The USA is a very rich country with many great universities and institutes and a history of technical innovation in multiple areas. That would continue to be true for medicine even were universal healthcare to be introduced. Pro-rata the USA isn’t leaps and bounds ahead of say the UK and Germany.
And one must also consider the net worth of any individual innovation and to what extent the money in the USA healthcare system drives the behaviours in USA medical innovation.
One anecdote (details changed to prevent me being sued) I was recently deeply involved in a project where a prestigious UK medical institute had developed several cutting-edge treatments that were potentially going to be brought to market by a US company. These potential treatments included one that was life-threatening but had limited application worldwide as only a very small number of patients would be affected. It was however pretty much a “magic bullet” that required one or two doses and a full cure was complete.
Other treatments were for far less serious complaints and required the patients to continue taking the treatment for a lifetime.
The only ones the US group were interested in were those in the latter group. The “magic bullet” remains to be picked up and brought to market in the UK first. On that score at least the innovation score will be 4-1 to the USA but does that actually paint a full picture?
Or, the invisible hand of the market may result in no-one coming to help you because when your furnace goes out when it’s 35 below, no sensible furnace repairperson is willing to leave their toasty warm house to come help you. (I speak from experience. :mad: )
What central planner? I think you’re making a major assumption there about how UHC systems work.
I am not an economist, do not play one on tv, and have no head for numbers. However, people who are economists say that health economics is a different breed of cat, warranting treatment as a separate field. Given my ignorance, I prefer to follow their lead. The differences are summarized in the wiki article on Health economics:
So that’s my starting point in these discussions: the pointy-headed folks with numbers on the brain say that health care is a sufficiently different field to warrant its own niche in economic theory. I don’t think we can just ignore that and say that health care is really just something that should be governed by the market.
Note that in health care, the third party decision-maker is not just an insurer, but also the doctor, who makes decisions about the course of treatment based on professional knowledge and judgment. Yes, the doctor has to advise the patient of those decisions, and have the patient agree with them, but the patient can never be as fully informed as the doctor. So if you have a system solely where the patient pays, with no insurance, the patient will not be in the same position as a consumer buying a car or a house. The knowledge asymmetry is just too great, and the patient’s emotional involvement in the decision has no equivalent in the new house or car decisions.
If you add in an insurer, then you have two layers of third party decision-makers. Then you add in that the doctor, who makes the initial call about the treatment, often has no idea how much the treatment will cost, and you have a situation where classic market analysis just has no place to play: the ultimate consumer, the patient, has no real way to judge the doctor’s recommendation, and usually does not know how much it will cost; the doctor making the recommendation has the knowledge about what is the best course of treatment, but is not the one who has to pay, and often does not know how much it will cost; the insurer knows how much it costs, but does not have direct knowledge of the exact medical situation faced by the patient and has the ultimate goal of keeping its costs down, not ensuring that the patient gets the medical care the doctor recommends.
How on earth can a market analysis, which depends on transparency, full knowledge, and rational decision-making by the consumer who pays, work in that situation?
md2000 has already addressed the issue of preventative care, and also this argument that contraception is a commonplace thing. Given the personal impact on the woman of an unplanned pregnancy, with the potential life-altering impact, both personal and economic, there are very strong reasons to include it in coverage.
But more generally, this comment highlights a major difference in thinking between the US and countries with UHC. For us, it’s not insurance, and using insurance talk is not very helpful. It is a public service that is being provided. In some countries (e.g. France, Germany, Australia), a variant on insurance is used to deliver that public service. In other countries (UK, Canada), it is a flat-out publicly funded service. (It is sometimes referred to as “health insurance” but it does not really meet any model of insurance in the traditional sense.)
If you approach the issue of coverage as a matter of a public service, just like roads, police, fire and education, you don’t have a discussion of “well, everyone needs to go to the doctor for routine matters, so it shouldn’t be insured against.” Rather, the discussion is based on the principle of universal health coverage: what is appropriate to be covered in a system of UHC, to ensure good public health?
I guess my basic point here is that the vocabulary we use just to talk about the issue contains hidden assumptions that affect the discussion. If someone always uses the language of insurance, that will inevitably affect the way that person perceives the issue. If someone else uses the language of a public service, that also will affect the way that person perceives the issue. And when two people try to discuss the matter using those two different vocabularies, they may find themselves talking at cross-purposes, even with the best will in the world.
[QUOTE=Nava]
Mainly because of** protectionist barriers **such as accepting the degree itself but requiring a new residency (those usually don’t get another diploma). There are also issues such as refusing to acknowledge the specialization (different names in different places), or trying to figure out what a specific type of nurse would translate to. Medical-sciences degrees now are supposed to travel well within the EU as one of the consequences of Bologna, but other first world locations aren’t part of that treaty.
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There’s that, but it’s also that medicine is one of those few professions (along with law) that requires state certification everywhere you go, be it by historical tradition or simply because they’re really sensitive jobs - nobody will die if you said you learned to code at Berkeley when you really did it on your own (or you never did learn and are just wasting everyone’s time) ; but medical impostors are another thing altogether.
And the certification board can much more easily verify that you really did intern at Wherever Mercy and did indeed specialize in Retrophrenology under Dr. Knock than they can check foreign credentials, whether the school your credentials come from isn’t some diploma mill or a dingy hospital somewhere out in the sticks of Burma where they’ve been using the same one training cadaver since 1973 along with 18th century textbooks, and so on.
Yeah well, that’s what Bologna is supposed to help with, by creating a common framework so that people don’t run into situations where the government of another country has no idea whether the University of BFE is an actual Uni or a paper mill.
I’m not sure what do you expect in terms of “state certification” for medical professionals through the EU, but it’s supposed to be relatively painless. Nobody who’s finished his residency wherever should need to retake it in another EU country, people who got the degree but didn’t do the residency are supposed to be able to start the residency process in any other EU country.
And “nobody dies if you lied about your programming credentials”… please tell me you don’t work in a factory. Or an automaker.
Just curious - does France really admit people to medical college and then flush a significant number of them? or is it like North America, where that 90% take basic BSc science for 2 or 3 years, then an exam, and a small percentage are admitted to medical School? Once in medical school, my friends who got in (Canada) told me it is difficult to wash out. They even allow students to repeat years if they fail. it seems like a cruel trick to tell someone they are in medical school and later flush them out - and a serious waste of resources. Second year science is early enough to switch - some people I knew became dentists (yes) and some went on to assorted other science careers.
(Thinking of Isaac Asimov, who tried for 3 years to get into medical school and failed, then went on to be a PhD professor of Chemistry and international renown for science fiction and science writing - obviously not bright enough to be a doctor…?)
Sidebar: Asimov’s BSc degree was from the Columbia Extension School, so not very high up in the pedigree of credentials for that time. When he was accepted for his chemistry post-grad, it was on a probationary basis, which suggests that perhaps his marks weren’t that good. Who knows? lots of people are smart but may not have academic cred. Note that his subsequent career was as an explainer of science (both fiction and non-fiction) not as a doer of science. Those are different skills.
And in his biography, he says he was admitted on probation because the admissions officer had skepticism, said “please tell me you aren’t just marking time while you keep applying to medical school…”
But he became a Chemistry professor and PhD, or as he mentions, “I figured out PhD stood for phony doctor. My mother would introduce me as Doctor Asimov, then her friends would figure out I wasn’t an MD and say, ‘Oh, so you’re not a real doctor?’”
I sure hope “Professor of Chemistry, PhD” is smart enough to do medicine.
In between, from what I understand. There is an entrance exam; the preparatory coursework doesn’t lead to a degree.
Spain used to have the same model for engineering, you could spend forever just trying to pass the entrance exam (examen de ingreso). My own engineering school came up with its own selection process when the ingreso was removed: our first “year” is selective, it takes in pretty much anybody who fulfills the conditions for it (“pass 12th grade”, when I did; we didn’t even need to pass the equivalent of the SAT), but there is a numerus clausus for the second one. 1/3 of students never make it to that second “year” (our failures are the A+ students of other nearby schools). And year is in quotes because the first one usually takes two.
No, it doesn’t paint the full picture. I was trying to, and continuing to, point out that there are parts of the picture which are missed when you go broad.
Do you have cites showing that American surgical theatres are built and left empty like Aus/NHS facilities?
I’ve already said I’m not going to do a literature review for you: if you want to learn about Aus / NHS medical systems you’re welcome to do you own work. If you are only interested, you may be amused by the classic “Yes Minister” episode: The empty hospital
Note: this was not a documentary. It’ was a joke about the NHS.
The latter. Med schools accept as many people as they can physically hold - for the first year. I got in with the equivalent of a C- on my final high school exam (though I did remarkably well in bio).
At the end of that year there’s an exam, and only a precious few make it through that exam (I’m talking something like 50 out of a 700+ amphitheatre’s worth of candidates). The remainder can either do the first year again, but only the once as there’s no third chance, or fuck off. If they do fuck off, they can’t use their years of med. school as a shortcut for anything nor as a platform to move into anything else (whereas, for example, when I went back to uni to try and earn a history degree I was offered to skip the first two years of the course because I’ve already got a 3rd year diploma in English and an MA-equivalent in translation - this despite the fact that those courses had precious little to do with history).
However, once you do get past the first year, you’re pretty much set. There are still exams and tests throughout your formation, and again during your internship just to make sure you don’t completely slack off and/or aren’t a klutzy nutter but they’re not about selection, they’re merely about validation.
[QUOTE=Nava]
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Oh yes. I wasn’t contradicting you, merely adding to your argument. And yes, it’s becoming easier for doctors to move within the EU - but that’s still a relatively small pond.
If you can’t code, your code won’t work and it won’t be put into production nor make it past QA. If you can’t doctor but still get to doctor, you’ll kill people - they don’t have iterative QA loops, or debuggers for that matter :).
Bugs don’t get into production code? I have to disagree with that. It is such a serious issue that there a whole host of engineering principles intended for software with very low fault tolerance with high cost of failure, the classic example is a valve controller at a nuclear power plant. The ultimate intent is that a software failure should result in a safe state for the system. Of course, your average piece of software does not use such stringent principles, the point is that it is a well-known in software engineering that software failures happen.
Of course bugs happen and are put in production. Bugs written in by people who actually know how to code well, too. But those would be hard to detect bugs in otherwise seemingly functional programs that perform well under whatever test- and usecases could be dreamed up and tested. If you can’t code for shit your code won’t make it to that point. Code that plain durn’t work isn’t typically put out, unless you’re working in the video gaming industry.
Further, the point is that these bugs by and large don’t result in dead people. Nobody will die because the payroll software barfed up and chewed through last year’s data - it’s just a pain in the arse. If people would die should the software conk out the QA loop usually is, as you say, more stringent - typically due to regulations & safety standards.
Doctors are *all *in the “people would die if fuckup allowed to drive” category - either through outright malpractice or simply misdiagnosing/ignoring life-threatening conditions that a real doctor would have addressed. I don’t think it’s “protectionist” to want to make super duper doubly sure the persons who are allowed to tinker with my body actually know state-of-the-art stuff about body tinkering.
Interesting. It just seems to me an incredible waste of resources to teach 700 students for a year to get 50 doctors, especially if the courses have zero alternate applicability. In Canada (and the Asimov example in the USA) people are in a standard 4-year BSc. program and apply after 2nd or 3rd year. Those that don’t succeed in their entry application go on to anything else that accepts the science courses they picked (Pharmacy, Physiology, Chemistry, Dentistry (also hard to get into), etc.)
Recall reading about a small rural Nova Scotia town many years ago shocked to discover their nice doctor for the last few years was a wannabe with zero training. Apparently he got by on ordering a bit too many tests, sending tough cases to specialists, guesswork, a bit of reading, etc. He was charged with restricted drug offenses for writing illegal (of course) invalid prescriptions. The townsfolk liked him and didn’t want to lose him.
I’m not making a claim. I do think it is important to challenge people to back up their points.
you said
but you give nothing to back that up, even though you’ve said that you read some figures. What figures? what source? where can we go to scrutinise them?
You also say
but you give nothing to back that up other than a reference to a 30 year old episode of a comedy program.
Either you’ve got evidence or you haven’t. In the current climate I think facts matter more than ever.
I’ve said that the American System is different to the American system. I live in Aus. I have much less knowledge of the American system. Three of the doctors in my immediate family have worked in the American medical system. If you think that the American System is the same as the Aus system, I invite you to find citations showing that Americans build surgical theatres and leave them vacant.
I’ve also demonstrated that this was so notoriously a feature of the NHS that it blead into popular TV comedy.
If you can’t find a citation showing that the American system is the same as the Australian system in this regard, perhaps you should examine your beliefs.
