Being a doctor was once a job with great purpose. Now it's just a business

[Ashton]

The 'free market' approach to care means seeing more patients in less time. We've lost the human connection in health reform As a physician, I resent the fact that the divisive healthcare reform debate has made my profession look like it is only a business, essentially a commodity. Growing up in the small hill-resort town of Nainital in northern India, I was the son of the only surgeon in this small town. Solely on his meager and fixed government salary, I saw my father care for scores of mostly poor people, operating on cases as diverse as cataracts, abdominal surgeries, gynecologic surgeries and even some types of neurosurgery. The power of the respect and gratitude that he received was the driving motivational force for a long and rewarding career in medicine. No amount of financial remuneration would have trumped this kind of professional satisfaction. Following my medical schooling in India, he encouraged me to immigrate to to the US so that I would have access to the best healthcare resources and facilities. Like the proverbial "kid in a candy store", I readily became part of what I perceived as a perfect system where I could order seemingly any medical test or procedure in the interest of the patient. Coupled with my vast repertoire of recently acquired medical knowledge, this seemed like professional nirvana. That was then – the mid-1980s. Almost three decades later, despite great professional accomplishments, I feel disappointed and frustrated. Why, I ask myself, do I not share the same rewarding relationship with my patients that my father shared with his? Why do I not experience an inner joy in my work that he did? The same "reward and punishment" that is the hallmark of the American free market system has rewarded physicians for seeing more patients (no different than hourly billing rewards for lawyers) and doing more to patients (such as surgical procedures and other interventions). Consequently, physicians have been pressured to see more and more patients in the same amount of time. It should be no surprise that such encounters have become more like business transactions rather than what they should be: rich and intensely human interactions potentially resulting in tremendous fulfillment for both parties. While newer systems are being developed to change the reward target from "volume" to "value", they continue to be a variation of carrots and sticks, and indeed perpetuate the notion that the delivery of healthcare can be commodifed. In his best-selling book, Drive, author Daniel Pink describes the "seven deadly flaws" associated with the concept of carrots and sticks: they extinguish intrinsic motivation, they diminish performance, they crush creativity, they can crowd out good behavior, they can encourage cheating, shortcuts and unethical behavior, they can become addictive and they can foster short term thinking. Arguably, all of the above have happened to some degree or more with healthcare in general and with physicians in particular. Recent healthcare reform efforts, while seemingly new, are really "old wine in a new bottle", a variation of the second of the two drivers of human motivation known since the early 1900s: reward and punishment (the first being biologic drives like hunger, thirst and sex). In healthcare, we need more than just this approach. In 1949, Harry F Harlow, Professor of Psychology at the University of Wisconsin, argued for a third drive – intrinsic motivation – the joy of the task itself. Daniel Pink focuses on this drive and elegantly demonstrates that for most complex tasks (what could be more complex and human than the practice of medicine?), intrinsic motivation is a much more powerful drive than any external motivator. A key part of this motivator is purpose. "The most highly motivated people," Pink writes, "not to mention those who are most productive and satisfied – hitch their drives to a cause larger than themselves." In other words, economic incentives alone do not cause individuals to perform complex tasks better. This is arguably the best evidence-based advice for physicians as well as health planners today. This is a call to begin a spirited discussion centering on such real healthcare reform. I am not naive to the hard economic realities of healthcare delivery or how civil discussions on reforming healthcare payments need to continue. However, meaningful and lasting solutions will not be found in models that commoditize health and continue to be based on a foundation of reward and punishment alone. They will be found in models that bring back the joy of healthcare to professionals who deliver it – physicians such as me and countless others who seem to have lost the single most powerful driving force – purpose. I am looking for the simple joy that large compensation packages will never bring: the joy that my father felt in treating the poor farmers and others in the small Indian town of Nainital.

 http://www.theguardian.com/commentisfree/2014/feb/22/obamacare-reform-doctors-lost-sense-of-purpose So its from a repsectable newspaper in the UK, so not your usual fluff from the red tops. I personally have to agree with him, i feel the human aspect has been completely removed. But I hope to get Stef's perspective on this as he is the free market man.

[dsayers]

He failed in the tag line, mentioning free market and reform as if they're compatible.

 

Then he failed in his first sentence saying "business" as if that's a bad thing and claiming the voluntary providing of any good or service is not a business.

 

Sorry, I didn't read on.

[Wuzzums]

I'm a medical student and what I can say for certain is that doctors have a ridiculous inflated sense of self worth. To a lesser extent, they're exposed to the same family-cult indoctrination like you see in the army. Special language, special uniforms, specials ranks, and so on. They should look at patients as clients, instead they see patients as a burden they have to suffer out of the goodness of their hearts. All through-out their career doctors have been fed this "noble profession", "saving lives", "fulfilling job", propaganda. And when they're treated the same as an electrician and not hailed as the gods of compassion and health they think they are, they recoil with phrases like "not what it used to be".And they always, always, allude to an earlier time they didn't even experience, for example: "the joy that my father felt in treating the poor farmers and others in the small Indian town of Nainital."

 

If you wanna see how ridiculous this article really sounds just replace the word "doctor" with "mechanic" and "patient" with "car". The self-entitlement becomes obvious.

 

"Consequently, mechanics have been pressured to see more and more cars in the same amount of time. It should be no surprise that such encounters have become more like business transactions rather than what they should be: rich and intensely human interactions potentially resulting in tremendous fulfillment for both parties."

[Daniel Unplugged]

All criticisms here are directed to the writer of the article, not to Ashton.

 

"The 'free market' approach to care means seeing more patients in less time." - Says who? A free market provides whatever the customer wants, short cheap visits, or long expensive visits, depending on personal preference. Oh, I so know he is about to confuse the US healthcare system with a free market. Socialists are so easy to spot, but I'll continue.

 

"No amount of financial remuneration would have trumped this kind of professional satisfaction." This is a personal choice, that does not apply to most people, and, I suspect, that if he was offered a large enough sum, he would have switched jobs as well.

 

"Why do I not experience an inner joy in my work that he did?" Obviously, he does not share his fathers motivations, which according to him enables just that "inner joy" - Very hypocritical, given the tone of his article, and quite pathetic since he "knew" this all along.

"The same "reward and punishment" that is the hallmark of the American free market system has rewarded physicians for seeing more patients (no different than hourly billing rewards for lawyers) and doing more to patients (such as surgical procedures and other interventions)" - Actually, seeing more patients in a flat-fee system is very different to billing by the hour. "doing more "to" patients"? I wonder if he is talking about himself, he doesn't state, but it seems that he probably did.

 

"Consequently, physicians have been pressured to see more and more patients in the same amount of time. It should be no surprise that such encounters have become more like business transactions rather than what they should be: rich and intensely human interactions potentially resulting in tremendous fulfillment for both parties." - Pressured? By whom? If the physicians derive their income from the government, as in a socialized system, then don't dare blame that on the free market. If it is in a free market, then the pressure was coming from the customers; Who are you to judge people, who want to purchase el-cheapo, no frills healthcare? So this guy thinks it is up to him to decide what healthcare should be (rich and fulfilling blah blah blah) for everybody, yet he admits he has done the opposite - hypocrite. Ahem, in a free market, they seem like business transactions, because that is what they are, does this surprise him? In a socialist system, they are not, which is why you get really shitty expensive services - paying customers are very demanding.

 

"...and indeed perpetuate the notion that the delivery of healthcare can be commodifed." - Prior to the (semi) socialization of the US healthcare system, healthcare was a 'commodity'. It was also very cheap and very good.

 

"In his best-selling book, Drive, author Daniel Pink describes the "seven deadly flaws" associated with the concept of carrots and sticks: they extinguish intrinsic motivation, they diminish performance, they crush creativity, they can crowd out good behavior, they can encourage cheating, shortcuts and unethical behavior, they can become addictive and they can foster short term thinking." - Yes, punishing those who work, and rewarding those who don't is a very bad thing. (Off the subject, but I couldn't help myself)

 

"Recent healthcare reform efforts, while seemingly new, are really "old wine in a new bottle"." True; they are just as socialistic (actually Obamacare is fascistic, but is still entirely un free-market) as the old reforms, so will achieve the same results, higher prices and lower quality.

 

"meaningful and lasting solutions will not be found in models that commoditize health and continue to be based on a foundation of reward and punishment alone." - Read some basic economics about why companies that provide high quality services at a low price, succeed, and those that provide the opposite, fail - or just think about it for a few seconds if you are capable of that.

 

"They will be found in models that bring back the joy of healthcare to professionals who deliver it – physicians such as me and countless others who seem to have lost the single most powerful driving force – purpose. I am looking for the simple joy that large compensation packages will never bring: the joy that my father felt in treating the poor farmers and others in the small Indian town of Nainital." - FFS, stop telling me that you know what your purpose is, that you are upset that you are not currently fulfilling it, and that you are writing articles instead of fixing your problem. Go and start providing that high quality, low cost healthcare to poor people like your father did, and get your fulfillment, unless of course, you are actually motivated by your own self interest like the rest of us.

[Magnus]

I like your answers, Daniel.

 

On the subject of motivation, I think psychologists did the world a disservice with the Intrinsic/Extrinsic dichotomy. It makes no sense. Some people are highly motivated by money and status, which are extrinsic, to do jobs that are difficult and costly, and thus have low intrinsic value.

 

The whole intrinsic/extrinsic theory was derived from the observation that school kids would work on projects with great enthusiasm when self-directed, but would lose interest when a teacher would dole out gold stars for the very same projects.

 

As an anarchist, my explanation for this phenomenon is simple -- a system of gold stars communicates to the kids that the adult in the room is in control of them. Being the gold-star-dispenser is a way of wordlessly establishing that the teacher controls the kids' status and favor and approval and success and failure. Gold stars = social dominance.

 

Instead of intrinsic or extrinsic, I prefer to think of the two main classes of motivation as Organic and Artificial.

 

For example, an entertainer will work very hard to obtain the approval of an audience. That reward is extrinsic to the tasks of training, practicing and all the 10,000 hours of work that it takes to be a world-class performer, which are intrinsically unpleasant. But the popularity that follows is organic. It's natural. You entertain people; they like being entertained. Performers are highly motivated to seek this reward, even though it's extrinsic.

 

But compare that experience to the same performer dealing with a gatekeeper in the entertainment industry -- someone who is not looking to be entertained, but who controls the choice of what to produce and who will produce it (studios, movie directors, book publishers, music executives, etc.). The approval or disapproval of that person is artificial. He's not deciding if he's entertained; he's deciding if he predicts other people will be entertained. Creative people HATE dealing with that kind of artificial selection process. The casting director is just the teacher handing out gold stars. What they love above all else is creative self-control (which they use to seek extrinsic, but organic, rewards).

 

I suspect that the doctor who wrote this piece is actually reacting to the same things that a lot of people resent -- control and social dominance. People naturally like helping others, but resent being forced into a redistribution system.

 

The problem isn't that medicine is a business. The de-motivator is that doctors are now just another type of government contractor.