Could Doctors Go the Way of Record Companies?

June 15, 2009

Those of us who follow health care may be overlooking the big picture. Most of the profound (and sometimes disruptive) changes of the last half century – computers, the Internet, social networks – weren’t initiated by the political process. They arose at the intersection of technology, economics, and mass social change. So here’s something to think about:

Could the medical profession go the way of the record industry?

Consider the path that led to the current crisis in the music business:

1. An industry with a near-total monopoly experiences a minor disruption (in music’s case, with the invention of cassette tape recording).
2. It ‘relaxes’ and assumes the crisis has past.
3. An even better technology comes along (the Internet) that includes lateral as well as vertical connections. (Individuals could only make tapes for themselves; sharing was possible but cumbersome, until the Net and mp3s made it instantaneous and worldwide.)
4. The industry fails to recognize the long-term significance and risks of this new tech.
5. Enterprising individuals use this new technology to distribute “information” of mutual interest – songs – through “P2P” (peer-to-peer) file sharing.

The result? A massive and ongoing implosion of the music biz. (David Byrne provided an excellent overview in Wired, with some corrections on his blog.)

Could the same thing happen to the medical profession? Many people’s immediate reaction will be to say ‘no.’ They’ll list the many barriers to what we might call a ‘P2PMed’ disruption of our medical economy (with ‘P2P’ here meaning either ‘peer-to-peer’ or ‘patient to patient’.) Doctors are too respected. Regulations won’t permit it. Doctors control access to medications. Medical information is walled off behind expensive, subscription-only medical journals. It’s unthinkable.

That’s pretty much how the record industry reacted in the 1990s. Let’s look at those objections:

160 million people looked up medical information on the Internet circa 2007, according to Harris polling data. Yet they still go to doctors. That’s true – just as millions of people made tape copies of music for decades without seriously undermining musical economics.

Each of these searches was a solitary activity. The difference will come when a new technology allows lateral information-sharing in a way that people trust. It hasn’t happened yet, but smart people are banking on the idea that it will soon. I agree with that assessment, although none of the many projects I’ve looked at so far struck me as a breakthrough. But a lot of folks are working on it.

Doctors monopolize access to medications through the power of the prescription pad. That monopoly’s already eroding as online pharmacies provide low-cost ‘doctor consults,’ a legal work-around that allows – to an sometimes disturbing extent – easy access to meds. Where there is demand, there will be suppliers.

People won’t spend money based on self-referral. The multi-billion dollar complementary medicine industry demonstrates this is untrue. Most “CAM” (complementary and alternative medicine) transactions are based on self-referral out of the traditional MD/patient relationship.

Medical information is walled off. True, but a backlash against the sequestering of research data is already underway. Case in point: A new publication called The Journal of Participatory Medicine hopes to provide peer-reviewed articles on self care for patients, as board member Kevin Kelly writes.

The Journal’s Advisory Board reads like a Who’s Who of Internet and medical business pioneers (and it’s an open-source publication, meaning its content will be free to all). The Journal goal of helping patients take “responsibility for their own health and healing” (in Kevin Kelly’s words) aligns with decades of movement toward a more patient-centric model championed by both the Left (as “patient’s rights”) and the Right (as with high-deductible “consumer-directed health plans”).

Once again, the left/right paradigm is ill-suited for new developments … and don’t blame initiatives like the Journal if medicine goes the way of record labels. They’re symptoms of broader socio-informational change, not its cause.

We can only guess what such change would look like: A widely trusted P2PMed platform catches fire, followed by widespread adoption of a model we might call “self-directed care.” People use online resources (best practices guidelines, diagnostic tools, etc.) to choose their own care path, then find direct or indirect ways to access the care they’ve chosen.

Not all doctors would go out of business after such a transition, of course. They’re still selling some CDs, too. So who would be most likely to thrive after the transformation?

High-touch practitioners: Empathetic, comforting, and warm doctors.
“Mechanics”: The most gifted and accomplished surgeons sometimes use this word to describe themselves. We will need talented neurosurgeons, cardiac surgeons, and other “fixers” for the foreseeable future (at least until the self-programmable nanobots take over).
Innovators: Doctors who are always exploring, changing, and trying new things, staying one step ahead of the curve.
Integrators: Doctors who can bring together seemingly unrelated ideas and solutions, whether in diagnosis or in treatment. Integration is the foundation of creativity, and creative doctors will always be valued.

Who’ll fail? Doctors who function by rote, who make routine diagnoses, and who connect patients to other resources based on past relationships and not need. Anyone whose expertise and connections are easily replicated on the Internet (think “travel agents”) will struggle to survive.

Watching the AMA defend its turf on issues like doctor reimbursement is like watching the RIAA file copyright lawsuits against teenagers, even as its business model collapses around it. You can’t fight your own market and win, and you can’t fight yesterday’s battles. Doctor groups should look more like think tanks and less like a lobbying groups. (Come to think of it, so should the RIAA.)

A topic this complex can’t be properly covered in a piece this short. And predicting this kind of change is not the same thing as endorsing it. But, like it or not, we should be talking about it now.

Because – like it or not – it, or something like it, is coming.


4 Responses to “Could Doctors Go the Way of Record Companies?”

  1. Don’t entirely agree. Skills is marketable. The recording industry built a pile of cards on top of the actual skills (creation and performance of music), and no one valued it. As soon as there was a choice, poof. We are enjoying watching the house of cards falling at the moment – but not choosing not enjoy music.

    Oh the other hand, doctors have real skills, even if at minimum it is judging between differential diagnoses based on experience. And people really value that. So maybe some parts will fall like a house of cards, but the bulk will survive relatively unscathed. What to watch out for: when the moneyed interests pay congress to hurt the patients (as we’ve seen with the RIAA fighting their losing rear-guard action). But in healthcare, the rest of the world will push back much more agressively against screwing with healthcare (unlike copyright)

  2. marvin thalenberg md Says:

    A well trained general physician listens to the music as well as the words.He, ( in my case) sorts out information, prompts new information and has developed an armature on which to fit changing pathology and physiology. It is the sorting which no computer can do. But I had the luxury of time, so that I could puzzle out Betsy’s constant sore throats and elicit that her husband choked her every morning.Or trade a South Mountain artist’s bad drawings for medical care.Or make house calls and see how my patients lived while I drank coffee in the kitchen.
    First problem is how to increase the number of primary care physicians when medical students finish $120000 in debt

  3. Richard Eskow Says:

    Undercompensation for primary care (ie. cognitive services) is one of the fundamental flaws in our system.

    Why should anyone need six figures to become educated for their profession? That’s a design problem in our social economy – one that ranks right up there with (and related to) our health financing mess.

    You’re quite right that a good general physician hears the music as well as the words. A doctor of tha description fits at least two of those ‘winner’ categories I laid out.

    And I miss South Mountain – bad drawings and all.

  4. marvin thalenberg md Says:

    I’d forgotten about this exchange.
    Only months later it is out of date. As California goes…and it is going – medical structures, schools,social networks. Our last chance to make some structure of the national medical system is disappearing as well.
    I have a prejudice in favor of government medial care.I spent my last 10 years in the county as Commissioner of Health. We ha a prenatal clinic which delivered 600 babies a year of the poorest and sickest women in our community- with better statistics than Westchester.We had 5100 women and babies in our WIC program.We had an effective AIDS clinic with 175 patients.And it was all very cost effective.
    When I mentioned an armature for including new research, it was because, being near New York, I could spend 24 years teaching at Columbia.So even in my 9th decade I read NEJM and stay fairly current.(As a curiosity, I tried for years to convince my closest friend, Larry Cremin, President of Teachers College, to work out an affiliation with Rockland Community College)

    I am of sanguine nature, but I have lost hope. We have an adult president, but an alarmngly ignorant population and a malevolent bunch of neocons willing to destroy governance to score political points.

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