Supreme Folly

I don't understand how Justice Ginsburg, a well educated and talented jurist, cannot "get" the relative simplicity of testing to determine qualifications for a desired position. One can argue over whether testing is the best way to determine qualifications, but testing, in one form or another, is very prevalent throughout the world. If everyone takes the same test on core knowledge, it makes the playing field as level as it possibly can be. If you can't score well on the SAT, you are not going to Cornell (her alma mater). If you can't pass the bar exam, you can't practice law. If you can't put the basketball in the hoop with regularity, you're not playing in the NBA. If you can't hit a golf ball, you're not going to beat Tiger Woods. If you don't pass the Medical College Admissions Test, you're not going to medical school. If you can't rap, you're not going to sell records on a rap label. If you can't pass a test on fire fighting, you shouldn't be a fire fighter, let alone be promoted to a position of authority.

The Forgotten Man of Socialized Medicine

In Ayn Rand's book Atlas Shrugged this is the explanation given by a distinguished brain surgeon of why he joined John Galt's strike of the men of the mind. This is why, under a current situation very similar to that described in the classic novel, free thinking, innovative, creative, intelligent "men of the mind" may just quit if they are enslaved.

Atlas Shrugged

The Neurosurgeon's Speech

"I quit when medicine was placed under State control, some years ago," said Dr. Hendricks. " Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill? That was what I would not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes at the point of a gun. I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or the choice of my patients, or the amount of my reward. I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything- except the desires of the doctors. Men only considered the "welfare" of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, only to "serve". That a man who's willing to work under compulsion is too dangerous a brute to entrust to a job in the stockyards- never occurred to those who proposed to help the sick by making life impossible for the healthy. I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind- yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it- and still less safe, if he is the sort who doesn't."

Division of Pie

The comments below were made in response to recent statements by other medical professionals. Their claim is that simply decreasing pay to specialists and increasing pay to primary care docs will decrease cost and improve health care for all. I don't think it will work out that way.

I agree that increasing the number of primary care physicians and the incentives for primary care is an important goal. Improving access to basic health care is important in improving the overall health of society. What I am not sure about is that it would truly reduce cost. I am not sure how effectively decreasing the number of procedural specialists and increasing primary care would hold down cost, unless as a by-product of that event, access to care was limited by fiat. The cost of a product is usually determined by the cost of production and delivery as well as demand. As an example, producing, delivering and implanting a knee joint replacement is a very expensive process, from the cost of R&D and skilled manufacturing, to the hospital OR where high tech equipment, anesthesia and drugs are used, to the post-op recovery unit and rehab unit, to the operating surgeon’s (the installer’s) fee, the surgical nurses and medical consultants, physical therapy and rehab devices such as crutches and walkers. Of all of these costs, the surgeons fee is a small but crucial fraction. Without the surgeon taking risk, paying high malpractice and working, there is no joint replacement. Without arbitrarily limiting access, I don’t see that any decrease in patient demand for such a proven, life changing procedure is going to happen. How is simply decreasing the joint replacement surgeons fees and increasing the primary care doctors fees going to decrease societal demand for knee replacements, a high tech and expensive procedure? There also seems to be a feeling by some, including some recently opining primary care physicians, that all of these procedures we do are somehow unnecessary and unindicated and are driving up cost. As a specialist, the vast majority of patients I see are referred to me by primary care physicians, because they feel their patients need additional care. Why would they send me patients if they felt that further treatment was not indicated? The primary care gatekeepers are deciding that surgery is likely to be appropriate before I see the patient. In addition, a good surgeon knows that doing unindicated procedures is a very fast way to get into trouble. Because of this, surgery is usually not the first treatment option in my practice. Already the wait to see me for a consult is too long and the primary care docs are sending me as many patients as I can handle. As the number of primary care docs increases and access improves this situation will only get worse, especially if the number of specialists are decreased at the same time. How can this improve patient care and satisfaction? I feel that improving basic health care is extremely important, but as an example, one could argue that from a cost to society perspective a knee replacement is more beneficial than controlling hypertension. Many people live their entire lives with hypertension without any outward dysfunction or disability. Only when later in life it catches up to them with cardiac disease or a stroke do we have a problem. On the other hand, I see many otherwise healthy 50 year olds (and even younger) with disabling knee arthritis that prevents them from working or enjoying their lives. Correcting this problem gives an immediate, long lasting benefit to the patient and society. I only raise this point to show that placing value judgments on types of medical care is very difficult and often inappropriate. I can only hope that by the time some of folks that want to decrease the number of specialists want their knees or hips replaced, because they can’t walk without pain, that they will not have gotten what they wished for: limited access to care.