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Saturday, July 25, 2009

Of course the cows were struck by lightning

President Obama was uncharacteristically on the defensive this past week. One particularly awkward episode was when he made a passing reference to money seeking behavior of physicians. He suggested that money considerations induced physicians to do procedures which were of little benefit to patients. The example he used, tonsillectomies on children done by pediatricians, was more than a bit off base.

He was hammered from multiple quarters. In particular Senator Tom Coburn of Oklahoma, a practicing physician, was indignant that the President could suggest that physicians were motivated by financial concerns. I find this discussion nothing short of bizarre. Of course physicians are influenced by financial concerns. How could you assume otherwise? If the expectation that whatever system we operate under will work only if physicians were immune to financial concerns you are frankly delusional.

However, the reality is a bit more nuanced than physicians are either saints immune to motivations like greed or they are money grubbing whores. I am reminded of a story which was relayed to me by my friend Doug who has a mountain home in Virginia. His home is surrounded by working farms with cattle. One day wandering his property Doug noted a putrid odor and determined it came from a decaying carcass of a cow in his neighbor's field. He contacted his neighbor to inform him of his find upon which time the neighbor queried him as to whether he knew how this animal met his demise. The neighbor went on to inform Doug that this animal was struck by lightning and when met by skepticism, he adamantly insisted to Doug this was unquestionably the case.

Only later did the Doug come to understand how this perspective came to be. Years ago selected farmers found that if they claimed lightning strike on an insurance claim, they could recover damages from their livestock loss. While the initial claims may have been placed because of actual lightning strikes, evidence of actual lightning strikes on subsequent claims may have been somewhat less solid. Over time, it came to be widely accepted that this series of events leading to livestock loss was actually true! No deception was intended.

Physicians are imperfect human beings. Despite the desire of various professional organizations to make this otherwise through education and indoctrination with the values of professionalism, we are and will always be "sinners" to some degree. A recent movement sweeping Academic Medical Centers, almost like a religious awakening, has targeted the relationship of physicians with pharmaceutical companies. The intellectual underpinnings of this attack rest to a great degree on scientific work looking at how gifts, no matter how small, influence decision making. Where the logic breaks down where this inquiry stops. If pens and lunches create an unacceptable skewing of medical decision making which impacts patient care, what about the influence of arbitrary payment schemes which enrich only certain elements of medicine and leave other elements grovelling for crumbs?

Heavy use of high margin medical services may share characteristics of the mindset which led farmers to believe their cows were struck by lightning. Some if not many patients may appear to benefit from such activities and physicians who provide those services likely believe in their heart of hearts that they are doing God's. work. However, a repetitive theme of medical practice over the past 40 years has been the the preferential aggressive adoption of specific high margin interventions at high cost (both financial and patient risk) only to discover they are essentially clinically useless except as financial engines.

The behavior does not stop with individual physicians. Listen to advertisements for health systems and the products they hawk. Do we hear advertisements for vaccinations, high blood pressure management, diabetes management, or the diagnosis and management of complex chronic disease? The answer is no because these are money losers. No rational business entity would invest large sums of money to recruit patients whose care will result in financial loss. No entity can serve human needs by going out of business.

Perhaps we should incorporate an oath of poverty into all elements of medical training. I do not think that would be particularly functional. It would serve as a disincentive for many to go into medicine except those who have no trouble being blatant hypocrites. Those are who we really want to attract. We need to understand that the health care industry runs to a great degree on the same motivations used by other industries which fulfill human needs. It should not come as any great shock that doctors are motivated by financial concerns. Those who deny this should be viewed in the same light as countless previous Utopians who have repeatedly tried to create more perfect human beings. Such desires are driven because perfect societies just cannot just do not work when they depend on flawed people. Unfortunately, Utopian movements at best simply fade away and at worst result in terrible human tragedy.

"It is not enough to declare an idea noble and ones hands clean: one needs to ask what will happen to that uplifting idea when people behave not like angels but like fallible human beings." Benjamin Barber, An Epitaph for Marxism. Society 1995 .

Money is the energy that drives complex human societies. It is the general impetus that serves as the motivation for people to get out of bed in the morning to do the things which are required to make this complex entity work. Many of us would serve without financial considerations for those to whom we have close personal ties . However, for the most part complex divisions of labor require we do things for and receive things from total strangers. Let us accept the fact that financial considerations are the primary considerations that allow this complex world to work. Individually we may aspire to a higher calling and set examples by our own behavior. Let us not delude ourselves into believing that we can create a more perfect world here on earth by changing people into something they are not.

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