The ‘free market‘ approach to care means seeing more patients in less time. We’ve lost the human connection in health reform
A baby holds a doctor's hand at Great Ormond Street Hospital on 16 June 2011. Photograph: Rowenna Davis for the Guardian

‘The divisive healthcare reform debate has made my profession look like it is only a business.’ Photograph: Rowenna Davis for the Guardian

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.


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