The Medical Bubble…


“In 1980, Congress passed the Depository Institutions Deregulation and Monetary Control Act, which served to deregulate financial institutions that accept deposits while strengthening the Federal Reserve’s control over monetary policy. This act upended the regulatory protections that had been established as a result of the Great Depression.

In 2008, the worst recession since the Great Depression occurred as a result of the sub-prime mortgage and bank failures.The checks and balances that had previously been in place because of the New Deal no longer existed, thanks to the lifting of regulatory safeguards by the act stated above. Prior to the crash, during the “housing bubble”, banks and hedge funds were profiting largely from selling unstable mortgage-backed securities. As long as the housing boom continued, they prospered. Predatory lending flourished. There were a few voices (Robert Shiller, Edward Gramlich,Raghuram Rajan, Dr. Madelyn Antocic, etc.), recognizing signs portending a financial collapse, who attempted to warn the industry. They were ignored. The money was just too good for these town criers to be acknowledged. Well, we all know what subsequently occurred, there is no need to elaborate.

We use the crash of 2008 as an analogy of what is occurring today in the house of medicine. Warnings were given about a calamity that was about to occur and individuals trying to do what was right by speaking out and up were either ignored, demoted, terminated and/or had their reputations destroyed. The powers that be could not allow something as basic as a conscience to interfere with their ability to make a profit. In every single case, those doing wrong were in the majority. “Victims” of crowd think. Believing that because everyone else was doing it, it somehow righted the wrong. It didn’t. The whistleblowers were vindicated, but not after enduring the ramifications of being honest. It made me wonder, why is it so easy for so many to do wrong? Especially when they know that what they are doing is unethical? And despite being alerted to the potential repercussions of that behavior? Those are the million dollar questions.

Permitting the practice of medicine by non-physician practitioners(NPPs) legislatively is iniquitous. Immoral. It is a smokescreen for what is really occurring, an attempt to transition into algorithmic medicine. To create a business model of “cookie-cutter” medicine so that costs can be minimized. “Fast food” medicine because quantity is what matters, not quality. For anyone who may suffer because they do not fit the algorithm, the consequences are inconsequential. Patients are just too damn expensive. Health insurance companies don’t really want to provide health insurance, they want to profit from it. Sick patients cost them money. So they deny claims, knowing sick patients cannot fight. Ultimately the goal is to thin the herd…rid the population of the people who are a financial drain. Legislators, health insurance executives, hospital executives, corporate medical groups, physicians and other health care professionals are all complicit in furthering this reprehensible agenda…for the almighty dollar.

Non-physician practitioners are the cheaper cogs in the wheel, simply being used to curb costs. We believe they are both victims and opportunists. Physician assistants(PAs) by and large remain supervised, even if loosely. However, nurse practitioners(NPs) do not. In 22 states and D.C., they are permitted to practice unsupervised, thanks to legislators. They “appear” to practice medicine which is apparently good enough for the unconscionable legislators. No one really knows how good their “practices” are because there is no oversight. For example, Arizona has had unsupervised practice of NPs since approximately 2001. Since that time, what legislative or regulatory body in Arizona has followed up their practices to confirm that the quality of care is what they claimed it would be? Especially when there is no filtering out of qualified vs. unqualified, poorly trained NPs? Who has taken a census of the patients managed by these NPs and evaluated outcomes? Or done a review of the board of nursing complaints or malpractice data of each unsupervised state? Where is the surveillance? Is it not important to validate clinical practice since no reliable objective data exists? In states where NPs are still seeking unsupervised practice, supportive legislators love to emphasize that NPs have “independence” in nearly half the country. From that they presume the practices are fine because “they haven’t heard anything to the contrary”. Heard from whom? Since legislators are the ones passing the laws, why aren’t they doing their due diligence in following up the end result of their decisions? Because they don’t care. It was never about their constituents. Had it been, they would not have been so sloppy in their passage of these laws. They would have made the effort to get informed about the inconsistent education and lack of oversight of today’s nurse practitioners. They would have done their homework more rigorously.

To allow anyone to practice medicine without the appropriate training or oversight is unethical and wrong. One cannot legislate good medicine. There is no physician so remarkable that he/she can train a non-physician to be a physician without the requisite standardized education, training and competency exams that makes one a medical expert. One cannot create an algorithm so exceptional that it can replace cognitive thinking. Let’s not forget, it is the physicians/scientists on the front lines who recognize new diseases that appear on the horizon. Can’t know new unless you know old. When the AIDS crisis began in the ‘80s, it was the primary care physicians who understood a new autoimmune disorder was affecting mostly young gay men and notified the CDC. In the ‘90s, it was the emergency medicine docs, primary care physicians, and other physicians, familiar with toxidromes(as it is part of our training), who informed the CDC of the drug addicts with unusual Parkinsonian-like symptoms which subsequently led to the discovery of MPTP, a contaminant in the synthetic heroin being made on the black market. Discoveries of previously unknown afflictions, medications or recognition of the recurrence of formerly eradicated diseases do not always occur in the research lab. Many times they occur in the clinical setting, within clinical practices. Algorithms cannot replace this. Artificial Intelligence cannot replace this. Astute awareness of a previously unknown condition is predicated upon one’s medical training and foundation of knowledge. Nothing can replace the art of medicine, including physician substitutes. Stating that there are other ways to learn medicine or suggesting that physicians are overeducated is absurd and an excuse to disparage an honorable profession so that one can pursue an unsavory goal unencumbered. Even worse, describing the unlawful practice of medicine as “advanced nursing” or “top of their license” practice is also nonsense. If it is trying to walk like a duck, if it is trying to quack like a duck, if it is trying to waddle like a duck, it is not trying to be a gorilla. It is trying to be a duck.

The warning bell has been rung. Take heed. We are in a medical bubble that is unsustainable. The picture may look rosy because the business people are making lots of money and the public supposedly has “access”. Programs creating online sham s**t doctorates abound. DOCTORATES FOR EVERYONE!! Who cares that they are not medical doctors? The patients think they are and that is all that matters. The deception. But much like the economists, hedge fund managers and banking executives who thought the housing boom would last forever, so do those representing CMGs, PBMs, GPOs, health insurance companies, corporate medicine, etc. However, this “boom” will not last and none of the above mentioned entities are too big to fail. Their professional Darwinism is misguided–there will be no survival of the fittest because the foundation is unstable. Medicine will not progress effectively without the involvement of those trained and licensed in it, no matter how much they try to demean and demoralize us and minimize our roles. 

In regards to the changing of the guard in medicine…We say to the naysayers who state that ship has sailed, that is an excuse to do nothing. Ships can be diverted. It’s inconvenient, it’s costly, but it can be done. And diversion is usually done to save lives. Stop making excuses to avoid doing the right thing. Physicians have to stop being followers and become the leaders we were meant to be. We must do right by the people because if we don’t, our patients will pay a steep price. THAT will be the collapse of the medical bubble. And our oath.

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  3 comments for “The Medical Bubble…

  1. Benjamin Van Raalte
    February 21, 2020 at 11:38 am

    The nurse practitioners are not fine. Many of them accomplish nothing. Everything that’s other than cold they refer elsewhere or they shotgun with expensive tests. Since it would take an impossible study to line up patient for patients since they’re seeing the lesssick patients to begin with, It cannot be proven that their costs are excessive. But being at the end of the referral line I can tell you that they are extremely expensive. They make referrals they’re inappropriate. They don’t know what they’re doing. They order lots of tests including CT scans and laboratories because they shotgun because they don’t have diagnostic skills or experience. however on paper it doesn’t look that bad because the majority of patients they see are there for uneventful treatments. And by the time it’s a problem they’ve been shunted off to a specialist or someone I had to retire from emergency room call at age 62 because I got tired of being called by an emergency room nurse practitioner to treat something that I did as a medical student and did not eat a specialist but they did not feel comfortable. That did not stop them from still charging exorbitant emergency room fees to the patient. So there’s no cost savings and in fact probably leading to an explosion in cost. Everyone knows of the experienced family practitioner or general practitioner from the 1970s that could diagnose everything with a minimum of testing. We have the opposite today.

    • Tim Blain, MD
      February 22, 2020 at 9:40 am

      In general if you compare a primary care physician who spends a comparable/adequate amount of time with a patient to come to an assessment and plan to an NP or PA, the NP or PA almost always orders more diagnostic testing and refers to more specialists which ultimately drives up cost even if they ultimately come to the same outcome/quality for the patient. With the corporatization of medicine it only makes sense to use NP or PA to maximize production and profits. I often have patients ask me why does it take 3 visits to figure out what is wrong with me when I go to urgent care or ER but when I see you it takes 1 visit. My guess is they use algorithm or practice like an algorithm due to time constraints.

    • Mamadoc
      February 26, 2020 at 10:02 pm

      And that my friends, is the dirty little secret: they are NOT less expensive. One of my orthopedist peeps told me he’d gotten 3 referrals from 3 different NPs within a month for sprained ankles…and every one of them had already had an MRI. For an ankle sprain.

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