“Chokepoint Medicine” has no place in the 21st Century
An excerpt from “The Debate on Health Care Policy Reform ~ an exercise in pseudo-journalism”
The definition of “chokepoint medicine” is simple: It means each and every non-urgent patient must first go thru the eye of a needle to see and be seen by a medical doctor (MD) before the patient can legally assess any other aspect of the allopathic health care system — nurse practitioners, professional midwives, physical therapy, dietitians, etc.
In many other instances, non-allopathic ‘healing arts’ such as naturopathic doctors, acupuncturists, and direct-entry midwives are not legally available due to successful efforts of the AMA to criminalize most non-allopathic healthcare providers by getting laws passed that defines these disciplines as an illegal practice of medicine.
This monopoly on health and medical care was purposefully created by organized medicine — the AMA in particular – in 1910. There purpose was to exclude all non-allopathic physicians and all non-physicians primary care practitioners from being able to legally provide care under the “Healing Arts” statutes of state medical practice legislation. In those states where their practice is lawful, laws promoted by the AMA still prevent these primary care practitioners from being reimbursed by insurance carriers or federal programs such as Medicare and Medicaid.
As a result of this purposeful chokepoint, medical care is unnecessarily inconvenient, time-consuming and expensive for patients. The best data on its efficacy (safety plus cost-effectiveness) from the Institute of Medicine reports that our current ‘sickness’ care system is extraordinarily wasteful (over a third of all care is unnecessary). Even more alarming, chokepoint medicine is associated with an unconscionably high rate of iatrogenic and nosocomial complications and preventable deaths.
It occasionally works great for those with really good luck and really good health insurance. For the rest of us however, it sucks.
One of many big questions about this chokepoint medicine is whether 9 to 13 years of medical school training in life-threatening medical emergencies and the use of prescription drugs and surgery is actually the most appropriate way to provide safe and cost-effective for every headache, earache, sniffles, sore throat, tummy ache, backache, athletes foot, trouble sleeping, normal pregnancy, healthy child and all the other non-urgent and self-limiting conditions that fill up a physician’s waiting room every day? Can this possibly be rewarding way for a highly-trained medical doctor to spend his (or her) time?
Relevant history and trends in the physician workforce:
Between 1970 and 2000, the average number of potential patients available to the medical profession was reduced from 641 people per physician to 373 per physician. This was due to a large increase in new doctors in the decades following the Health Professions Education Assistance Act of 1963, which dramatically increased the number of medical schools in the United States. Between 1960 and 1988, the number of first-year students in US medical schools more than doubled.
While it was obvious that the number of new graduates would lead to an oversupply of physicians, no medical schools were willing to give up federal dollars by closing or significantly reducing their class sizes. During that period, new physicians entered the workforce at three times the rate that older physicians left practice. [Ref #26 -“Physician characteristics and distribution in the US”; 2000 edition Chicago American Medical Association 2000,page 352]
Defending professional turf: The explosive growth in the supply of physicians during the 1970s and 1980s was not offset by an aging population or greater use of sophisticated medical technology. With such a prolonged oversupply of medical doctors, organized medicine (OM) became even more aggressive in protecting itself against competition from non-physician practitioners and alternative health care professions.
In the last few years, the previous oversupply of MDs has been reversed by the mass retirement of physicians from the baby-boomer generation, leaving a hole that is not matched the number of med students in the educational pipeline.
This disparity in supply and demand is so daunting that many states are wondering how they will be able to provide primary care to vulnerable populations, especially the poor and those living in rural areas or inner cities. More than three-quarters of all new graduates go into the specially practice of medicine, leaving less than 25% of all physicians to provide primary care. Primary care emphasizes first contact care, continuity of care, comprehensive care, and coordinated care.
The Numbers ~ Everyday Non-urgent Health Care: Approximately 90% of all medical appointments are for non-acute healthcare. This category includes “self-limiting conditions” i.e., temporary situations that resolve spontaneously. By definition, self-limiting conditions do not need or benefit from sophisticated medical technology, prescription drugs or surgery.
The illustration often used is that a cold, if untreated, will go away in seven days; if treated, it will go away in one week. Ordinary, garden-variety complaints include mild illness or minor injury, psychological states such as anxiety or mild depression, normal biological conditions such as pregnancy, breastfeeding, newborn follow-up, well-woman care (contraception, pap smear), normal aspects of aging, life-style issues (diet, exercise and questions about sexual topics), school and work physicals, vaccinations, testing for STDs, managing a stable chronic disease, etc.
Challenging Chokepoint Medicine: In the early 1900s, primary care was provided by a mixture of MDs, non-allopathic physicians (osteopathic, naturopathic and eclectic doctors) and non-physician practitioners (including midwives). Organized medicine chose to do away with the traditional multi-discipline form of health care and replace it with an exclusively medical model that was purposefully configured to have a chokepoint.
This decision to get rid of non-allopathic physicians and non-physician practitioners occurred without any prior scientific research and without making any distinction between ambulatory care — non-urgent care for everyday self-limiting conditions — and urgent medical intervention for serious and acute problems.
Chokepoint medicine means that every non-urgent patient must first go thru the eye of a needle to see and be seen by a medical doctor before any other aspect of the health care system can be accessed. The big question is whether 9 to 13 years of medical school training in life-threatening medical emergencies and the use of prescription drugs and surgery is actually the most appropriate way to provide safe and cost-effective for every headache, earache, sniffles, sore throat, tummy ache, backache, athletes foot, trouble sleeping, normal pregnancy, healthy child and all the other non-urgent and self-limiting conditions that fill up a physician’s waiting room every day? Can this possibly be rewarding way for a highly-trained medical doctor to spend his (or her) time?
Time vs. money: These health concerns are not medically complicated, but can be time consuming and certainly take more than the 6 to 10 minutes allotted for the typical non-urgent medical or OB appointment.
What people seeking non-urgent health care want and need is a relationship with an unhurried primary-care practitioner who is able and willing to be empathetically present, to listen, talk, ask questions, sympathize, make suggestions, and spend whatever time it takes to educate the patient (or parents) about how best to manage their health.
Not enough of both to go around: By 2025 the growing US population, which includes children and increased proportion of elderly people, is expected to raise the number of ambulatory care visits by 42 %. The number of patients with chronic diseases – a category who benefit most from the coordination of care and continuity of care — is also increasing. [Am Coll Physicians – White Pager 2008]. By reducing rate of obesity, diabetes, osteoporosis and many other chronic and expensive diseases thru high-quality primary care, it eliminates the great volume of expensive and invasive procedures currently driving up the cost of health-related services.
Institutionalized Mismatch: According to Dr. Atul Grover, chief lobbyist for the Association of American Medical Colleges (an arm of the AMA), the answer is a 30% increase in medical school enrollments, to produce 5,000 additional new doctors each year.
However, this still misses the point, which is the extreme mismatch between what patients need and want from primary care providers, what society needs from them and what graduate doctors themselves need and want from the practice of medicine.
From a patient’s perspective, it must be nearly impossible to get cost-effective services for routine low-tech care from a physician who is trying to pay off an average of $140,000 in med school loans and simultaneously meet staff payroll, office overhead and malpractice insurance premiums.
There is already one MD for every 373 people in the US. The number of doctors who report giving up primary practice because they couldn’t make enough money to stay in business is both eye-opening and distressing – primary practice by MDs does not work.
Un-choked, unhurried primary care: Time and relationship-intensive non-urgent care is most satisfactorily provided by non-physician primary care practitioners – physician assistants, nurse practitioners, professional midwives, naturopaths. This is where preventative medicine actually starts; it is also how the routine overuse of Rx drugs and procedures is stopped.
A consensus of the scientific literature identifies primary health care by independently practicing non-physician practitioners to be comparatively safe, more cost-effective than MD care and to have a high patient-satisfaction rating. Currently there are about 140,000 non-physician practitioners practicing in the US. In event of a serious or urgent medical situation or request by the patient, non-physician primary care practitioners arranged for referral, consultation or a transfer of care to an MD or emergency facility.
