WOW! If doctors are not able to make these decisions in a manner that is cost effective, then someone else will do it for them. There are many moving parts to this. Will there still be a difference between 'defensive medicine' and 'good medicine'?

Ronald:

You make a great point that typifies, I believe, the choice in front of us.

Option One: We decide that physicians are simply too expensive a resource to make these two decisions, as least much of the time, and we opt to have others make the when and where decisions instead.

Option Two: We figure out how to really streamline the patient information process to the physician, thus enabling the doctor to make these most important calls.

Granted, that pretends this is a false dicotomy, which it is not. We'll have elements of both, for sure. But which of the two levers will we focus on the most?

Quick personal story: After a fall on the ice this winter and with an ankle the size of a spare tire, the physician's assistant said to throw away the crutches and put all my weight on it. A week later, with no relief of pain or swelling, the foot and ankle specialist said, 'Grade three sprain on both sides, several slight fractures, some torn ligaments. Immobilization for three weeks and let's hope the past week did not too much permanent damage.' Here's hoping the when and where care decisions don't really have long term consequences.

Tim