Put medical culture in tune with calling

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."

Listening to him, I thought of one tale. A friend had an appointment to consider a rather serious heart procedure. After 15 minutes, the cardiologist stood up to leave. "I have more questions," my friend said. He answered, "I have another patient," and walked away. I am sure he didn't become a cardiologist to treat patients like travelers in a revolving door. I am also sure no rational system would allot minimum time and payment for an office visit to decide on a procedure that will cost $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, twice as high as those in its demographic twin El Paso. "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 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 as individuals rather than as a team.

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

My friend 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 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 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 10 years, while the public thinks doctors are money-grubbing. Doctors are sick of hurdles, wary of regulations saying which procedures are useful. But the message from McAllen is that doctors need to reform their culture in tune with their calling.

At the recent 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.

© 2009, Washington Post Writers Group