1.) The FDA is imposing stricter limits on how doctors prescribe.

2.) The insurance companies are imposing limits on what doctors can do.

The trend has been developing for several decades, but it only came into clear focus during the 1990s, when the HMOs first gained prominence. Doctors have lost a great deal of independence compared to what they had 100 years ago, or even 50 years ago.

#1 has at least 2 parts:

a.) The War On Drugs: this has lead to limits on how aggressively doctors can manage pain. Too aggressive and the doctor comes under scrutiny.

b.) The widening powers of the FDA. Over the last 50 years the FDA has become a general clearing house for all new technologies that effect health. Whereas its focus was once on drugs, it now has substantial say over every kind of medial procedure, including such things as pacemakers.

A simple model of the contending forces might include these main actors:

1.) patients

2.) doctors

3.) government

4.) hospitals

5.) patient insurance companies

6.) doctor liability insurance companies

A simple model would simply assert that each of these is trying to lower their risk, partly by moving the risk onto one of the other players. (A more complicated model would have trial lawyers as their own element, but here the trial lawyers are assumed to be part of #1). In a simple model, you could assert:

risk = the power to make decisions

The more each group tries to get rid of its own risk, the more it also loses the power to make its own decisions. This is a simple model, but it clearly has some truth.

What we've also seen in the last few decades is that when risk in the system goes beyond what private sector actors can manage, then the risk, and the decision making, gets taken over by the government. This was a long term trend, but the trend was made very explicit and visible during the crisis of 2008/2009, when lots of private sector actors failed (Lehman, General Motors, etc) and were taken over by the government.

I keep looking for some sign that this trend might abate, but for now, it seems likely to continue, if in modified form.

Conclusions?

You can become a doctor. You will be respected. You will be well paid. You will lack the independence that has been traditionally associated with the role. But despite that, you may enjoy the work.

I'm not entirely sure what I think about that. On the one hand, it seems bad, that instead of having the freedom to exercise situation-specific judgment, doctors are increasingly being pressured to follow predefined flow charts and rubrics, turning it into a sort of cookie-cutter medicine. On the other hand, the statistical evidence in some cases is actually pretty good: for at least a few kinds of things that have been tested, doctors who mindlessly follow a validated process have, on average, better outcomes than the more traditional approach. One explanation that's been advanced for that is that humans are not very good at conditional probabilities, so doctors often make intuitive decisions that, if you run the numbers, aren't statistically the best choice, based on available data. If so, they're better off strictly following a data-derived procedure rather than trying to improvise.

It's a lot worse than pacemakers. Desktop medical image viewing software is also regulated under FDA-510k procedures. Our iPhone viewer has been tied up in the FDA morass for more than two years now. We're submitting a 510k for our cloud image sharing service, just in case.

Basically, if you market your product with the intent for it to be in any way involved with medical procedures, you fall under the purview of the FDA. Which is much, much harder to deal with than the iso equivalents. To the extent that we, as a small american company, have been launching things first in europe.

The idea was that eventually the software, and the equipment, would be released in the USA. This never happened. It is in use in the UK, but bringing into the US would require far more of an up front investment than anyone is willing to make.

In theory, the FDA exists to keep Americans safe. However, it is possible to look at some of its regulatory moves as aiming at consolidation within the industries that supply drugs and equipment to the medical field. I imagine it is easier to regulate an industry with 10 companies than an industry with 10,000 companies. However, the true cost is that a lot of innovation gets squeezed out.

[1] http://www.ourcivilisation.com/medicine/usamed/deaths.htm

"Everything about us was different, and we were naturally resented. While the neighbouring [sic] adults never confronted my father, their children were delighted to bully his children. My siblings and myself became social half-castes, accepted by no class and despised by all. The result in my case was an initial bitter resentment of my community, along with the traditional notions that I should pursue a university education then a career; so I dropped out of school to take a job as a bus conductor...

With determination, skill and a little luck I forged a career in computers before being forced into retirement in 1991...

Of course I could have restarted the education that I abandoned in my teens, but by then the true nature of universities had become obvious; they were no longer centres of learning pursuing truth but centres of profit pursuing customers. Inevitably striving for popularity with youth has made universities bastions of Political Correctness, and full of the kind of people who wanted to burn Galileo for daring to question that the sun circled the earth. So I spent my enforced idleness applying the skills acquired as a system's analyst to discover why my society is disintegrating into delusion and impotence...

In January 2000 I became an Internet publisher, placing a variety of books 'online' at my own expense, in an attempt to preserve some of the vanishing wisdom of humanity...

Indeed I am the first philosopher to realise that philosophy is the study of understanding."

Hmmm...

Weingart SN, Ship AN, Aronson MD (2000). "Confidential clinician-reported surveillance of adverse events among medical inpatients". J Gen Intern Med 15 (7): 470–7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495482/?tool=pm...

The "as many as 18%", "admitted to hospitals" and "Iatrogenic injuries" bits make this article say something dramatically different than "1 in 3 of all Americans (not just those hospitalized) die because of an error made by a physician".

Even still that doesn't have much relevance to the 1 in 3 claim, because most people go to the doctors more than once in their life.

Again, no offense - please feel free to quote the JAMA article itself that supports this. Atkinson does a bit more than simply cite actual journal articles, he's taking, to put it lightly, some liberties with information he compiles and personally interprets at will.

Not really because because most people only die after 4 or 5 things go wrong, which means that the causes of death sum to way over 100. E.g. close to 1 in 3 Americans die from drug use, and 7 out of 10 Americans die from chronic illness. But the way it works is that first someone will start smoking (drug use), which then causes chronic obstructive pulmonary disease (chronic illness), and then they will go to the hospital get MRSA because the doctor didn't wash his hands (iatrogenic death).

In Malcolm Gladwell's book Outliers there is a whole chapter on planes that is actually very similar, in that usually 4 or 5 small mistakes have to be made to actually cause a crash.

Now, there are two caveats, other than the (necessarily) very rough nature of the above calculation. First, you may believe that some of the other categories in that row are also things that would be reduced by reducing doctor independence. "Unnecessary procedures" seems like a reasonable candidate for this, though I would assume that since Medical Error is its own category that it tries to be fairly inclusive. Second, you may believe a different number for medical error itself:

"We could have an even higher death rate by using Dr. Lucien Leape's 1997 medical and drug error rate of 3 million. (14) Multiplied by the fatality rate of 14 percent (that Leape used in 1994 (16) we arrive at an annual death rate of 420,000 for drug errors and medical errors combined. If we put this number in place of Lazorou's 106,000 drug errors and the Institute of Medicine's (IOM) 98,000 medical errors, we could add another 216,000 deaths making a total of 999,936 deaths annually."

Side note: Is it just me, or does the author sound hopeful that we might be able to add to the death toll?

If you believe that 420,000 number (about 4x higher than what's in the table), that'd be about 10%.

Did you get "1 in 3" by attributing all iatrogenic deaths to doctor error?

Yes, because despite the fact that there is a category called medical errors, almost all of the other deaths listed are medical errors as well. It's not like there is really any legitimate reason for more than a trivial amount of people to get MRSA in a hospital seeing as when best practices are followed the rate of line infections goes from 4% to 0%.

"How do you figure, even assuming these figures are (still) accurate (many of them are 10-20 years old)?"

The NY Times just published an article a week ago saying the rate of medical errors hasn't gotten any better, which I linked to below.

This thread was originally about decision-making power being shifted from doctors (M.D.s) to insurance companies, administrators, regulators, laywers, and even patients themselves. Your first comment suggested that this is a good thing because those same M.D.s kill 1/3 of all Americans (and as a corollary, the other parties involved plus the other healthcare providers that outnumber M.D.s many-to-one kill nobody).

I think it's pretty suspect that the linked page cherry-picks its numbers, rather than trying to assemble them all from a single source which has taken some care not to double-count. Granted, such a source may not exist, but essentially the death toll for each cause X is taken from a paper which is trying to make a big deal out of X.

The fact that those numbers sound fishy is orthogonal to the fact that I don't think they would be any better if the power to make treatment decisions is taken from those best equipped to make it.

And all of that is orthogonal to the fact that the linked page does not even attempt to show this, so it doesn't really seem to support the point you were making with that citation.

So that'll mean you'll probably start seeing more checklists, set procedures, expert systems, etc etc. And it will reduce your independence. But it'll also (if we do it right) be better for your patients.

If you want an example of stuff engineers get brain boggled at, look at the labels on drugs used in hospital. The vials are typically sized for one dosage and so are fairly small, so you have small label to begin with (nothing -wrong- with that). And then half the label is taken up by a company label (at best). And then the full drug name is written out in tiny print.

"Integrative medicine" is just another term invented for "alternative medicine". A few respectable universities have centers/institutes for this, but it is almost always the result of a specific effort on the part of big money donors.

I think, as many others have mentioned, that more data is becoming available, largely due to the shift to electronic medical records. As a physician, especially if you're involved in research, being able to make sense of that data will be very valuable.

I would suggest checking out http://forums.studentdoctor.net if you don't already read that forum.

Look back 20 years to see what's changed to get an idea of what may happen in the next ten. Look for more innovation to take place in cosmetic surgery, veterinary medicine, and other practices where the patient (broadly defined) pays.

Insurance, while necessary for catastrophic events, has crept into almost every transaction. It distorts incentives and is less concerned with improving outcomes than minimizing and shifting costs. The financial incentives and economic models for medicine have to change before you will substantially alter the pace of innovation.

Medicare has a much larger say in what sorts of procedures will be used (the ever widening--yet still not wide enough--umbrella of PET imaging is a great example).

I question that assertion. Source?

Note that it is not sufficient to merely say "if you have condition X, it's better to have caught it early", because that ignores (a) the cost of testing all the people who don't have condition X for that condition and (b) the cost when widespread testing leads to false positives which cause one to think the patient has condition X leading to treatment which produces needless expense, disability and/or death.

Every time you take your car in for an inspection the mechanic is likely to find things that are wrong and need fixing; ditto for taking your body in for a check-up. But on the margin, medicine is just about as likely to make you less healthy as more healthy, so being prescribed more of it is not a clear win. (see the Rand study, MRFIT, and so on)

Doctors are being paid less and less while patients expect more and more (and they expect it to be free).

B/c of HIPAA, most of the obvious IT innovations will be stymied by bureaucracy and stagnation. The recent backlash against personalized DNA testing shows that regulators are looking forward to squashing that as well.

Waits are long now and will be longer in the future. Doctors are harried now and will be more harried in the future.

Most speciality medical care (other than plastic surgery and other borderline areas that people willingly pay out of pocket for) is a financial racket akin to the banking fiasco. The AMA keeps supply of specialists low to keep salaries high, and battles are fought over regulations that lead to more billable procedures, gaming of the medicare system, etc.

Many commonly used procedures and drugs have very little effect and drain money from society. If you think critically and read the studies you will realize this. Then consider the Billions being paid the respected specialists who do these mostly useless procedures. Consider the influence they have in hospital policy and government policy.

Medicine in the US is a phenomenon of the American psyche. We have too much faith in the latest buzzword or technology to solve our problems, and we want to cheat death. Meanwhile, medical diagnoses are the only validation provided to so many desperate souls whose miserable lives are spent in constant complaint and agony, defined by their illness.

So many doctors traffic in the misery of these people, and the institution of medicine legitimizes it (for profit).

There are some niche areas where science is actually making amazing progress (some kinds of cancer research, mostly) but overall the medical class (those enriched by the status quo) are exploiters of human vulnerability, hope, and malaise.

Yes there are some amazing doctors and most I've met are incredibly hard working, caring people. But there are so many lies so deeply ingrained into our system that it will be hard ever to change it.

If you're a 60 year old man with significant arterial blockage, it's considered normal. You'll be sent home on an expensive pharmaceutical and told to switch from steak to chicken. The population of aging adults (55+) are the human batteries that power the medical matrix.

I am not sure exactly what will happen in response to the forces you outline, nor am I sure when it will happen. I can only say with confidence that something will. It is absolutely impossible that we will in 2050 be in a world that is simply a straight-line projection from the one we live in today.

- Life expectancy is an s-curve, and recently we've seen the middle get nudged to the right, creating the impression of tremendous progress. The low hanging fruit have been picked, so the trend will likely not continue.

BS, medical inflation doesn't support that. In the US we pay roughly twice as much as any comparable industrial country in:

    -prescription drug costs
    -doctor salaries
    -insurance/bureaucratic overhead

>The AMA keeps supply of specialists low to keep salaries high.

Yes.

With your interests I'd suggest looking into MD/PhD programs - granted, that's a long time to spend in school (7+ years for both doctorates, then residency or postdoc or whatever), but if your interest is really in medical science, it can be a great opportunity. Also, these programs generally pay your tuition plus a stipend the whole time you're in school, so you can live comfortably instead of acquiring hundreds of thousands in debt.

Good luck!

I would start the company now if not for the issue of funding. As I do not possess the correct shibboleths (i.e., formal education, published papers, etc.), the odds of funding are literally zero (you can stow the replies claiming otherwise, I've checked). And the no funding trend continues despite being able to show time and again that my ideas are congruent with, and sometimes predict, the latest medical research in the above specified fields.

Also, if anyone else is wanting to do a similar track, the key to having your degree be an advantage to getting out of the United States is ensuring your university (and specifically your degree) is accredited by a signatory to the Washington Accord.

It's a field where people are inherently afraid of change due to the lives at stake. I think it really takes some doctors who aren't afraid to step out of the system and do awesome things. One of the few I've found is Jay Parkinson (http://blog.jayparkinsonmd.com/).

Jay noted that the healthcare system in the US is one of the best at acute care, but one of the worst at preventative medicine, which is why everyone is dying of chronic illnesses these days.

As a Biomedical Engineering Major originally going the pre-med route, I got really discouraged by the amount of work/studying/brainwashing required to work in such a highly regulated system where saving lives is secondary to your fear of getting sued.

And then you have the healthcare and pharmaceutical giants pulling many of the strings in the background amidst all the crazy regulation from the FDA, it's just sort of depressing at the moment.

But on the bright side, I do think it's all on the brink of some sort of revolution. I don't see the current model being very sustainable in the long term. It's quite possible that by the time you're done with your residency (and subsequent fellowship?) things could look a lot different.

That is, if a new technological evolution, can make it possible to diagnose the human body with a simple and small device, no one will probably need a doctor and the device can prescribe you the treatment with even more accuracy.

You can also take daily inspection with the device and it'll follow your health and gives you suggestions based on that.

You may think I'm too optimistic, but who thought that one day we can see the interior of the human body without surgery?

Doctors perhaps need to start specializing more in areas where it is harder for technology to reach. Maybe they need to think more holistically (something difficult for computers to do). Perhaps they need to actually learn about people in intricate detail - about their diet, habits, health history, etc. prior to diagnosing. Perhaps they need to become strictly health advisors, or partners of health. Maybe they should perform weekly/monthly/yearly meetings with individuals, learning about them over time through spending time with them. Decisions would be truly informed and they would develop true care for the person (and quality as a result).

In addition, it's important that doctors stop being viewed as creatures with omnipotent and infallible knowledge and decision making powers (I know there are exceptions to this but I believe it's true for a lot of people).

It takes lot of time, and the patient won't remember anything. However, the device can know all that and with precision. The patient doesn't need to tell the device that he smokes, but it'll discover alone and with high accuracy. It can uses for example, a combination of radiographic images of the lungs, some proteins concentration in the blood....

It is important to remember that GPs are much more than diagnostic engines. GPs are concerned with the entire health and wellbeing of their patients - mental, emotional and physical. The human aspect of medicine isn't something I would want to see us lose. Do I think we can build software that can help great GPs to be excellent GPs? Absolutely.

Hopefully, I'm wrong. The medical research community needs to focus on analysis of the huge datasets that will be becoming available over the next 10 years. Coaxing trends and patterns out of medical data could result in big breakthroughs, but it is going to need a radical change in how medical information is shared.

Nowadays clinical trials are usually managed by web applications, which give a real-time view of how the trial is progressing. We're also beginning to see drug trials targeted at specific generic groups. The idea is that you need a smaller sample size to prove a drug works for a certain genetic subset of the population, so less initial investment is required. If the drug is successful, further trials can expand the number of people that can use it.

Becoming a doctor sounds like a great idea, though. Good luck!

There will be cures for a few more things than now, but the average person won't be able to afford it (if you live in the USA).

A ride in an ambulance will cost $50k instead of $10k today (if you live in the USA).

An aspirin in a hospital will cost you $500 instead of $100 today (if you live in the USA).

Somehow the masses will be convinced to still fight against single-payer and defend massively profitable insurance companies and hospitals (if you live in the USA).

But if you want to be a doctor to help people and can maintain that attitude for a decade, then I applaud you, for what it's worth, you are truly a noble human being.

But there is something certain, technology will play a enormous role in medicine. You shouldn't be worried about whether or not we will see such things in a 10 year lapse.

The broad view: First, life is precious. Our time here on earth is extremely limited, and despite our best efforts, we have only begun to improve and increase our time here. Every time I hear about stories like Ebenezer Scrooge or rich philanthropists donating their money for secure a legacy, I am reminded of our inherent mortality and life is one of the few things that you cannot buy. Any society where the basic needs of food, shelter, and entertainment are largely met, an increasing amount of money is spent on healthcare. I think it is no coincidence that the proportion of GDP spent on healthcare correlates extremely well with the GDP proper. This is in part due to extremely poor diminishing returns – hypothetically $10m spent on running water can increase the life expectancy of 10,000+ people by more than 20 years, but $10m can fund at most 100 open heart surgeries (which here the 5 year mortality benefit is only marginal). But with increases in the standard of living, expectations of health increase. Barring catastrophic changes, our emphasis on health will not diminish. If you want to work in a field of high importance, where effort will be rewarded, there are many challenges, and technology is constantly changing and improving, medicine is a good choice.

A ground level perspective: Second, medicine is difficult. Undoubtedly there are many challenges in the path to become and the practice of a physician. There are many problems in the structure of healthcare, there is decreasing independence, and the training path is only lengthening as medicine becomes more and more specialized, but there are many benefits and joys unique to the medical profession. You are privy to the breadth of human experience, from life to death, and are gifted with a perspective unparalleled in beauty and complexity. When you work with a cadaver for the first time, I hope you are overwhelmed by how inherently private and precious the gift is before you. I am convinced that are few experiences more acutely beautiful or overwhelming than helping someone overcome an illness or witnessing a birth or death. Biological science is an incredibly diverse, complicated, and fascinating field - as a physician, you can help facilitate the next big breakthrough or be part of its implementation. Technology will only facilitate and augment the physician’s ability to diagnose and treat disease – there will always be need for someone who understands and appreciates the mechanisms of the human body.

As a physician, you will be respected and will be compensated by your ability to help others. I am certain that medicine will be vastly different in ten and twenty years, but I think the things I mentioned above are constant. If you are passionate about science, appreciate the ability to help others, and willing to work hard, medicine can be a good choice. You don’t have to worry about it disappearing.

For that reason, I downvoted.

1. Despite diminishing returns, medicine/health is a social/individual priority and significant resources are dedicated to this field.

2. Health is a core necessity similar to food and shelter - I find it difficult to imagine a future of substantially decreased health resources.

3. Current aims are to improve efficiency, and slow the growth of healthcare as a proportion of GDP, but it would be difficult to actually decrease its proportion of GDP, particularly if expectations for standard of living and health continue to increase.

4. Biological science is really interesting and medicine allows you to help others.

5. You get to see some really cool things that most people can't see.

6. The above reasons are things that won't be changing in the foreseeable future.

For any career, there are intangible and unquantifiable reasons and benefits. I am not, and not seeking to, make a completely objective, metric based argument for medicine. To be successful, I think you need to have a passion for your career, and I am simply trying to identify the aspects of medicine that one can find passion for. For that matter, if the decision to choose medicine is purely quantitative and pragmatic, I would advise you against medicine. We don't need physicians like that.

From my perspective, there are probably three important things occurring at a fundamental level which may be likely to dramatically change medicine in the relatively short-term.

1. Electronic medical records and more accountability in medicine through the (eventual) re-alignment of incentives for hospitals and physician practices.

EMR makes it fundamentally easier to track where a physician practice's money is flowing, and to collect data on the effectiveness of treatments for different classes of patients. Right now, physician practices are not incentivized to focus on metrics from a business standpoint because its often not (a) viable from a cost standpoint or (b) able to be easily actionable for the physicians. As EMR technology continues to improve (see Practice Fusion for an example of a great technology which is incidentally free) and as the policy environment slowly adapts to incentivize doing what's best for the patient, I think outcomes will improve. This is, IMO, the messiest problem confronting medicine today.

2. Genetics and genetics research

I work for a diagnostic genetics startup. DNA sequencing technology is finally getting to the point where doing business in this field is able to be viable from a cost standpoint. As sequencing technology becomes 'democratized' to the extent that individual research labs are able to purchase essentially desktop sequencers to conduct research, the quality and breadth of genetics research will probably be significantly greater.

3. Bio-engineering

MIT recently added a bio-engineering major. Much of the early-stage research occurring at MIT, Rice, and other colleges with dedicated bio-engineering departments is extremely interesting. I hope that more colleges and the government will put money into translational research programs aimed at bringing discoveries in the lab into the clinic. Though I'm not qualified to write about this in depth, I considered attending graduate school in bio-engineering and found much of the research in tissue engineering and the like to be very, very interesting. It's just so early that it's hard to tell. However, I've found bioengineering departments to have this sort of inspiring zeitgeist pervading them that I imagine is similar to how physics felt at the dawn of the 20th-century. They aren't exactly sure what they're doing, they simply can't be at this early stage, but they know it has the potential to be very important.

I think that medicine will remain viable. Things will change, that's for sure, but I think it can be a net win.

So instead I went into creating consumer products and am now moving on to the internet space because of new government regulations making the other space to expensive. As you can figure, I hate the government, you have bureaucrats making rules on subjects in which they have zero understanding. You have the lobbyists from the large companies using regulations to great huge barriers to entry to protect their fiefdoms. Unless the ridiculous health care law is repealed, the advances and success the USA enjoy will disappear. Before people quote survival stats, make sure you compare apples to apples, for example infant mortality is calculated completely different around the world (the definition of live birth).

My hope is that the US embraces a true free market health care system. The problem is that we have removed the pricing effect that creates efficient markets from the health care industry. What we should have is true insurance where it pays 50% over say $2,000/yr, 80% over $5,000, and so on. Your company places a set amount of say $3k per year on to a credit card (that roles over yr to yr) and you can use the card to buy any health related service or product. This eliminates all the paper cost in the system and brings back the pricing effect since people will now shop for better deals (ie why does a procedure cost $7k at one place and $2k at another across town?).