My grandfather was a psychiatrist from the 50’s through the 90s. My mom was a pediatrician, then a dermatologist from the 80s through the 2010s. Between the two of them, I’ve gotten a good sense of the way medicine has shifted through the last 70 years or so: the rise of the FDA, the growth of modern pharmaceuticals, the domination of the “fee-for-service” model, the increasing influence of the insurance companies, and, more recently, the pernicious influence of electronic medical records.
One of the things I noticed talking to my grandfather while he was still alive and my mom now is the way in which their medical thinking was influenced by the structure of the medical establishment while they were being trained. My grandfather, trained in an era before strong FDA regulation of medications, was mostly distrustful of medications. He much preferred talk therapy and psychoanalysis, seeing medications as a last resort when those failed. He was very conversant in the studies themselves, though, constantly reading journals to see the latest advances in pharmaceuticals.
Meanwhile, my mom was trained in an era before prior authorizations and the fear of malpractice suits were quite so pervasive. So my mom has always been very comfortable prescribing a variety of medications both on and off-label depending on her patients’ needs. She felt confident in her ability to help her patients navigate side effects when or if they experienced them.
It’s also worth noting that both my grandfather and mom were small business owners, through and through. They had employees, a reputation in their community, mostly straightforward commercial relationships with their patients (including, occasionally, barter), and their own unique ways of both practicing and administering their practice based on what they thought was necessary.
These stories likely seem unexceptional to you. And they’d be unexceptional to the doctors of my grandfather and mom’s time as well. They’re also not particularly exceptional to the veterinarians of their time, or, indeed, of this time. However, they are exceptional to the American doctors of this year 2022. And that, to me, is interesting: in many ways, vets in 2022 are more similar to doctors of the 80s than doctors in 2022 are.
In many ways, veterinarians in the year 2022 are much like my mom used to be. By and large, they own small practices. The amount of regulation on their work is relatively limited, so most of how they practice and administer their practice is based on what they think is necessary. Their relationships with their patients are, for the most part, straightforwardly commercial: they perform services and sell products for fees, with only a limited amount of interaction with pet insurance. They see themselves in that way, too. A good veterinarian will tell their patient, “Here are a few options for your pet’s health issue. Here are the benefits, drawbacks, and costs associated with these options. I’ll let you make the decision.”
Interestingly, in some ways, they’re even like my grandfather used to be. Many of the conditions that vets see don’t have specific drugs associated with them (or even high quality studies), so vets often have to get creative. It’s very common for them to repurpose human drugs or use compounding pharmacies to treat their patients. Specializing in a subset of veterinary medicine (like canine neurology) is still rare, and specializing in a condition is basically unheard of. Pretty much every vet has to be comfortable treating every condition in whatever species they treat. There aren’t really experts in conditions in the same way there are in human medicine, so folklore and word-of-mouth is very important for spreading knowledge.
American doctors in 2022, by contrast, are not at all like my mom used to be. By and large, they belong to large practices or hospitals. They face an enormous amount of regulation on how they practice, what insurance and licenses they need [1], and how they keep records. These regulations add a significant amount of time, expense, and complexity to how they work [2]. Their commercial relationships with patients are anything but straightforward. The commercial relationship ends up being between the doctor or hospital’s billing specialist and the patient’s insurance company, with both the doctor and the patient having no idea what the end result will be. Very few American doctors even consider cost.
They do, however, get very concerned about adverse effects. One of the positive developments in medicine over the past few decades has been the explosion of treatment regimens and drugs for highly specific conditions, which has really improved the well-being of patients in a number of conditions. But, a negative result of this is that doctors are way, way more comfortable following treatment algorithms for a condition rather than being creative. If they’re forced to be creative, they’d rather focus on minimizing side effects rather than maximizing efficacy for any condition. Only specialists (and frequently specialists in an exact condition) usually feel comfortable going “off-script”. Specialists feel comfortable to be creative because they’ve often gotten their knowledge directly from high-quality studies, although personal experience, folklore, and word-of-mouth still play large roles in how they think.
This ends up determining how drug manufacturers like my company market to these respective fields. If I want to market to doctors, I’m best served by having high-profile researchers in that specific indication and high profile studies. Ideally, I’d also get a change to the treatment protocols, too. If I want to market to vets, I’m best served by having well-known speakers (who don’t necessarily specialize in that indication) and well-run (not high-profile) studies. Both efforts are supported by robust traditional sales and marketing, of course, especially the ubiquitous “lunch-and-learn”, in which you bribe people with lunch in exchange for letting you pitch them.
There's something sad about what American physicians have become. Many of the young physicians I’ve talked to are so terrified by the prospect of a malpractice suit and already burnt out by dealing with insurance and electronic medical records. They practice medicine by following treatment algorithms and are barely aware of how much various treatments cost, even though their patients can be devastated by an unexpected cost. The country doc mentality exemplified by my mom, grandfather, and the vets of today has disappeared.
In fact, if you want a real sign of the times, the last time I visited my mom, she told me that it was probably for the best that neither me or my brothers became doctors. For a Jewish woman (and a doctor herself, no less) to tell her son that she’s glad he’s not a doctor? You know things are real bad.
[1] Insurance costs for doctors are crazy compared to vets, especially malpractice insurance. The malpractice insurance of an average veterinary practice is $350 a year. The malpractice insurance of a family doctor is $13,000 a year, while an obstetrician’s insurance can cost $71,000 a year. You have to pay this before you see patients. So, doctors often have to work for hospitals just so the hospitals will pay their malpractice insurance.
[2] The biggest contributors to these are the twin demons of prior authorization and electronic medical records. Prior authorization is when health insurance companies require doctors to ask for permission to perform specific services for specific patients. This is incredibly time consuming (14.4 hours per week as of 2020) and also demoralizing for the physicians, as the ultimate decision on how to treat a patient is often not made by the highly-trained physician or the patient in need, but instead by a 25 year old making 40k/year reading off a script over the phone.
Electronic medical records, by contrast, are what they sound like. However, like any software built to spec (rather than for the end user), they are horrendous to use. Doctors spend roughly as much time on their electronic medical records as they do on seeing their patient. The two of these are additive, so, assuming a 40 hour work week, doctors are left with only about 1.5 days per week to actually practice medicine.
I remember one M.D. commenting on a columnist, "We used to be in the 1% and now we're only in the 5%." There's been immense pressure from insurance companies to trim billings and make M.D.s more productive (in terms of patients per hour) and life as an M.D. has gotten a lot worse and worse paid. And I remember another article about the insides of the (small) industry of abortion providers, saying "it is blessedly free of managed care", meaning that the providers could largely charge what they wanted.
We had pets when I was young, in the 60s and 70s, and we didn't use vets much, only when we thought there was a serious problem. People have started to use vets like people started to use M.D.s in the 60s, dealing with every petty problem. But now people have started buying vet insurance, and I'm sure that vet insurance is starting to apply "managed care", much to the detriment of the vets.
> The biggest contributors to these are the twin demons of prior authorization and electronic medical records. Prior authorization is when health insurance companies require doctors to ask for permission to perform specific services for specific patients. This is incredibly time consuming (14.4 hours per week as of 2020) and also demoralizing for the physicians, as the ultimate decision on how to treat a patient is often not made by the highly-trained physician or the patient in need, but instead by a 25 year old making 40k/year reading off a script over the phone.
From what I've seen of algorithmic auditing literature in the context of health insurance, this is just a horrible tragedy. It means that despite high quality comparative effectiveness studies on optimal clinical decision making, insurance companies can often overrule good clinical & evidence based judgement