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Sunday, August 8, 2010

Escape from the health care gulag

I was at a party last night of colleagues from work. We were all of similar age, being in our late 50's or early sixties and all of us have lived in in our fair city for at least 10 years. All of us had children who had taken various pathways for education and many have children who were the product of the public school system (including my own children). I too was a product of the public school system and until recently have been an advocate of public education.

The landscape is changing and the public education systems in my area appear to be unraveling. My children are done with that phase of their education and I am somewhat removed from these as immediate issues although I do read about them almost daily in the local papers. Some of the attendees of the party have children younger than mine and and still have to grapple of how they will educate them. Of course there is the private school option but even among the university associated parent crowd, home schooling is an option. Hoe schooling is not just for religious fundamentalist crack pots any more.

I was fascinated by some of the stories about the development of the home schooling networks and the remarkable tools at their disposal. It now appears that home schooling is not an all or none phenomena. One of the mothers at this party described the various options available to the families in her neighborhood. Obviously, one can take on all aspects of schooling your children at home and  there are all types of resources to do so. More often, groups of families form cooperative arrangements which divide responsibilities and more effectively identify specific areas of expertise. Furthermore they provide the social elements which may be lacking from an environment where children are schooled only by their parents.

The options go beyond even these. There are now opportunities for online courses and also for students to attend private schools for just specific courses. Obviously it takes motivated and bright students and parents to make this work but the outcomes are impressive with home schooled children outperforming their colleagues from public and private schools in almost all arenas. On top of this home schooling is growing in leaps and bounds basically doubling to 1.5 million children between 1997 and 2007. This may bode well for education in general but it does not bode well for the entrenched primary and secondary educational system which has become to a great degree ineffective and bloated.

What I find remarkable about this story is it is a grass roots story. The remarkable and apparently multiple  effective options have developed without a central directing force and without massive state spending. As the old model of education has become less and less effective while at the same time more and more expensive, this alternative pathway has emerged in what appears to be a self organizing way.  Frederich von Hayek should only be alive to see this!

I think there are lessons from this that we can take to the health care world.  The teaching profession was professionalized about the same time that the health care world was as well. The teaching profession created an increasingly ineffective and expensive bureaucracy associated with failing public schools. Those with money escaped to private schools and until recently, those without money were stuck in the public school gulag. The home schooling movement allowed them to escape and for their children to thrive. It did not require a grand plan or obscene amounts of money. It was driven by an army of parents, amateur educators, relatively devoid of specific teaching credentials. The home school phenomena is yet another example of the rise of the amateurs as described by Clay Shirkey and the homeschooling movement can be viewed as a twist on the phenomena of crowdsourcing.

I pose the question to my readers - what elements of healthcare can and will be crowdsourced? I view the major push in the latest round of "reforms" as pushing for the creation of a large public system of health care.  As health care reform is implemented and further entrenches an increasingly ineffective health care bureaucracy, we will see the rise of outlets that develop which allow for the public to escape the health care gulag. We all know about concierge medicine, but what other forms will develop and who will offer to provide what the public wants? Will the equivalent of the home health care network, analogous to the homeschooling movement arise?   What tasks presently delegated to health care professionals can and will be done by amateurs?  How will the state respond to this, as a facilitator or barrier to innovation?


  1. My wife and I home schooled 2 of our five kids for about 3 years. Quite an experience. Tremendous advantages, and some drawbacks, for the kids. Tremendous amount of work for the teachers - us! This is no longer a practice restricted to fundamentalists and Christians, since we are neither.

  2. Chauncey McHargue M.D.August 10, 2010 at 6:02 PM

    I've always believed that anything that could be done by someone other than a physician should be, so I'm a proponent of using NPs, PAs or anyone else trained specifically for a medical task to be deployed to provide medical care. So crowdsourcing is fine with me—but caveat emptor. Independent practice is fine with me as well but the enthusiasm for that by non-physician practitioners will evaporate after the first few malpractice suits and professional liability insurance that will quickly approach that of physicians.

    Currently physician extenders are being used more as economic extenders than to free up providers to concentrate on more difficult medical problems. Given that the principal objective of state run medical care is to keep the majority of people content, not well necessarily, the government will quickly (and of necessity in a decade) jump on board with turning out physician extenders to bridge the anxiety gap of patients who would otherwise have to endure National Health Service waiting periods to be seen. So crowdsourcing by these individuals will also be co-opted, regulated and reimbursed by bureaucratic diktat. And, identical to the homeschooling analogy, the then entrenched "professionals" and their bureaucracy, or even union, will use political and regulatory leverage to limit any truly informal medical care that informally trained individuals might provide, however competently they might do do.

  3. The education of one's children has long been held (at least in the United States) to be the province of the parent(s). The parent can choose to send the child to public school, private school, or to home school. While home schooling may have been the province of "religious fundamentalist crack pots" (strikes me as an unfairly snide remark, but then again I've never had much involvement with the home-schooling crowd) in the past, high-quality and viable home-schooling alternatives have arisen because of need and because of lack of institutional or governmental impediments.

    The situation with medicine is different at several levels. In the days before the Flexner Report things were much less regulated, and the very definition of medical practitioner was not clear. Today, anyone involved in "practicing" medicine--be it nurse, nurse practitioner, physician assistant, pharmacist, physician, technologist, etc., etc., has specific rules that guide his or her licensure and practice. In short, medicine is not the province of the patient. Of course, a patient can legally consult any shaman, herbal therapist, or "do it yourself" book. But the legal impediments to providing any sort "official" medical advice without the "ok" of the bureaucratic system seems far greater than in education.

    Leaving aside the legal barriers, there is also a knowledge barrier. Parents often have a knowledge base that encompasses elementary and high school education. Such is not the case with much of medicine. Highly intelligent people--even those more intelligent than the physicians that they rely on--don't have sufficient knowledge to diagnose and treat. It's true that a whole lot of visits to the doctor don't actually require a doctor or any medical expertise, for that matter. But patients don't know that. This could be overcome by educational efforts on the part of the medical community, but from where I sit, doctors are more concerned about "reeling in" more patients than about educating them about when not to come visit.

  4. The crack pot comment was unfortunate. This was more of a comment on the perception of who home schooled their children as opposed to reality of who actually did.

    I am not so sure about the proprietary nature of the information needed to diagnose and treat disease as well as cope with disease. (See previous blog -

    I am also not so certain that the rules which have been put in place regulating the practice of medicine serve patients more than they serve providers.

  5. Thanks for the clarification about the crack pot comment.

    I completely agree about the rules that have been put in place regulating the practice of medicine--I was commenting about the reality rather than what *should* be. The rules do serve the interests of patients more than they do providers. In fact, that was (a perhaps not clearly stated) part of my point.

    Many aspects of medicine, including the complex language that we use to describe phenomena that could be easily defined in layman's terms, serve to protect the interests of providers over physicians.

    Regarding the "proprietary" nature of information, I went back and read the entry that you referred to. Indeed, I too look up information right in front of my patients and refer them to the public websites that I use. As you say, in non-emergent situations, after a patient has been reassured that the problem does not require immediate attention, patients may be comfortable reading on their own and deciding on a course of action. This may eliminate the need for some follow-up visits in the setting of chronic disease, as you describe.

    Additionally, for highly intelligent patients with a fair degree of self-confidence, even the need for an initial visit may be eliminated with effective use of the internet. I'm all for that. But I think that this represents a fairly small portion of the population.

    As you noted, our school system is in bad shape. It should be no surprise, therefore, that a very large portion of the population "educated" by the public school system cannot navigate these information sources on their own. It may be disappointing to think of the role of the physician as providing information or expertise that a patient could have figured out on his/her own, but I think that that's true of most service-oriented professions.

  6. Sorry for the obvious errors in the above reply. It's the end of a long day. The second paragraph should read: "The rules do serve the interests of providers more than they do patients," and the third paragraph should read "protect the interests of providers over patients."

  7. Chauncey McHargue M.D.August 11, 2010 at 12:57 PM

    "I remember going to the British Museum one day to read up on the treatment for some slight ailment of which I had a touch. I got down the book and read all I came to read; and then, in an unthinking moment, I idly turned the leaves, and began to indolently study diseases. Bright's disease, I was relieved to find, I had only in a modified form, and so far as I was concerned, I might live for years. Cholera, I had, with severe complications: and diphtheria I seemed to have been born with. I plodded conscientiously through the twenty-six letters and the only malady I could conclude I had not got was housemaid's knee."

    Jerome K. Jerome (1859-1927)
 English Writer

    The internet in my experience generates considerable business from the worried well, especially the educated worried well. And it frequently discourages or deters patients from undertaking appropriate care for fear of what they've read online. The potential for reasonable self-help is there though. Realizing it will take time and refinement.