Insufficient evidence

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.

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23 Responses

  1. James Hanley says:

    There’s a relevant story in Milton Friedman’s Capitalism and Freedom:

    At a meeting of lawyers at which problems of admission were being discussed, a colleague of mine, arguing against restrictive admission standards, used an analogy from the automobile industry. Would it not, he said, be absurd if the automobile industry were to argue that no one should drive a low quality car and therefore that no automobile manufacturer should be permitted to produce a car that did not come up to the Cadillac standard. One member of the audience rose and approved the analogy, saying that, of course, the country cannot afford any thing but Cadillac lawyers! This tends to be the professional attitude. The members look solely at technical standards of performance, and argue in effect that we must have only first-rate physicians even if this means that some people get no medical service — though of course they never put it that way. Nonetheless, the view that people should get only the “optimum” medical service always lead to a restrictive policy, a policy that keeps down the number of physicians. I would not, of course, want to argue that this is the only force at work, but only that this kind of consideration leads many well-meaning physicians to go along with policies that they would reject out-of-hand if they did not have this kind of comforting rationalization.

    Dr. Sibert mistakenly seems to think the choice is solely between working full-time and working part-time, apparently not comprehending that opting out of the profession entirely is also a realistic choice. I have a colleague who created a mid-career transition program for doctors who were burned out–apparently it’s a major problem. So if we’re concerned about access to physicians, the goal ought to be to keep as many of them with a hand in the game as possible at whatever level they’re willing to do, rather than to make demands that will simply drive them out.Report

  2. Burt Likko says:

    All this hand-wringing over the fact that some doctors decide to practice part-time for personal reasons.

    To maintain a medical license, one must remain abreast of developments in the field by way of continuing education, no? And for bread-and-butter kinds of practices, not that much is going to change over time anyway, right? So it’s not really a question of whether a part-time doctor is rendering acceptably competent care.

    It’s a question of whether they’re “real” doctors because they work part-time instead of residents’ hours. (I have doubts about whether residents should work residents’ hours. Less desirable shifts, sure. But 48 hours at a stretch? Sounds like a good way for a junior doc to become addicted to self-prescribed amphetamine substitutes, if you ask me, and thus risk doing serious harm to a patient. But that’s a story for another day.) A doctor is no less “real” for her failure to log in sixty hours of practice a week — how much of which is taken up doing paperwork and how much of which is spent interacting with patients? The medical license and privileges appurtenant thereto, and the education and experience backing up that license, are still the same. She’s still a “real” doctor and the rest is just snobbery.

    I’m aware, but admittedly not fully informed, that there are specialities in the medical profession that are underserved as well as geographic areas. When I got my vasectomy, my urologist complained that he lacks colleagues and has to work harder than he really wants to because of that. Maybe the market takes care of that, but I’m not sure that’s the case when laser eye surgery, face lifts and boob jobs, and “medical weight loss” dominate the consumer market. If a few doctors want to work part time but can be persuaded to work in underserved areas or underserved specialties, that may be a pretty good trade-off from a 10,000-foot policy perspective.Report

  3. Pat Cahalan says:

    > Fine, so I didn’t try all that hard to keep my disdain out
    > of my response.

    I dunno, Doc, I’ve seen magnificently scathing responses to articles like these that would take the paint off your house. In fact, I bet I can find one on the blogoblog within an hour. I think you restrained yourself fairly well 🙂

    > And, it seems, it can only be a life’s work if it consumes a
    > sufficient amount of said life.

    I’m curious as to how much “productivity” a male doctor produces in the study she references (but. does. not. cite!)

    Because if work-hours are the only metric in the study, my immediate question is: hey, isn’t there a fairly well established correlation between medical misadventure and work hours? Don’t these overly “productive” male doctors make the lion’s share of the screwups, from fatigue?Report

  4. This was a really informative post on which I wish I had more time to comment.

    For now, though, one out-of-left-field question: is there any evidence that part-time primary care doctors help to reduce overall demand on the system by discouraging their patients from showing up for trivial reasons? I believe one of our guest authors (or maybe it was you) once wrote a piece that discussed the effects of excess demand on health care costs and on the system as a whole.

    For instance, our pediatrician is a solo practitioner with quite limited office hours (max. 5 hours/day). She has a sparkling reputation and is the top recommendation of other doctors all over the area. I don’t think she turns new patients down, either. So her overall patient load is almost certainly comparable to other pediatricians in the area who work longer hours.

    But because of her limited office hours (perhaps combined with the fact that she makes abundantly clear to all and sundry that calls outside of office hours are for real emergencies only), it seems like outside of regular checkups, the only time we even think to send our child to the doctor is either where daycare mandates that we obtain a doctor’s note before she can return (ie, she was sent home with a really high fever) or where she has symptoms that persist for an extended period of time (a week or more). My assumption is that other parents who use this pediatrician act similarly since she is able to maintain a pretty sizable patient base without increasing her hours, as I mention above. It may or may not help that she has a well-known policy of prescribing antibiotics only as a very last resort such that he ordinary advice is just to let an illness run its course.Report

    • DensityDuck in reply to Mark Thompson says:

      “[I]s there any evidence that part-time primary care doctors help to reduce overall demand on the system by discouraging their patients from showing up for trivial reasons?”

      I think that the converse is true–that visits for trivial reasons go instead to emergency departments and contribute to wait times.Report

      • Trumwill in reply to DensityDuck says:

        That was the hope in Massachusetts, that with universal insurance, emergency rooms would become less full. But it didn’t really work out that way.

        The famed McKinsey report referred repeatedly to demand rising to meet supply in the medical profession. This is one of the things that has me concerned about increasing the number of doctors. Without other changes taking place at about the same time, I fear that it would end up costing our system more rather than less as new doctors (often with the best of intentions) drum up new business.Report

      • I have no doubt that some do, but certainly not all, right? The question focuses on overall demand on the system (though I’ll stipulate that an emergency room visit quite likely has a greater marginal effect on overall demand than a primary care visit).Report

  5. Trumwill says:

    There was a Herculean doctor that was the only obstetrics-trained doctor in this town for about 18 months. He never left town during that period. He delivered every single baby while maintaining a full GP loan. This town owes him a debt of gratitude, but the legend of Dr. Hercules has had a pervasive effect on the medical community.

    My wife works about 70 hours a week right now and is on call 3 weekends of every four and thus can’t leave town. Everyone agrees that this is not desirable, but the hospital is of the mind that if they get her hours down to 60, she should be grateful. We get the impression that they consider our target – 50 hours – to be the stuff of laziness. After all, Dr. Hercules worked for 18 months! And he had two small kids! We seriously wonder if she would have to go “part-time” just to keep her workload at 40 hours.

    Not to make this “all about Trumwill (and Dr. Wife)!” but it all kept going through my mind as I was reading this. Doctors have among the lowest job and life satisfaction rates of any profession. The wife and I are racking our brains trying to figure out how it is we’re going to start a family. Dr. Hercules has two kids, but it’s easier when you can outsource all your parenting to the non-doc (my breasts, I fear, are barren).

    And because of all of this, I tend to view Sibert as “the enemy.” The ones that scoffed when residency was broken down to “only” 80 hours a week (even while the AMA was advocating stricter regulations on truck-driver and pilot hours due to fatigue). I tend to associate these views with men, but Sibert reminds me that it’s equal opportunity.Report

  6. rj says:

    Big-firm big-city lawyers have a similar issue. Associates are expected to be accessable 24 hours a day by BlackBerry and are told not to talk back if a partner cancels a vacation when they are at the airport half an hour before departure. It’s part of the culture.

    The problem with part-timers comes from the resentment of those people, both male and female, who have never had a boss recognize that they had a life outside work now seeing management bend over backwards for the sake of someone else’s “balance.” People who don’t have kids (or are fathers) have a life to balance too!

    Besides, if you’re expected to work nights and weekends, what use is a colleague who you can’t work or communicate with half the time?

    Perhaps this would be less of an issue if we reformed the debt peonage system of legal and medical education and placed some limits on the hours of salaried employees and medical interns.Report

  7. DensityDuck says:

    As you point out, if a part-time doctor can get the job done, then maaaaaaybe we don’t need providers of basic healthcare services to be Medical Doctors Who Totally Went To School For Like Twelve Years And Have Letters After Their Name And Get Called ‘Doctor’ And Don’t You Fucking FORGET TO CALL ME THAT!!!Report

    • Trumwill in reply to DensityDuck says:

      My wife had actually intended to let patients call her by her first name. Unfortunately, that only lead people to assume that she was a nurse. Right now it falls into the category of something male doctors can more easily get away with than female ones.Report

  8. Thoreau says:

    It’s interesting that the insane hours worked by doctors are attributed to shortages. I’m a professor, and I attribute our insane hours and demands as the result of over-supply. The world is full of desperate PhD students and postdocs and adjuncts who are sweating and suffering for their shot at the tenure track. Few will make it, due to the odds and the way that PhD production outstrips demand. Those who do make it are in a job with too many people competing for too few research grants. The whole system is insane, and it’s because of PhD over-production.

    What’s funny is that some of the loudest complainers about work-life balance in academic science are also the ones who completely fail to understand the nature of the pyramid scheme, and what it does to working conditions.Report

  9. Jaybird says:

    When all you have is a hammer, everything looks like a nail.

    With that said, what’s one of the libertarian takes on the problem? Well, the obvious one, it seems to me, is that becoming a doctor has a great many barriers to entry and it does not seem obvious to me that the barriers are necessary to provide quality health care to our nation’s children (among others).

    Medical School? Sure, let’s keep that one. Residency? Well… does that *REALLY* result in higher quality health care? It seems to me, someone who is *NOT* a doctor, that Residency has more in common with Fraternity Hazing than Medical Care. Everybody gets “war stories” out of it, you have stuff to break the ice at doctor parties, and memories to last a lifetime.

    I’m sure that there are a lot of things that are similarly impediments to being a doctor out there that don’t have anything to do with making someone be a better doctor.

    As I’ve said a hundred times before, medical care consists of two things: physical objects (hospital beds, tongue depressors, drugs) and the time of medical professionals (be they doctors, nurses, candy stripers, or what have you). If a law gets passed that will not result in more physical objects *AND* it will not result in more people entering the medical profession, then it’s a law that will, at best, do nothing to help with the health care problem.

    We need more doctors. We need more nurses. I don’t know if we need more candy stripers.

    But it seems the best way to get more of these is not to have stuff like “residency” and to say “no part time doctors!”
    That’s a good way to get rid of people who want to work and it’s not obvious to me that it’s the best way to cull the worst 10% (or whatever %) from the bottom.Report

    • Residency is a necessary part of medical education. It’s the time when one learns the necessary information and skills to function as a specialist. A new medical school graduate is grossly unprepared to function as a pediatrician or surgeon or neurologist. The time during which one becomes an actual doctor, as opposed to some guy with a bunch of book learning and a couple of letters behind his name, is residency.

      Must it be as brutal and exhausting as has traditionally been the case? No. I am very much in favor of reforming the system. But residency per se is a necessary part of learning how to practice medicine.Report

      • From the outside, when I think of “Residency”, I don’t think of “apprenticing oneself to doctors for a couple of years” but “48 hour shifts” and “uppers”.

        The apprenticing part is necessary, I absolutely agree.

        I suspect that if you asked the average non-doctor what they thought of when they thought of residency, they’d talk about the “hazing” parts and not the “apprentice” parts. But, then again, I project a lot.

        That’s okay though, everybody does.Report

      • Lyle in reply to Russell Saunders says:

        But with the move to hospitalists, why not residencies in group outpatient practices, not hospitals. As long as the physician knows when to put someone in the hospital, then the physician can go on to the next patient. So it would become a true apprenticeship based upon doing the work that will be done later. (Also have more reasonable hours)Report

        • Russell Saunders in reply to Lyle says:

          Physicians in any given field need to know that field as comprehensively as possible. Diseases manifest along a spectrum of severity, and learning how to manage them in one setting only will lead to sharply circumscribed areas of competence. Residents should learn how to manage patients’ care in both hospitals and clinics. If they want to focus solely on one clinical context after that, then they have the training to do either.Report