The widening income gap between primary care and other types of physicians is one of many reasons that fewer medical students have been choosing careers in family medicine, general internal medicine, or general pediatrics. So it stands to reason that if any doctors will be paid less money in a reformed U.S. health care system, it ought to be the specialists. Up to this point, however, no physican organizations have offered to reduce their members' incomes in order to help control health care costs. In an editorial in last week's New England Journal of Medicine, medical ethicist Howard Brody points out the ethical problem with this uncompromising stance:
Early in 2009, insurance companies, pharmaceutical manufacturers, medical device makers, and hospitals all agreed to forgo some future profits to show support for the Obama administration's health care reform efforts. ... Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests - including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the "special interests" affected by health care reform, justify demanding protection from revenue losses?
Brody goes on to assert that physicians could lower health care costs simply by paying more attention to evidence-based care guidelines, since studies have shown that areas of the U.S. which use more health resources (e.g., diagnostic scans, surgical procedures) do not have better health outcomes. He then challenges each medical specialty society to draw up a "Top Five" list of expensive tests or treatments that provide little or no health benefit and to develop a plan to discourage its members from ordering items on this list.
Unfortunately, I would be shocked if any physician groups actually stepped up to the plate to do this. In our current health system, all of the incentives - financial and psychological (see my previous post on reform "scare stories") - are aligned so that physicians provide more wasteful care, not less. But just as we all make difficult-to-attain resolutions every New Year - "I'll start an exercise program" or "I'll lose ten pounds" or "I'll be nicer to people who get on my nerves" - all doctors, regardless of specialty, should resolve to set aside self-interest and order fewer tests, treatments, and procedures that are not supported by good evidence in 2010. And in 2011. And in every year after that, until it actually happens.