Response to the 2011 Question of the Year
In 1993, Chef Daniel Boulud opened his eponymous restaurant Daniel in New York City, which subsequently became one of the top restaurants in the world. Chef Boulud, being a professional, focused on using the freshest ingredients and the best cooking techniques to create sophisticated dishes for his customers. However, Chef Boulud also attended to the delivery of his dishes. He hired a top-notch wait staff and made sure they were well supervised. He arranged for the procurement of ingredients. He carefully taught his sous chefs how to create the dishes. He ensured that the maitre d' seated people on time and smoothly. He put into place measures to guarantee that phones were answered and reservations honored. Finally, Chef Boulud thoughtfully set the pricing of the meals he served to ensure that the costs matched the expectations of the clientele whom he imagined would frequent the restaurant.
Professionals—whether they are chefs, lawyers, or doctors—must be adept at many aspects of their trade. However, medical education in this country poorly prepares new physicians to effectively manage all the aspects of theirs. One theme that has surfaced during the recent debates on health care reform is that physicians “just want to take care of patients.” Some physicians state that they received training in diagnosing and treating illness and that's what they want to spend their time doing, rather than focusing on the business aspects of medicine.1 However, patients expect physicians to be responsible not only for direct patient care but also for the total delivery of health care. When patients find the delivery system fragmented, inefficient, impersonal, and unaffordable, they ultimately hold the professionals—the physicians—accountable.
The health care delivery environment is changing around us. Some physicians lament the loss of the traditional model of patient care: the kindly doctor (who might appear in a Rockwell painting) who provided individualized care in a private office at fees that he set based on the services rendered and each patient's ability to pay. However, this model of care is no longer realistic. Increasing technology, including laboratory services, specialized procedures, advanced pharmaceuticals, and new imaging modalities, has created an environment of care that is much more complex and fragmented than before. Physicians can no longer practice independently; they must practice within a complex web of other professionals and entities. These changes have also contributed to the unsustainable rise in national health care expenditures2 that threaten to make health care prohibitively expensive for large portions of our population.
Physicians have increasingly ceded their responsibility for the coordination of care, the financing of health care, and the development of delivery systems to hospital administrators, insurers, and government payers. When discussing the finite financial resources available to pay for health care, physicians often cite the ethical standard of “doing everything I can” for each individual patient when, in fact, they are abdicating their responsibility for making sure that health care is affordable and its delivery sustainable.
We now face a health care delivery system that many view as inadequate to meet the health care needs of the American people. Attempts at reforming this system have been hindered by physicians taking a back seat to designing a comprehensive health care system. Physicians, represented publicly by the American Medical Association (AMA), have resisted any kind of change time and time again.3 Instead, the AMA has often represented those physicians who have gained the most financially from the fee-for-service status quo.
Lamentably, doctors often learn of the realities of the financial and logisticical aspects of providing care only after they become attending physicians. Not knowing the history of how the system evolved to its current state, they often feel frustrated and powerless, unable to change structures that work neither for them nor for their patients. Our nation needs physicians to lead the way toward designing a rational health care delivery system. Course work in health economics, policy, and management, such as those offered in introductory masters of public health classes, could bridge this gap in medical education and could be achieved by adding a relatively small number of lectures to current curricula.
As professionals, we owe it to our patients to make sure that those designing the health care system are practicing physicians who have both the medical knowledge and the ethical standing to put patients first and to make decisions that make good sense. We must teach our students and residents to become the leaders in health care and health care delivery that our country needs them to be.
3 Madison DL. From Bismarck to Medicare: A brief history of medical care payment in America. In: Oberlander J, Churchill LR, Estroff SE, Henderson GE, King NMP, Strauss RP, eds. The Social Medicine Reader: Health Policy, Markets, and Medicine. 2nd ed, vol III. Durham, NC: Duke University Press; 2005:31–66.