I used to joke that medical school was like an incubator for narcissism. The ingredients were impossible tasks: sleep deprivation, grateful patients, the legal ability to give orders, and the role as leader of a team, all cooked in life-and-death drama. Pathological narcissists lack empathy and tend to implode or blame others when criticized. Back to that patient-doctor relationship: time spent in the imperfect human dialogue with patients tends to moderate narcissism. We’re on this scary, touching voyage together—sometimes succeeding, sometimes failing—and we need a clear destination toward which to navigate. We physicians and our patients also need the time with one another to work through the changes we face.
We are faced with a multifaceted problem: a financial crisis; not enough nurses; not enough home health care workers; doctor shortages (how long does it take you to get an appointment?); people out of work; people doing without medical care; people frustrated because their doctors won’t give them enough time to describe their physical or emotional complaints; people who can’t afford to pay their debts. And when, as reported by Himmelstein and colleagues2 in the June 2009 issue of the American Journal of Medicine, 62% of bankruptcies are precipitated by medical debt, it makes little sense to postpone health care reform until the economy improves.
Let’s return to the lecture in which I was told that the only solution to the problem of rising health care costs was to fracture the physician-patient bond. Perhaps rising health care costs are not the problem. Perhaps we should spend more. This is the central point of an opinion piece in the August 17, 2009, Wall Street Journal.3 The author, Craig Karpel, writes, “No one thinks the 20% of GDP [gross domestic product] that’s attributed to manufacturing is weighing down the economy.” Currently we spend about 17% of our GDP or $2.4 trillion a year on health care—but, as Karpel notes, this money “is paid to Americans.” He quotes Stanford economists Robert E. Hall (president-elect of the American Economic Association to serve in 2010) and Charles I. Jones, who report in a 2007 study that their models predict that expenditures on health care in the mid-21st century should optimally amount to 30% of GDP or more.4
The economies of early civilizations were driven by basic material needs for food, clothing, and shelter. During the past 50 years, about a third of new jobs in this country were “directly or indirectly related to housing.” Karpel makes a strong case that once material needs are substantially met, the desire for health care naturally becomes a significant driver of the economy and that “the US health-care [sic] economy should be viewed not as a burden but as an engine of growth.” He ends by exhorting politicians to preserve the ability of Americans to choose life over money.
So the answer is not to further weaken the bond between patient and physician. I don’t pretend to know how to get there, but I see the long-term solution as including a natural migration of the workforce away from unemployment and jobs in sectors of the economy for which evidence demonstrates more harm than benefit and toward providing goods and direct services for which there is need and natural demand.
I’m all for competition in the marketplace, but the bond between health care providers and those they serve is vital. We need universal coverage and a strong public health care option to offer an alternative to the private insurance and managed care system that has tried to break the relationship. We must allow patients the choice to pay for services that exceed coverage restrictions, and we should be care-ful not to promulgate most-favored-nation restrictions or other policies that prohibit physicians from offering charity care or discounts. It is important to allow physicians to know their patients well enough to see and feelthe direct effect of clinical decisions—our mistakes as well as our successes. The reduction of health care spending should not be a primary goal, only a necessary evil in the short run, while we work toward the rational health care system that our country deserves.