Prognosis worsening

My good friend Adam Walinsky, the idiosyncratic but brilliant former Bobby Kennedy speechwriter, has an opinion on just about everything. A few years ago he told me that he believes virtually every proposal to “reform” the nation’s healthcare system is doomed for a very simple reason.

The problem, he said, is that we have managed to make the practice of medicine so unattractive that fewer and fewer young people are becoming doctors at a time when almost everyone is talking about programs that will generate a demand for many more doctors.

{mosads}Walinsky contends that physicians have tended to be the offspring of physicians and that this is no longer true. Walinsky had suggested that someone ought to poll about 500 doctors to find out why they went into medicine in the first place and to see if their children have or are considering doing the same.

I hadn’t thought much about the supply-and-demand situation for doctors, but decided to test out Adam’s theory by asking my own physician if his children had considered following in his footsteps. “Why would they?” was his prompt reply. “Physicians today spend their time filling out forms, earning money to pay for liability insurance, and dodging trial lawyers. The quasi-romantic view that medicine helps mankind that prompted me to go to medical school just isn’t there for them.”

He said he spent 12 years training for the work he does, but doesn’t make any more money and, in his opinion at least, has to work a lot harder than someone who went to law school for three years and sues folks like him. My doctor trained as a specialist, and the most serious shortage today is of primary care physicians, but his point is well-taken.

Medical schools nationally are finding it increasingly difficult to recruit and hold qualified students. My pre-med daughter decided recently for some of those same reasons to go into nursing. She discovered that it is often harder to get into nursing school than medical school, so she told me that if she can’t get into nursing school, she “guesses” she’ll go to medical school.

Nurses, you see, are in short supply as well, but can do good and make a decent living without the schooling and the hassle that faces a doctor. Politicians in recent years have squeezed physicians on every front. The Congress and the HMOs that are the de facto employers of so many of them tell them what they can and cannot do, how much they can charge and force them to spend an inordinate amount of time filling out forms rather than treating patients. Most — though certainly not all — of them make a pretty good living, but few of them went into medicine just to buy groceries and BMWs.

The difficulties Massachusetts has confronted in extending access and coverage to all have been largely traceable to the fact that it is difficult to increase the workload and paperwork on healthcare professionals who are already overworked and then expect better results. And it isn’t just the highly regulated states; my psychotherapist mother-in-law and others in her generation retired early rather than join HMOs to reduce the risks of private practice.

Healthcare experts and reformers are beginning to realize that increasing the demand for services beyond the ability of the number of professionals trained to deliver them could be a recipe for disaster. What’s worse are the “solutions” to this problem contemplated by congressional and administration reformers. Amid almost universal recognition that primary care physicians don’t receive anything approaching a fair reimbursement under current government rules, it is proposed that they receive more from Medicare and that the money to be paid them be taken out of the hides of more highly trained specialists who would get less. This would pit doctor against doctor in the quest for government money and would, some hope, ultimately lead to a different mix of doctors coming out of our medical schools.

This idea has merit only if reducing the number of heart specialists, oncologists and highly skilled surgeons improves care for Americans, but do we want a system capable of diagnosing but not treating the really sick? There are various ways to “ration” healthcare. It can be done by fiat or by reducing the number of professionals capable of delivering it, but in either case, the result is the same: poorer care at higher prices.

Keene, chairman of the American Conservative Union, can be reached at Keeneacu@aol.com.