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Free Trade (in Doctors) 

If physicians really cared about our health, they'd drop their iron wall against immigrant doctors

Wednesday, Mar 7 2007
With its thousands of acres of universities, conservatories, libraries, bookstores, teaching hospitals, med schools, and other enterprises dedicated to sharing knowledge, San Francisco is a place where problems are no sooner identified than solved.

Take the problem of swelling, fever, lesions, and pain, for instance. The Bay Area, just like the rest of the country, suffers from a dire shortage of primary care physicians. The result is millions of Americans paying through the nose for insurance, then waiting dangerously long for doctors. Millions more simply postpone medical care, thus courting graver health problems and possible financial catastrophe.

A UCSF professor last month published a medical journal article highlighting the disease behind this symptom: medical doctors' greed.

It wouldn't be fair to ask doctors themselves to cure such an affliction. But thanks to San Francisco's aforementioned intellectual ferment, no sooner did the UCSF article hit the streets than another author across town proffered a perfect cure: international free trade in doctors.

"Our trade policy on manufactured goods makes it incredibly easy to bring products here. We're very, very far from that with doctors," said Dean Baker, co-director of the Center for Economic and Policy Research in Washington, D.C., who was in San Francisco Feb. 21 promoting his book The Conservative Nanny State, which argues that government subsidies for the rich hurt the poor. (See

Making it easier for overseas doctors to become licensed to practice in the U.S. while still in their home country, and then easing immigration here, would make health care cheaper and more widely available for all of us. Though it might dock U.S. physicians' salaries.

"I understand a lot of [doctors] are going to be upset. They took out big loans to go to med school," Baker said. "But life's tough. Mothers raising kids on $18,000 a year with no access to medical care — that's real tough."

In a Feb. 20 article in the Annals of Internal Medicine, UCSF's Thomas Bodenheimer, the Urban Institute's Robert Berenson, and Washington lawyer Paul Rudolf argue the reason that even people with expensive insurance can't find a regular doctor is simple. Primary care physicians earn median pay of $156,000 per year, while cardiologists, neurosurgeons, and orthopedists can earn $600,000 annually. Given that medical students aren't immune to greed, the number of them choosing to become family practitioners dropped from 14 percent in 2000 to 8 percent in 2005.

If this trend continues, there will be no new general practitioners left by my 50th birthday.

What to do from a doctor's point of view? In the Annals column, Bodenheimer et al. recommend jiggering the insurance company and MediCare payment formulas so that primary care physicians earn more money, while "reviewing" high specialists' fees.

Bodenheimer et al. note that doctors will resist any change that endangers their payments: "It's unclear whether the medical profession — with different specialties having distinct monetary interests and different estimations of the professional value of their work — can agree on substantial change in payment policy on its own," they write.

Thankfully, an economic expert from outside the medical profession was at Modern Times Bookstore the day after Bodenheimer's essay hit the streets, explaining how free trade in doctors would solve this problem.

Doctors in India earn around $20,000 per year. If they want to move to the U.S., they must first obtain a scarce work visa, and once here they must comply with one of many different U.S. state-licensing standards, even if they've already had years of experience as a physician.

This process could be streamlined by creating a system to efficiently and rigorously license physicians overseas, while expanding the number of immigration quota spots for doctors. This would boost the quality, reduce the cost, and expand the accessibility of medical care in the same way that falling tariffs have made high-quality cameras, cars, and computers cheap in the U.S.

As might be expected, Bodenheimer rejected this idea out of hand when I ran it by him. His response seemed to confirm his essay's assertion that physicians are too greedy to agree to any solution that might reduce doctors' pay.

"I find this solution about as awful as anything I could imagine," Bodenheimer told me in an e-mail. "It steals physicians away from nations who need them much more than we do. We can afford to train our own physicians."

In practice, America trains so few physicians that doctors can earn several times the salary of their average patients.

And the idea that free trade in doctors would create a physician shortage in the developing world is as fallacious as the idea that free trade in televisions creates a TV shortage in Korea.

Already, doctors from the developing world treat legions of patients from the First World, a phenomenon that actually boosts those countries' access to good health care.

Cuba, Singapore, India, Thailand, Brunei, and a half-dozen other countries are international destinations for what is called "medical tourism," where patients travel to seek cheap high-quality care. In Havana, for example, entire new hospital wings are devoted to dollar-paying foreign patients. This means medicine is one of the few Cuban professions where university students can actually find jobs. Profits, meanwhile, fund medical care for Cubans.

A system such as the one proposed by Baker — where patients don't travel to the developing world, but instead it becomes easy for doctors to come and practice here — would create incentives for more developing-world students to pay for and attend medical school, and for the expansion of medical schools overseas.

The likelihood of such a U.S. program is dim, however.

"Doctors are a very powerful lobby. They're much more powerful than textile workers or auto workers," notes Baker, citing occupations whose wages have been diminished by free trade, while their health care has been diminished by a lack of free trade in doctors.

Perhaps it's time for medical patients — that means all of us, sooner or later — to form our own free-trade lobby.

On S.F. sidewalks, the blind are feeling misled by the blind.

A week ago, while walking on Market Street's western sidewalk, I was passed in the opposite direction by a man holding a red-tipped cane, wearing dark glasses, with a yellow handicapped-logo sign hung around his neck. He was traveling 12 mph on a Segway, the gyroscopically balanced scooters that never quite became the next new thing.

This, I realized, was the trigger event in a coming stampede, a vicious cycle where San Franciscans will soon perch dorklike on lawnmower-esque Segways, handicapped placards flapping on all our necks.

Segways are banned on San Francisco sidewalks because back in 2001, when the scooter was introduced, groups such as Senior Action Network and the California Council of the Blind lobbied for a resolution keeping what they saw as dangerous devices separate from pedestrians.

"When a Segway travels at 10 mph or even more, it can, due to its weight, seriously injure a pedestrian," California Council of the Blind President Jeff Thom says of the 83-pound devices. "The blind and visually impaired individuals, children, and others ... either can't, or are less likely to, see the approach of this device."

However, there's an exception to the San Francisco ban; disabled people who use the Segway as a mobility device may ride on sidewalks. San Francisco has purposely kept quiet about this loophole, however, for fear of inviting people to play sidewalk roller derby.

"We had a discussion as to how much to publicize this exception, and were persuaded to make it low-key," wrote Susan Mizner, director of the Mayor's Office of Disability, in a recent e-mail to her counterpart at the National Parks Service. "There was concern of non-disabled people claiming to have a disability so as to be able to ride the Segway anywhere."

Judging from my "blind" sidewalk Segway speedster earlier this month, the cat's been let out of the bag.

A pro-Segway advocacy group recently published a flier urging its handicapped members to come to San Francisco and ride them around.

"Pack up your Segway and enjoy one of the world's most beautiful cities," urges a flier published on the Web site of Disability Rights Advocates for Technology (DRAFT), a national Segway enthusiasts' group based in St. Louis, which is not connected to Segway Inc.

If people take this suggestion seriously, they will set in motion a negative feedback loop where more people ride Segways among pedestrians. Given these awkward devices' great weight, moderately swift speed, and maneuverability that varies with the driver's skill level, they will inevitably run down pedestrians.

As noted earlier, there will be fewer and fewer doctors to attend to these injured people. So their wounds will inevitably fester into permanent disabilities. These newly disabled people will, in turn, ride more Segways, injuring more people, until eventually nobody is left walking.

So when I saw the supposedly sightless sidewalk Segway speedster on Market Street, I imagined a public health crisis.

Perhaps I should quit being so hysterical.

Fred Kaplan, a member of the pro-sidewalk-Segway group DRAFT, tells me the mysterious stranger who passed me on Market Street fits the description of a Concord man named Scott Deaver who has poor peripheral vision and often travels to the city.

"He can see, but his vision sure as hell isn't as good as yours and mine," says Kaplan. "He's ridden a bicycle and he's had problems where police have said, "You're not supposed to ride on the sidewalk, you're supposed to ride on the street.' But he can't see the cars."

Kaplan told me he'd repeatedly asked that Deaver call me, but I haven't heard from him.

But I'll take Kaplan's word for it.

I urge San Franciscans to welcome Mr. Deaver and his Segway to the city's sidewalks. But please, please — don't start riding one yourself should he accidentally run into you. (Kaplan says Deaver's had no Segway accidents.)

The last thing our city needs is an unstoppable Segway plague.

About The Author

Matt Smith


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