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Normally, I am in complete agreement with Dr. Paul Krugman, Nobel Laureate, Professor of Economics at Princeton. Today I am not so sure.

The gist of his column today is that Obama did a reasonably good job of describing the health care crisis and the kinds of fixes that he hopes the Congress will deliver this year. The axis of Obama's and Krugman's take on health care reform is compassion ... and I do not diverge from either on that essential point. It is, I think, a statement about and a measure of how civilized we really are. Without compassion we are a pretty ugly species.

But, Krugman aligns himself with others who say that fee for service is counterproductive:
Many health care experts believe that one main reason we spend far more on health than any other advanced nation, without better health outcomes, is the fee-for-service system in which hospitals and doctors are paid for procedures, not results. As the president said Wednesday, this creates an incentive for health providers to do more tests, more operations, and so on, whether or not these procedures actually help patients.


It seems to me that this is equivalent to saying that the medical profession should not be paid for "unfortunate results." This is a completely untenable idea. First, the progress of a disease (or an injury with infection a constant threat) is something you treat, but really do not have fundamental control over. There are so many variables in a cancer or pneumonia, for examples, that begin with patient readiness, attitude, behaviors, autonomic systems, coexisting ailments, and so forth that medical practitioners cannot or should not be held to a standard that would be reasonable if they actually controlled the entire situation. Believe me, just like classroom teachers, they do not!

Second, medical practice is accomplished by a "team" or sometimes a "congeries" of individuals of various levels of authority, education, skill, attitude, and experience. Nominally the attending physician is held responsible for the performance of all the duties of all the personnel, but in fact that lone physician depends on the good will and competence of people with whom he or she never really comes into contact, including the folks who clean (or notoriously do not clean) hospitals under vendor contracts.

Do we look to hospital administration then for solutions to the "who's in charge here" question? Watch two episodes of "House" and you realize that Administrator Cutty is so far from the hands on part of medicine that she could not possibly be held finally accountable ... but of course in our system she could be sued.
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Medicine has evolved tremendously since my father was born at the beginning of the last century. His life expectancy at birth was something on the order of 45 years. Mine in 1940 was 47. He lived 78 years and I am clearly over 50 and expect now to live well into my 80's or 90's, if nothing terrible happens. Medicine and sanitation and nutrition have been very successful, but the organization of medicine has not evolved in parallel and is inappropriately centered on individuals ... largely because Law centers on individuals and their behaviors.

Medicine has held onto the idea that doctors have a transcendent authority, which in itself inspires auto-immune responses in patients and gives the grievously injured hope for survival. Doctors have played on this psychological effect for material benefits to themselves and have in the process forfeited much of their authority to insurance companies, which supported doctors' life-style expectations, exporting the costs to the general public.

In fact, medicine is (like architectural engineering) a field in which it is vital for individuals to remain plugged-in to the body of evolving knowledge and practice continuously. In this sense medicine is a social organism ... and there needs to be a body of conspicuous integrity within this organism governing both knowledge and practice. The AMA and the APA are notoriously inbred and self-serving organizations that long ago forfeited their best claims to integrity. The National Institutes of Health together with the Centers for Disease Control have virtually no power over practice (and malpractice). Insurance companies are for-profit corporations constrained by corporation law to be profitable, all the consequences of this orientation registering less.

Krugman is part of a system at Princeton in which faculty as teachers and researchers are hired, retained, tenured, and (presumably) periodically reviewed. And as an Economist Krugman belongs to the discipline of Economics and his colleagues throughout the country and world also sit in judgment on his academic work. This academic system works, but just barely, permitting the sort of slovenly teaching and research that would sink a medical practice in weeks. But, the organization of academe does lead toward a solution for medicine. It just has to have teeth.

One of the things that has to change is the psychology underlying the prideful refrain "My son (daughter) the doctor." Medicine is a noble calling, to be sure, but so is bridge engineering and librarianship, etc. The rewards for being a person who is required to prepare for many years and then must continue to learn to stay abreast should be good rewards. There needs to be a way, however, to acknowledge inferior practice with sufficiently reduced rewards so to encourage these to find other employment, perhaps on the sidelines or background of medicine, but clearly not in the mainstream.

I have not read the latest version of the House or the Senate versions of the health care reform legislation. In skimming through a week or two ago, however, it is clear that an organic body will emerge that governs medicine in ways that it has not been able to govern itself. With the public option, this organic body will be sufficiently removed from the profit nexus to maintain its integrity, but there will many hazards. It is essential that this body be launched well.

JB
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James R. Brett, Ph.D. taught Russian History before (and during) long stint as an academic administrator in faculty research administration. His academic interests are the modern period of Russian History since Peter the Great, Chinese History, (more...)
 

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