melinoe's comments

This was the most frustrating thing for me reading this, how the issue has become artificially dichotomized. There's obvious solutions that don't involve criminalizing but also recognize mental illness as such. It's almost a made-up problem in the sense that there's an obvious type of solution that seems to be ignored in public discussions.

Yeah, no kidding. Seems pretty significant, like pretty much a non-negotiable reason to switch to another browser if there is one with extension support.

The bigger issue this discussion is pointing to is how too much power/status/etc is concentrated among physicians in healthcare. It's too hierarchical. Not saying physicians are poor at their jobs, but there's very little evidence, when any evidence has been collected, that when another type of provider, with a different educational and training history, has moved into roles previously occupied by physicians, that outcomes are any different.

So, for example, I doubt that if NPs were specifically trained in specialty area X, you'd see any real differences. If we're going to do anecdotes, my personal experiences have been that the care provided by NPs (or PAs) has not been any different from physicians, even in relatively specialty areas I've dealt with. In fact, in some ways the care was better because we weren't trying to pressured into expensive procedures with absolutely zero scientific evidence of improved outcomes (having a hammer makes everything a nail).

What seems to be going under the radar is that the vast majority of MD programs are moving to 1.5 years or even less of academic training, with the rest being a variety of clinical experiences and quick rotations. This is fine, but what it means is that if you have a need for a provider in specialty area X, there's little difference between an MD + 4 years of specialty training, and something like a PA or NP + 6 years of training. We could get into discussions about academic preparedness, but at that point you're making a lot of assumptions averaging over individual variability, and ignoring things like nurses often having a ton of very technical training in actual physical technique.

I would love nothing more than for competition to open up dramatically in healthcare in terms of access, training, provider, and administrator models. This is happening to some extent now but it needs to be dramatically expanded. I see very little empirical or logical reason to assume that 4 years of general MD/DO training to something more specialized, is better than alternate training trajectories. Many of the professions in healthcare, such as nurses, PAs, pharmacists, psychologists, dentists, optometrists, etc. could be dramatically increased in scope of care, and new roles created that don't even exist currently, if there wasn't such territoriality and hierarchy in healthcare. Costs are spiraling currently in part because of rent-seeking problems. We've built our current system on a very dated set of stereotypes and outmoded assumptions, and are paying for it.

This has always been interesting to me. It's been awhile since I read about it last, though, and I remember reading some criticisms or concerns that posits (or unums? what's the difference?) would end up being slower for some reason. I don't remember the arguments though, or where I saw them; I think the idea was that there were some edge cases that were common enough in practice that overall it would slow things down. It would be nice to see a balanced discussion of the ideas (pros and cons).