Before I begin, I must beg your forgiveness. It is late and this idea has been rattling around in my skull. I must let it out before it pulverizes itself into a puff of dust and logic. I apologize in advance for any typo’s, errors, and omissions in this rant. I am going to scribble down as if it were crayon on a cave wall and then go back to bed without so much as a second glance.
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For a long time I have taken a very primitive view of health care and tried to apply it to the modern condition. I reasoned that until very recently in our collective history people worked and played in very consistent groups. These groups had three types of people: harvesters, traders, and servicers. The harvesters were the people who farmed or mined. They- like their modern counterparts in Eve, WoW, or LOTRO- brought forth the raw materials from the Earth. Tradesmen bartered for these raw materials with refined items their talents had created. Industrialists of all kinds are the modern equivalent. Whether a person is making the widget or selling it, they are a tradesman. The servicers didn’t manipulate the Earth or materials directly, they provided a secure and stable environment for these more basic market activities to occur. Servicers included everyone from chieftain and shamans, priests and pastors, police and firemen, entertainers and scholars, garbage men and doctors.
While the primitive world may have had chieftain farming crops in addition to being old school community organizers, the larger the community became the less time the chief had for farming. The modern world has brought us the double edged sword of being so specialized that we forget our basic nature; and people in service forget the meaning of service.
It is decidedly unfair to say that servicers are a drain, because the market tells us otherwise. But there is something easily forgotten: overspecialization leads to inefficiency and waste. One does not have to think too hard about bureaucracy to see this is true. Image your daily life where perhaps you can do something yourself in half an hour at a cost to you of $50 or you can give it to another person to do in an hour at a cost of $40. While you have lost time in the transaction you have gained capital, but what happens if the second person take two hours and costs you $80? This is a very oversimplified example of problems we face in the real world everyday. Given the example above, you would not have the second person do the task, unless you had a guarantee that the work would take less then an hour and fifteen minutes. But in the modern world, the reality is seldom that transparent.
In the primitive times, the tribe toiled long to rip life from the earth. Few people specialized, and fewer still invested in the service of others. Instead of standing police forces or armies, civilizations had wartime conscription and militia. Instead of large universities with medical centers, the tribe had an elderly shaman and a few amateur star gazers.
But through the history of man we developed. We specialized. We entered the market of ideas, saw a need and filled it. Advances in technology skyrocketed the quality of life and standard of living around the globe. Humanity proved again and again that a net positive interaction is possible.
But we are increasingly furthering ourselves from the tribe of the past. One thing the small tribe had, was a sense of community. The tribe had its servicers, its tradesmen, and its harvesters and each knew their part. Dunbar’s number insured that the small tribe knew who to go to for every vital service and material need.
Only in the last hundred years has the service of medicine come to be thought of as a trade. And it is hard not to blame the profession for falling victim to that mistaken identity. So many advances in the material dimension of the profession were made that these service providers actually started to believe they were tradesmen. And to compound the problem, modern technology shifted the balance of tradesmen away from production of items to support of those items. But material support and communal service are not the same thing.
Doctors are not businessmen anymore then politicians, soldiers, firemen, police, or census takers are businessmen. Anyone who goes into the “business” of medicine is not a doctor. They are pharmaceutical researchers, cancer researchers, scientists, and inventors. But they are not doctors. The lines are blurry, but they do exist.
Do doctors make money? Yes. But that money is a reward for the place they hold in society. Reward for the special service they provide. Should doctors make money? Yes. Just as anyone who becomes specialized and fills a highly demanded need should be.
When asked how to reduce the percentage of harvested resources devoted to health, the question of efficiency is rarely talked about in basic terms. If we do not talk in basic terms we can never identify the systemic problems.
What is a doctor? A doctor is the member of the tribe whose purpose is to provide services designed to prolong the health of fellow tribesmen. Why is the doctor important? Because prolonging the life of fellow tribesmen increases their overall productivity both in quality (average output) and quantity (lifespan). Because of the complexity that doctors deal with they must be highly trained. This is a significant investment that needs to be recovered by the investor. It is also a generator of scarcity. While a nurse or a medic may be 95% as good as a doctor and keep you alive in the vast majority of cases, the diminishing returns in education versus application required to achieve that last 5% are significant. The threats faced by doctors also represent a further divide in knowledge, while 4 of that last 5% will be generally known, that last percentage point makes all the difference. This is an incentive for doctors to specialize.
But these leaves us with some interesting questions. If a Nurse is say half (or 3/4 or 90%) as good as a doctor, wouldn’t it make sense to have more nurses? Or more medics? Or more general practitioners? Yes, that is probably true, but unfortunately there are artificial barriers that keep this from happening. The same systems of certification that make the medical service professionals so good also hamstring their dissemination among the general population.
Cuba is lauded for having 1 doctor per every 30 citizens. But how good is that doctor, or better yet, how good is that doctors material support?
The increase of the medical trade has allowed for great increases to the outcomes of the medical industry in practice. But the tribe is now spending more on the doctors tools then the doctor. This creates a shortage of actual doctors, and leaves those unable to trade for that service without supply. The demand goes unsatisfied.
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This relates to the average worker, and how health care usage naturally follows a production bais; those who don’t produce, don’t get service that enables their continued production. But this is a broader topic for another time. How does the tribe act to differentiate between need and greed, productivity and sloth?
It is fair to say that we should all be equal before the doctor as we are before the law. That even though one person may produce more (and thereby help the tribe more), that a persons lesser production is not viewed as a barrier towards continued ability to produce. The far more difficult question to answer is what about the person who does not produce? Does the tribe have a responsibility to see that they continue not to produce?
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Gnite.