sloping demand curve).

Exactly. So let’s start small by doing exactly that - namely by eliminating requirements for plastic surgeons to be licensed. You can still have licenses for plastic surgeons, but just not REQUIRE licenses.

I fully recognize that there are areas of possible danger - i.e. your unconscious ER patient for example. But that’s no excuse to not tinker with areas for which free information is clearly available and in which unlicensed practitioners already abound, i.e. plastic surgery via medical tourism.

However, the AMA and other medical groups do not want to countenance reform AT ALL, not even in the case of cosmetic surgery. They won’t even consider the option of unlicensed plastic surgeons in the US. Why not? This should be left to the free market to decide.

But don’t you see? This is a case of letting the market decide. The consumers decide whether it is important to patronize a board-certified physician. So, if consumers are allowed free choice to make that decision, then is it really so radical to let them make a free choice to decide whether to patronize a licensed doctor? In other words, why is certification voluntary, but licensing required? It seems to me that they should either BOTH be voluntary, or BOTH required.

my_0.02 · September 9, 2006, 12:49am

The practice of plastic surgery is among the least regulated of all areas of medicine: Dentists do facelifts, ER docs do liposuction, OB-GYN’s do laser skin resurfacing. Requiring a medical license is a minimal restriction.

Well informed consumers could base their physician patronage on board certification, but most rely on unsupported lay recommendations.

bluedevilmike · September 9, 2006, 1:12am

Think about it this way:

Two provisional assumptions:

1.) Rural areas have FAR too few doctors. While this is not in question, I believe we get empirically confirmed predictions if we assume that cities ALSO have noticeably too few doctors. So let’s start with this assumption.

2.) Try this assumption, too: the major deterrent for people visiting doctors, going to the ER, etc., is not monetary price - especially for insured people. The major deterrent is, in fact, time. This is the main reason, I think, why people (again, esp. people with insurance) avoid doctors and such - because appointments take weeks to make, ER visits can take 12 hours, etc. The time cost (once again, for emphasis, this is mostly true of the 85% of the country with insurance) outweighs the monetary cost.

The bottom line: Our country has dramatically too few doctors, cities included. This clogs up the system with time costs, which leads to underservice and dead weight losses.

I believe these two assumptions give us substantially accurate predictions.

<hr>

Prediction #1: More doctors, more expenditure

What you’d normally expect: You would normally expect an increase in quantity to decrease price and thus increase quantity, but quite possibly without an increase in total expenditure, and certainly not a dramatic enough increase to upset afan the way it seems to.

**What we see:**Increasing the number of doctors in cities seems to increase quantity of care, dramatically increasing total expenditure.

Why a shortage would explain it: Patients are considerably underserved, and would want more medical care if only they could find doctors to provide it within any kind of reasonable timeframe.

Implication: More doctors does in fact lead to more usage of medical services, but this is not a bad thing - in fact, it’s what patients would do if only they could find the doctors to do it.

<hr>

Prediction #2: More doctors, but prices don’t drop.

What you’d normally expect: You increase supply, and prices should drop.

What we see: I don’t really know - maybe somebody else can supply this information. The tone of some of afan’s posts seems to imply that he doesn’t believe prices are falling, which would be consistent with the assumptions I’ve made.

Why a shortage would explain it: Doctors currently charge their patients a very high time cost as well as the monetary costs. If an increased number of physicians reduces the time costs, then they actually are saving patients’ resources, and so cost actually IS going down.

Other factors at work: Medicare’s cost restrictions and fee schedules.

Implication: Doctors are in scarce supply, and patients really do want to see more doctors - it’s just that the time cost is currently prohibitive. Reductions in this type of cost (say, nursing phone staff hotlines?) are crucial, and probably even justify increasing the monetary cost of medical care, if that will actually help.

Why time costs are deadweight loss and worse than monetary costs: At least if you charge patients an extra $1000, that money goes to somebody who can use it. If you force a patient to sit in your office for three hours, then that lost time doesn’t do anything productive for anybody.

On the other hand: Time costs are more expensive for rich patients and less expensive for poor ones; monetary costs are vice versa. It’s currently poor patients who have more underservice problems, so increasing monetary costs to save time costs might generate equity concerns.

<hr>

Prediction #3: More doctors, but no expansion

What you’d normally expect: You increase supply in one market, prices drop, and suppliers (physicians) expand to underserved markets.

What we see: New doctors, even after mild increases in supply, seem to continue to congregate towards cities.

Why a shortage would explain it: If cities are 10% underserved, then a 3% increase isn’t going to do it, since doctors will still be able to make a fine living there.

Other factors at work: Highly educated people tend to prefer cities, and med school is a very high level of education.

Implication: Want to push doctors into rural areas? You have to increase the supply by a lot more than we’ve done in the past.

bluedevilmike · September 9, 2006, 2:19am

First line under Prediction #1 should read:
“You would normally expect an increase in supply to decrease price and thus increase quantity consumed.”

afan · September 10, 2006, 9:17am

Bluedevil,

I can see you are giving this alot of thought. As for Sakky, I suggest you read the literature. Much of it is quite readable even without expertise in the area. It is definitely true, as you say, that docs prefer to practice in cities and will give up very large income incentives to move to other areas. If you look at current regional average incomes, you will see huge variations, with compensation lower in the most overserved areas (fits with economics). However, this has been the case for many years, ie. docs know that they can make more money by moving to less competitive areas, but they don’t want to.

Staffing hotlines is a great idea. Problems are that there is an unequivocal shortage of nurses. Well, to be exact, there is an abundance of nurses, but there is a shortage of nurses who want to work as nurses. So the nursing shortage would disappear overnight if all the exisiting trained nurses went back to nursing, but they don’t. Again, this has been a stable situation for many years. Also, currently insurance companies refuse to pay for these services at all, so few practices can afford to offer them.

If you look through the literature it is hard to sustain an argument that the increases in medical expenditures that accompany increases in physician supply are due to severe shortages everywhere. You can find several fold differences in intensity of care from some cities to others unaccompanied by variations in medical outcomes. In other words, it is hard to show that the higher expenditures in some areas reflect delivery of more care that is useful. So even if one did increase the number of physicians, and the amount of care in some of these places, there is little evidence that the patients would be any better off.

afan · September 10, 2006, 9:26am

Way too dangerous to permit this. People die from bungled plastic surgery. It may be trivial in its goals, but not in its risks.

It certainly is. Whether anyone would win a Nobel Prize depends on whether anyone solves the problems. Remember, any solutions will be bound up in political and economic considerations wholly unrelated to the best way to operate the health care system. Most economists who study the area think that the rules of the free market just do not apply, and recommend some form of government-sponsored or highly regulated system, perhaps single payer.

bluedevilmike · September 10, 2006, 1:36pm

Still might be measuring differences in time costs.

highest acceptance rate

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