Read time: 14 minutes
Job security is one of the reasons people enter medicine to become a doctor. “People will always be sick,” is a common boilerplate in the profession, as if that attitude is something to be proud of.
Even as a medical student, I found this notion to be naïve. Increasingly, I feel changes in technology, as well as in the macro environment in which healthcare is deployed is proving me right.
AI, machine learning, pattern recognition software, virtual avatars, crowd-sourced medical information, Google – all of these are IT enabled disruptors to the traditional source of medical authority, namely MD’s. AI will eventually be able to search and computer the world’s medical literature in a way that a human can never do (whether or not AI will be able to evaluate and rate such literature, much of which is frankly garbage, is a different matter).
Patients can access PubMed, connect online in Facebook groups and patientslikeme.com, and learn more about their illness than a general provider can. Yes, your Google search doesn’t replace my MD. But the one hour lecture I received in medical school on a particular condition doesn’t replace the years of experience any given patient has had coping with that same problem.
And tele-health likes Doctor on Demand and HealthTap are lowering costs of access for patients to interact with physicians. But you can’t get personalized service, some say. It can’t replace the breadth and depth of knowledge of a full interaction with an in person physician. That may be true, but similar arguments were leveled against Netflix as it went up against Blockbuster and we know how that ended up.
We now live in an age where expertise has now died. The radical democratization of information through technology has enabled all comers to the table. Overall, this is a dramatic development, and the profundity of this transformative effect has yet to be fully appreciated. However, in the case of healthcare, it means that everyone now has the right be a self-titled “nutrition coach,” or “fitness expert.” Online, everyone’s 1’s and 0’s are the same. Access, convenience, social proof, and a radical focus on the end-user experience trumps pedigree, credentials, and traditional authority. In fact, in some health circles, being a physician is actually counter-productive because of all the negative connotations that position comes with.
In other words, technology is radically changing how patients and providers connect. Reimbursement changes are doing the same.
Despite efforts to curb national healthcare expenditures, costs continue to rise in the US for both healthcare organizations and in the aggregate. Given the existential threat of these unsustainable costs, budgetary pressures will supercede all other considerations in the delivery of healthcare. What does that mean? A look at the role of mid-level practitioners such as nurse practitioners or physician assistants provides some insights.
Let’s be honest, you don’t need a deep understanding of embryology to treat most clinical conditions, such as hypertension. A significant percentage of basic science taught in medical school is frankly irrelevant. That time, while academically valuable, has little pragmatic value. Patients’ care if you can help their abdominal pain, not if you filled in a bubble correctly about neuralation involving ectoderm during embryogenesis. Clinical data bears this out. For many common primary care conditions, mid-level practitioners such as NP meet if not exceed primary care physicians in outcome studies.
In my field, you don’t need to be a fellowship-trained gastroenterologist to manage celiac disease, IBS, GERD, rectal bleeding, iron deficiency anemia, constipation or any of the common conditions that I often see. Especially in the case of diseases like IBS and Celiac, which are prototypical patient centered conditions, episodic care in the bio-medical framework is grossly inadequate to address these problems. Health coaching, behavioral medicine, and lifestyle counseling are more essential – skillsets that mid-level practitioners tend to have developed more effectively because of their training.
In fact, a good percentage of my patients could be well served by a primary care physician or NP after some basic clinical training. Liability and time pressures have limited this development from spreading, in practice – but not for long.
So what is a C-suite executive of a healthcare system with thin profit margins (which is most healthcare organizations to be honest) to do? Well, hire more NP’s and PA’s and limit the role of MD’s, of course. We’re expensive to hire, often egotistical, and generally poor communicators, which is tragi-comically ironic given our chosen profession. The value of an MD is in doing an initial consult, and not in conducting follow-up visits. It is also in scoping in the case of a procedural field like GI (ignoring the fact that in some rare parts of the country, NP’s are scoping). Patients will likely be happier, be served, and overall costs will diminish because NP’s are paid less. Frankly, I’m somewhat surprised this has not happened already.
Doctors traditionally have a “come to me” attitude because of our training and arrogance. But we are no longer the only game in town. We’ve forgotten the simple fact that we can’t be experts if people can’t afford to the see us. People have been suffering and we’ve been yelling in the wind, not realizing that we as profession have shirked our leadership on a whole host of important topics that are all too real for our patients including: cost of medications, access to providers, nutrition, navigating the insurance system, and healthcare literacy.
So what has happened? Nurses have stepped up. “Holistic” and “integrative” practitioners have become immensely popular, and have capitalized on increasing anti-medicine sentiment but marketing themselves as “natural” and “organic.” People are getting diet advice at their local Cross Fit box because, well, of course physicians don’t know anything about nutrition (as with many clichés, there is a nugget of truth in this but it’s been grossly overplayed. How can anyone profess to understand nutrition and not know the basics of the GI tract is beyond me…). People read health articles on wellness and lifestyle portals online.
These issues of cost and access haven’t escaped corporate America’s attention. Minute clinics by CVS staffed by PA’s, and the rise of urgent care are a sign of what’s to come – decoupling medicine from doctors and hospitals. The typical response by medical societies is that these are “stop-gap measures,” and then they complain about the lack of continuity of care with an established PCP. This neglects the fact that too many people don’t have primary care doctors to begin with or that one of the largest groups of patients in ER’s are those who have PMD’s but can’t see them in time or have too high co-pay’s. For many people, the sad reality is that having a primary care doctor is not a sustainable solution.
Some of you may have been following Amazon’s plans in this space, including buying the online pharmacy PillPak, and hiring noted physician-researcher Dr Atul Gawande. Many have noted correctly that Amazon is trying to get a piece of the 2.7 trillion dollar US healthcare market. The other reality is that for most major corporations (and frankly, even small businesses), finding their own ways to cut medical costs is now an essential element of corporate strategy – especially given the gridlock on healthcare reform in Washington DC. General Motors, as many have stated, is a healthcare insurance company that occasionally makes cars. You can bet that future efforts for major employers to reduce healthcare costs will involve greater use of automation and technology and reduce dependence on physicians.
Doctors will always be needed, but neither in the same numbers nor in the same function as before. Complex cases and medical and surgical procedures are safely in our literal and metaphorical hands for now. But as the scope of practice for physicians narrows to more specialized areas, I think we can expect more in fighting over turf battles as jurisdiction policies get redefined. If family medicine doctors can do screening flexible sigmoidoscopies and colonoscopies in many parts of the country, why not everywhere else? Who’s to stop internal medicine doctors from doing the same? The guild structure of medicine that protects professional societies will be effective for only so long.
Welcome to a brave new world.
I hope the patient will see me now.