In Re Medical Licensing

As Alexander Woollcott said, everything I really like to do it illegal, immoral, or fattening. That seems to be true for the solutions to policy problems proposed by pundits as well. At least that’s what I thought when I read this post at RealClearMarkets from academic Edward Timmons on the adverse effects of restrictive medical licensing on the supply of physicians. Here’s an example of an proposal that’s immoral:

Many wonder if the looming shortage of physicians can be fixed, and the answer is undoubtedly so, but how? Allowing and recruiting foreign-trained physicians from abroad would be a good start.

As anyone who’s been to a hospital or group medical practice recently could attest, “foreign-trained physicians” doesn’t mean we’re recruiting physicians from the United Kingdom, France, or Germany or any other rich country. It means we’re recruiting them from poor countries.

In most of those countries medical education is paid for in whole or part out of tax dollars. In other words the poor (people in the physician-sending countries) are being taxed so that the rich (us) can see doctors more easily. Pursuing that as a policy is immoral on its face.

It also highlights something else that I think is too little appreciated. The incomes of physicians in general or internal medicine (rather than other specialties) are much closer together in OECD countries than those of specialists. There’s a good reason for that. It’s easier, quicker, and cheaper for a foreign-trained physician to become licensed as an internist in the United States than it is in other specialties. Since all of the rich countries of the OECD are in competition for foreign-trained physicians, that means that at least to some degrees internists are a commodity and there’s a competitive global market for them and that has meant that the prices for these workers have tended to converge.

Dr. Timmons’s proposal for overcoming the effects of the laws governing medical licensing is to relax the law:

The problem with this, however, is that current regulations have created sizeable barriers to opportunity, making it very difficult for foreign-educated physicians to enter the U.S. job market. The main culprit, it appears, is an overly convoluted and lengthy process that foreign educated physicians are required to follow in order to practice in the U.S.

Additionally, non-physicians – both foreign and domestic – should be granted more autonomy and a broader scope of practice. Currently, most states allow physician assistants and nurse practitioners to prescribe controlled substances and physical therapists to see patients without physician referrals. Several additional states allow nurse practitioners to prescribe without physician supervision.

Dr. Timmons ignores the risks in his proposals. Among the risks is fraud. Although most states have laws against misrepresentation, it’s quite difficult to enforce. If India can’t enforce its own laws governing misrepresentation, how are U. S. institutions expected to screen Indian-trained practitioners?

Other risks include diminished levels of care, increased levels of medical mistakes, reduced levels of representation among physicians belonging to domestic minority groups, and increased costs of healthcare around the world (other than in the United States).

There are several alternative proposals that might be considered. The first and most obvious is to increase the sizes and/or numbers of U. S. medical schools. If the number of domestic grads had just kept pace with their numbers in 1960 (when a prominent report highly influential in the enacting of Medicare/Medicaid warned of an impending physician shortage—such warnings are endemic in the U. S.), we’d be graduating about 20% more doctors annually than we are.

The main bottleneck to this is medical residencies and the main barrier is cost. U. S. medical schools are expensive although most Americans aren’t aware of it every single medical residency in the U. S. is subsidized by the Medicare system to the tune of about $80,000 per resident per year (paid to the institution not the resident). To increase the number of grads, Medicare would need to raise its spending caps, which would require Congressional approval.

As an aside I’ve always believed that if anarcho-capitalists understood how our healthcare system actually functioned it would be much harder for them to decry the horrors of socialized medicine with a straight face. Our healthcare system is plenty socialized but its socialized in the peculiar way that programs tend to be in the United States in which costs are socialized and profits are privatized.

Even more practical would be to redraw the line between science and art in the practice of medicine. The art of medicine should be practiced by living, breathing human doctors (and our system of medical education changed appropriately) while much more of the science of medicine should be performed by machines than is presently the case.

The greatest potential for automation replacing human workers isn’t in automating the tasks performed by people working for minimum wage but in healthcare. It will take two forms. One is in the form of expert systems that will do what human diagnosticians do now but will do it more reliably at less cost. The other way is in medical recordkeeping.

Although its presently being done to some degree we’re in the infancy of the Internet of Things as it applies to medical technology. Imagine if every measuring device, every stethoscope, every sphygmomanometer, every syringe were recording data and those data were recorded automatically. If you’ve ever watched your physician struggle with the computer system in her practice or his hospital, you’ll see the potential for improvement.