by Patrick Appel

Responding to Conor's healthcare musings, a reader writes:

I am a beginning doctor who finished my general cardiology fellowship last month and am leaving the nest of academic training for the wide world of private practice.  Not surprisingly, the hospitals and clinics to which I have applied for practice privileges require a list of the medical tasks I have performed in my training. The cardiology certification boards and societies also require a minimum number to these procedures before I am allowed to practice. These tasks are typical, standard cardiology diagnostic and therapeutic techniques, including catheterizations, stress tests, electrocardiograms and ultrasounds, among others, and the list I have completed in my training is likely quite representative of a normal cardiology fellowship graduate. They are not exotic or unusual procedures, just the bread and butter of cardiology, and account for much of the nation's medical bill for heart care. My list includes several thousand of these procedures that I have completed over nearly three years.

Why do you think that it would be cheaper to train nonphysicians to do those thousands of training procedures and then perform them in my stead as accredited practitioners?

I was paid a fellow's salary, in the range of $40,000 to $50,000 per year, which is less than typical wages for an experienced pharmacist or nurse or nurse practitioner, so how would you induce one of them to take the place of a physician, and a pay cut, for three years? Promise them higher income when they complete training? Hmmmm.... seems like that will just lead you back to the same situation in the end, don't you think? With purportedly the same skills to sell, why would they take a discriminatory pay cut severe enough to provide a significant dent in the US health care budget?  You might think to flood the market with lots of cardiologists to drive down prices, but there's a sizable literature suggesting that rising numbers of practitioners may actually INCREASE costs. And wages are not an especially large part of the medical budget, so even if there was a large pool of unemployed cardiologists every year, it's not clear to me that the resulting potential marginal wage reduction wouldn't be mostly offset by the costs of training all the new, redundant providers required to knock the salaries down.

You might think that we can 'unbundle' cardiology practice into discrete, low-cost components-- I guess you were thinking of something similar with regards to "professional bone setters" and emergency or orthopedic practice-- but even if you teach a high-school graduate how to perform, say, hands-on cardiac catheterizations, the patient still requires SOMEONE to make an informed judgment about the feasibility, risks and benefits, technical reliability and accuracy, importance and clinical meaning of a test result. Who should that be? A general doctor, perhaps? Let's imagine how that would turn out: 'Well, sir, I think the catheterization results show that your (son/daughter/father/mother/etc.) does not need heart surgery or a stent for their symptoms, although, yes, I did not actually DO the catheterization myself, and in fact have never actually performed a catheterization or learned how to read the cath lab images, but that's what the cath guy said and so I'm sure he's right!' Do you expect a system built on this type of arrangement to out-compete what we have currently, at least from a patient's perspective? For another example, again typical, when a patient is rushed to the ER with chest pain, which of these two would be chosen more often? The 'I-know-how-to-do-caths' guy or the experienced cardiologist who knows how to do the cath, how to look at the ECG to make sure a cath is actually necessary, who can put in a balloon pump if the patient's blood pressure drops precipitously during the procedure, who can start the patient on appropriate medications for shock or fibrillation which may occur during catheterization, etc.?

Even so-called 'standard' procedures require a great deal of knowledge, experience and direct expertise, along with good judgment. I don't see your idea as either technically feasible or able to provide quality care at a reduced cost. Why do you think it would work?

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