Tuesday, February 22, 2005

In response...
As a lead-in to Grand Rounds XXII Dr. Wilde puts forth a post describing the crises facing the current health care system, and some solutions:Health Care Problems and Solutions. Dr. Wilde discusses problems with health insurance, liability, drug approval, and the topic Mr. McBride took me to task for: board certification and physician licensure:
Licensing and monopoly privilege have harmed the growth of medicine as a field, lowered the quality of care patients receive, and degraded the working environment for many health care professionals. The primary economic effect of licensing is to artificially limit the supply of a good. There are less physicians practicing medicine than would be without licensing. Though such measures are usually justified for safety reasons, there is no reason licensing cannot be supplied privately as it is in other fields. Greater openness would allow different approaches to medical care to compete with each other, result in a more adequate supply of house staff, and produce better overall patient care.
The utility of government licensure for physicians was a subject of one of the first posts of this blog. I had been waiting to re-post it in anticipation of Mr. McBride getting around to what was going to be part IV in his Paternalism in Medicine series. The post was an email I had sent libertarian talk show host Neal Boortz, in reply to this portion of his program notes for July 3, 2003:
Inform your representatives that you want to be free to make your own consumer choices, and that includes choices of which professional you want to use for medical and legal services. Tell them that you are perfectly willing to rely on your own judgment, or the judgment of private accrediting agencies when it comes to selecting an attorney or a doctor. You might add that you don't like the idea that you have to go to the government to ask who may and who may not clip your fingernails.
To which I replied:
I have also heard you mention on your program that you do not feel that physicians should be licensed by the state. I am a licensed physician in the state of Georgia and I must tell you that I disagree with you on this issue.
Let us compare a medical license with the most common license issued by the state, a driver's license. To obtain a driver's license one must pass a test on the rules of the road and pass a driving test. This is done to insure a basic level of competency before one is allowed to possibly endanger one's self and others behind the wheel of a car. To obtain my license to practice medicine I had to provide documentation of my education and training. This was to insure that I had at least gone to medical school and done additional training before I could possibly endanger some poor soul
who had become my patient. This is also to insure a basic level of compentency. By requiring licensure, the state fulfills a duty to protect the citizenry against potential harm. In the paragraph above you advocate the use of private agencies to
monitor and provide accreditation of physicians. The danger in this is that, as the cliché states, "Who watches the watchers?". Physicians have the choice to submit to further examination in their field of specialty and become "board certified". Board certification is not required for licensure or for admitting and treating patients in some hospitals. If private agencies are responsible for accrediting physicians then a group of physicians can get together and form a new board or "private agency" who will then sign off on them, even if they cannot become certified by an established specialty board. You can see the potential danger this brings up.
But what about the judgment of the individual? Medicine is very complex and if a physician states he is "certified by the xyz board of specialists" the patient may accept that as adequate. At the least a patient would have to do some research to determine if that is a legitimate accrediting board, or something thrown together by some physicians of dubious credentials. By requiring licensure the state also provides accountability. A physician must meet certain requirements to maintain a license. Patient's may complain to the Board of Medicine and an investigation may be initiated. The physician may have his license revoked or put on probation. A
"private agency" may be reluctant to discipline one of its' own (dues-paying) members, and if it did, what would stop the physician from starting up his own "Board of abc specialists"? The civil litigation system would not be a good policeman either, as the physician in question could simply operate without insurance. This would remove the "deep pocket" of the liability underwriter, making the financial benefit of a case minimal.
I agree that some of the professions that require licensure and their boards are a method to limit competition (real estate agents and funeral directors come to mind), but professions that require specialized expertise (physicians, dentists, plumbers, and yes even lawyers) licensure is a method to insure a basic level of education and compentency.
So while the system is not perfect, it beats the alternative of caveat emptor.
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