As a pre-medical student, it’s very interesting to see how patients and physicians interact with each other. Since I haven’t entered medical school yet, I identify more with the patient than the doctor, but I know that in a few short years, I will be on the other side of the encounter, treating my own patients with the care that they do. I have shadowed physicians in a variety of settings, and have noticed that patients are increasingly apathetic towards their doctor’s recommendations.
This pernicious trend is alarming—the physician-patient interaction seems like one where the patient should have an active interest in managing their own health, and a choice to take their care to someone else who could provide better care at a lower cost based on their own judgement. As I parsed through the economic history of the American health care system, a free-market system like I had described was available in the 19th century in America. Although it is hard to know whether patient choice was informed by increasing scientific evidence, evidence has shown that during the later parts of the 19th century patients favored physicians who practiced using the germ theory of disease.
However, as time went on, state-based licensure and accreditation policies increasingly took hold due to, in part, Abraham Flexner’s influential report on Medical Education in the United States and Canada. These reforms reduced the competition which drove the medical industry to expand in the late 19th century. Although the intentions of the regulation were to phase out charlatans and quacks, it also had the unintended consequences of reducing the supply of physicians who, while still qualified, were not licensed and therefore couldn’t sell their care. In addition, without “skin in the game,” the providers had no incentive to innovate or provide better care. Even further, patients became more apathetic towards their standard of care, and lay prostrate as they assumed that medical professionals had the ability to self-regulate.
Why should we care about physician’s licensing laws as patients? Shouldn’t we care about our health first?
Patients have an obligation to ask about these licensure and accreditation requirements because they indirectly contribute to the rising costs of health care by reducing patient choice and therefore contribute to our health outcomes. As mentioned, these licensing requirements were useful to phase out less competent physicians from the workforce, but they also limited the supply of potential physicians due to the barrier of entry.
This limiting effect begins, I believe, at the beginning of medical training and continues throughout physicians’ careers. The LCME (Liaison Committee on Medical Education) exists to make sure that medical schools are training physicians-to-be properly by accrediting medical schools and examining them every eight years, as per the requirements set in motion by the Flexnerian reforms in the beginning of the 20th century.
However, the LCME’s accreditation process has the unintended consequence of limiting qualified applicants from being physicians—in order to jump through the hoops of accreditation, schools must go through an arduous process of submitting multiple data collection instruments (DCIs) and passing stringent survey visits. Again, by increasing the amount of regulations to comply with, costs and access to medical education for qualified candidates is lessened. Although accreditation in a strict sense is voluntary, it is mandated de facto as attendance at a LCME-accredited school is mandated to be a licensed physician.
Increasing this supply of providers for the increasing demand that the United States’ health care market calls for may take the form of a national competency-based licensing program and loosening LCME and ACGME accreditation regulations.
By increasing qualified US medical graduates through competency-based measures and loosening regulations, for-profit colleges would have a lower barrier of entry to form in the United States. Competency-based measures, furthermore, promote better physicians while setting utilitarian, learner-centered milestones and allow the freedom for curricular change without supposedly reducing the quality of graduating physicians.
As of right now, I am in my third year of a accelerated BS/MD program—having been granted admission into medical school out of high school. Studies have shown that exceptional, driven students have an ability to shorten the medical school curriculum, save money from medical debt, and become competent doctors. This type of experimentation will be possible on a larger scale rather than a few select programs with lesser regulations to promote an increased quantity of qualified of physicians from a multitude of schools, for-profit and non-profit.
In addition, career competency can be portable: these standards may provide nurse practitioners (NPs) and physician assistants (PAs) increased scope of practice, thereby granting an independent way to combat the nation-wide healthcare demands. Paradigm shifts take time, of course, but career-competency provides an incentive for physicians to keep abreast of scientific advancement (to provide better care and enhance their reputation in a free market system) rather than mandating continuing medical education credits for mid-career physicians.
Furthermore, loosening Graduate Medical Education (GME) requirements which require the retraining of international medical graduates (IMGs) increases the supply of physicians in areas which are underserved. These retraining policies preserve national Eductional Commision For Foreign Medical Graduates (ECFMG) licensing procedures which may prevent qualified IMGs from finding GME slots for residency.
The opportunity cost of the retraining may be gained for useful labor in part by providing competency standards via a provisional national-based license in a hospital system and have each hospital system assume the risk of hiring physicians which they deem qualified based on competency criteria and evaluating IMGs periodically, just as they do for hospital privileges. This will prevent lost labor when there are competent physicians in the United States which are dissuaded from pursuing medicine due to the innumerable hurdles they have to jump through.
Medical errors are common. We do need a licensing program to prevent physicians from prescribing treatments which do not work. However, the formation of state based licensing programs only increase bureaucratic waste, are not a call for regulation by the public, and only serve powerful interests which have the ability to change scope of practice laws for physicians. In fact, Veterans Administration facilities allow physicians who hold a license from any state to practice in any of their locations across the United States.
Patients should be more invested in who is providing their health, and focusing on whether they are qualified in meeting their unique health needs. Having a nationally agreed set of competency-based values set by the American Medical Association is needed to prevent against quacks, but consumers should be able to decide, amongst a plethora of providers, who will provide them the best care and be more involved in combating illness. Self-reliance in health incentivizes preventative measures and protecting health, but also serves as a check on hot your doctor is treating the patient. Providers, in turn, would need to compete and provide the best services to patients, forcing them to innovate in a cycle which benefits providers and patients rather than bureaucratic officials.