Money and medicine — only a fool denies the connection. Aligning monetary incentives to encourage high quality patient care is a fundamental tenet of health policy — Hal Luft’s comprehensive approach is available here (full disclosure: Hal is a mentor). In cancer, economists have documented some troubling perverse effects of how oncologists make money by re-selling chemotherapy drugs, and there’s the concern about how money drives cancer research I talked about in my last post. “Money rules medicine” is the conventional wisdom in health policy circles — the dog bites man story at AcademyHealth, which recently concluded its annual research meeting. But, even at AcademyHealth, there are some subversive hints about powerful non-monetary motivators in medicine.
New Yorker writer and Harvard faculty member Atul Gawande won the AcademyHealth Impact Award for work demonstrating how a simple checklist can improve surgical outcomes — an idea driven by money hardly at all. The AcademyHealth New Investigator award went to Aaron Kesselheim, who has defied conventional wisdom by arguing that the market might not be the best way to drive biomedical innovation and discovery. Both gave great speeches at the awards banquet. Gawande optimistically suggested that the US healthcare system, like Billy Bean’s legendary Oakland A’s baseball teams, could learn to do more with less by using new data in better ways. Kesselheim hilariously described how inside-the-beltway types might receive these new ideas; their reactions to his own work, he said, have ranged from “I respectfully disagree” to “I know where you live.”
Listening to the talks at AcademyHealth with these words in mind, my mind returned to three themes about motivation in medicine that have recurred repeatedly in my research and teaching at UCSF.
- Aren’t there easier and faster ways to make money than being a doctor?
- How could we compare the influence of money to the influence of other things that motivate medicine, like scientific curiosity or a desire to heal?
- Even if health care is big business, does that necessarily mean money is the motivation for medicine?
None of these are easy questions to answer, and none of the answers are objective — all reflect politics and philosophy. But they’re questions we’ll return to again and again on this blog.