Medicine: culture vs. calling

BOSTON — There will be time to talk about costs and coverage, about public and private plans, about reasoning and rationing in health-care reform. So the president began this week speaking to the workers in the system: doctors.

At the meeting of the American Medical Association, Barack Obama tackled the model "that has taken the pursuit of medicine from a profession — a calling — to a business." He reminded doctors: "You didn't enter this profession to become bean counters and paper pushers. You entered this profession to be healers. And that's what our health-care system should let you be."

Listening to him, I thought of one small tale from the annals of medicine. A few days earlier, a friend had an appointment to consider a rather serious heart procedure. After 15 minutes, the cardiologist stood up to leave. My friend was startled. "I have more questions," she said. He answered, "I have another patient," and walked away.

I am sure that he didn't become a cardiologist to treat patients like travelers in a revolving door. I am also sure that no rational system would allot minimum time and payment for an office visit to decide on a procedure that will cost, on average, $35,000. But there we are.

Somewhere along the way, with the help of insurers and incentives, by paying for procedures rather than patient care, we have created a culture of medicine that pushes doctors away from the "calling."

In his speech, Obama mentioned McAllen, Texas. This little-known city has become the infamous poster town for runaway health-care costs since Atul Gawande wrote about it in The New Yorker.

McAllen has the second-highest per capita health-care costs in the nation, a fact it doesn't post on its Web site. Costs are twice as high as those in its demographic twin, El Paso. Not because the people are sicker. Not because they are kept healthier. And not because of malpractice suits.

"The primary cause of McAllen's extreme costs was, very simply, the across-the-board overuse of medicine," wrote Gawande. It was reminiscent of other high-cost areas where people "got more of the stuff that cost more, but not more of what they needed."

In McAllen, Gawande unhappily concluded that this overuse came because too many doctors saw their practice "primarily as a revenue stream." It wasn't just some aberrant character, it was the system that pays doctors for quantity, not quality — and pays them as individuals rather than as members of a team.

He compares this failure to the success of places such as the Mayo Clinic, with lower costs and higher quality.

When my friend, the patient of the 15-minute consult, sent The New Yorker piece to her daughter, one of the most dedicated primary-care doctors I know, she got this e-mail in return: "I can only speak for my friends/partners over the years. I think all of us hate money being part of any decision-making process. We love tight, up-to-date, data-driven, lifesaving, critical thinking. We love talking to people, touching them (literally and figuratively) and feeling useful/important in our communities. We all hate figuring out what drug is on the formulary, appealing a refused claim ... seeing problems get worse because the patient decides they cannot afford a medication."

She also hates thinking about medical school debts, not to mention an income that has been flat for the past 10 years, while the public thinks doctors are money-grubbing. "It's hard to keep up an altruistic head of steam," she continued. "The truth is, I'm not encouraging my kids to go into medicine. ... That feels sad and ominous."

Ominous indeed. Doctors are sick of hoops and hurdles, wary of more regulations saying which procedures are useful and which are "overuse." But the message from McAllen is that doctors need to reform their culture in tune with their calling.

At the Harvard Medical School commencement, Steve Bergman — known to generations of medical students as Samuel Shem, author of "The House of God," the satirical novel about medical training — told the new doctors:

"Has anyone ever heard, in a crowded theater when someone collapses, the call go out: 'Is there an insurance executive in the house?' We do the work. We have the power. Without us, there's no health care. If we stick together, we can take action and change things."

That's something to be written — legibly, please — on the prescription pad for health — care reform.

Ellen Goodman's column appears Friday on editorial pages of The Times. Her e-mail address is ellengoodman1@me.com