Ryan Gamlin

Welcome to Medical Economics' blog section

 which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by

, a former health care management consultant and current medical student at the University of Cincinnati. The views expressed in these blogs are those of their respective contributors and do not represent the views of 

	The United States faces an unenviable paradox: the healthcare sector is an important source of job growth and economic output, but healthcare costs-now comprising nearly one fifth of economic output-are dramatically higher than those in other developed nations, and continue to rise.

Ryan GamlinWarren Buffet summed up this dilemma vividly, saying that healthcare is the “… 

tapeworm of the American economy… I think the healthcare problem is the No. 1 problem of America and of American business.

Reexamining the 80-hour medical resident workweek

	Adding proverbial insult to injury, the United States-for all it spends on healthcare-gets far less for its money.

 on international health system efficiency ranks the United States last of 11 developed nations on measures such as quality of care, access to care, efficiency of care, and equity of care. The work of the Commonwealth Fund contributes to a body of evidence suggesting that what we’re doing to provide, administer, and finance healthcare is just not working.

 is one of a number of organizations working to understand the drivers of inefficiency, waste, and harm in U.S. healthcare, and I recently had the opportunity to attend their annual conference. While there, I presented my research exploring the relationship between a country’s administrative expenditures and health system efficiency. 

as countries spend a larger percentage of their healthcare dollars on administration (as opposed to public health, or providing patient care, for example), things get worse for patients and healthcare providers

. High administrative expenditures seem to be associated with negative experiences of providing and receiving healthcare.

Next: Hope for the next generation of physicians

	While other countries devote a large share of their resources towards the prevention and treatment of disease, the United States spends a huge portion of our healthcare dollars on feeding the system itself. These huge administrative expenditures “crowd out” other important areas of health investment like public health (

US public health expenditures are the lowest among all OECD nations

	Not long after presenting my research on administrative costs, I had a curious experience. Listening to a medical school lecture on healthcare payment reform, I heard a number of second-year medical students arguing vigorously that 

the only way to reduce healthcare expenditures was to pay doctors less

As a percentage of total national healthcare costs, U.S. physician wages are small – approximately 9% – a number among the lowest in the developed world

	Not only were these students arguing in opposition to their own self-interest, they were arguing against the facts.

Medicine’s Top Earners Are Not the M.D.s

The U.S. devotes a larger percentage of it healthcare economy to administration (doing things like moving a claim through the system, answering patient phone calls, and yes, paying the innumerable and sometimes incomprehensibly large salaries of administrators at insurers, hospitals, and healthcare systems) than any other country.

	I know few physicians at any level of training or practice who believe that administrators are the primary determinant in their ability to deliver safe, effective, and humane care. How then, have we ended up with a top-heavy system, one in which decisions about how care will (or often 

) be provided are made by those far removed from the experience of caring for patients? 

	It’s my hope that the next generation of physicians will reverse this trend by contributing their perspective and expertise to serve as leaders within their hospitals, health systems, and beyond. Clinicians must first care for the sick, but our system itself is sick, too, and I believe that doctors are the best ones to cure it. 

Articles

The United States faces an unenviable paradox: the healthcare sector is an important source of job growth and economic output, but healthcare costs-now comprising nearly one fifth of economic output-are dramatically higher than those in other developed nations, and continue to rise.

Administrative costs are killing U.S. healthcare

 Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series begins with this blog by Ryan Gamlin, a former health care management consultant and current medical student at the University of Cincinnati. The views expressed in these blogs are those of their respective contributors and do not represent the views of 

Ryan GamlinToday finds us at an inflection point in medicine, and no, it’s not CRISPR, the opiate epidemic, nor the development of targeted biological therapies.

Hot topic: Top 12 worst and best paying states for internists

	Rather, I find it fascinating that an increasing proportion of the roughly 100,000 doctors in medical school today do not intend to treat patients as their primary career – or at all.

	The movement of doctors from patient care to non-clinical roles has caused no shortage of hand-wringing, from NPR’s December 2015 story, “

Siren Song Of Tech Lures New Doctors Away From Medicine

” to a recent lament in the Society of Hospital Medicine’s monthly 

Concerns Grow as Top Clinicians Choose Nonclinical Roles

	I suspect, however, that most physicians view those who leave clinical practice behind, either in whole or part, with some degree of envy. These “Drop Out Docs” (complete with a 

) have weighed their opportunities as a practicing physician or surgeon – long held as one of the most prestigious and well-remunerated professions in the United States – against the alternatives, and still choose to leave. Why?

How Measurement Fails Doctors and Teachers

 makes a strong case that the erosion of physician autonomy and ceaseless quantification of the measureable aspects of care delivery (often with thin evidence supporting their importance) has come at the expense of the humane practice of medicine.

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	In short, generations of doctors, demoralized by checklists and “process for the sake of process,” have lost touch with their motivations for patient care. It should come as no surprise, then, that many medical students and residents, upon seeing what practice beyond their training holds, cast their sights beyond clinical medicine.

	For many young doctors, the appeal of a non-clinical job is the opportunity to touch more lives, and to make a bigger difference in healthcare than possible by treating one patient at a time.

	The increasingly pervasive influence of technology in medicine means that with the right application or insight, one doctor can be in the pockets (or rather “in the smart phones”) of millions of people.

Next: Where many go, a path is made, and more follow

	New programming languages mean that a medical student, resident, or practicing doctor can get a first iteration of a product to market in months, not years – and if it fails… they’re back to plan A, having taken a relatively short time away from their training or career.

	Similarly, in the sphere of public service, few would argue that Vivek Murthy’s impact on the health and well being of the United States were greater as a full-time practicing internist than as Surgeon General.

Top 10 highest and lowest paying states for PCPs

	Finally, many physicians’ belief that one can make a bigger difference by treating the system rather than patients is compounded by the growing incursion of mid-level providers, like nurse practitioners, in to areas of medical practice once available exclusively to medical doctors. “If my patient doesn’t need a doctor (according to the insurance company, at least)” – the thinking goes – “then I’ll take my education and training where it is more fairly valued.”

Where many go, a path is made, and more follow

	The hierarchical nature of medical training encourages trainees to seek out, observe, and emulate superiors in their chosen field of specialization. As more doctors pursue “clinically adjacent” careers, increasing numbers of doctors in training see the breadth of non-clinical opportunities, making it more likely that they themselves will leave-or never enter--clinical practice.

Next: The start of a solution, not the beginning of a problem

The start of a solution, not the beginning of a problem

	It was likely physicians’ persistent abdication of non-clinical leadership roles that caused many of the problems that plague U.S. healthcare.

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	For generations, doctors were content to confine their work to healing the sick, all too happy to turn management of “their” hospitals, clinics, and the healthcare system overall to a professional class of managers. As a result, no other industry has so wide a gulf between the human capital invested in service delivery (doctors) and management (administration).

	In one realm, however-hospital administration, doctors’ increasing prominence in non-clinical roles may be an encouraging sign. I believe that problems are best solved by those closest to them, and that the challenges facing U.S. healthcare are best solved by those who deliver care: clinicians are the best leaders of a clinical enterprise. The data support this view. Two studies, 

 have shown that the more doctors are involved in a hospital’s management, the better that hospital performs.

	I, for one, am not surprised at these findings in hospital administration. Nor will I be surprised when (if?) the next transformative product or service in health technology is created (in whole or part) by a non-clinical doctor.

Top 10 challenges facing physicians in 2016

	While the medical education system will have to grapple with the workforce implications of training physicians not destined for a career in patient care, I am heartened and made optimistic by the increasing numbers of doctors who choose to treat the healthcare system as a whole, even if it means not treating patients directly.

) is a former health care management consultant and current medical student at the University of Cincinnati.

In his debut blog, Ryan Gamlin writes why he thinks the increasing proportion of doctors in medical school today do not intend to treat patients as their primary career-or at all.

Author | Ryan Gamlin

Articles

Administrative costs are killing U.S. healthcare

Young doctors are jumping ship to non-clinical roles