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Will Doctors Be An Impediment To Reform?

Some progressive doctor friends have asked me to take Ezra Klein outside and knock him around a bit for a chat comment the other day. When asked in a chat session "why is it that so many doctors are opposed to Obama's plan?" Ezra attracted my friends' gentle wrath with the response:

I haven't seen any good polling of doctors. But in part, it's a simple function of being worried that they'll make less in profits. One reason health care is very expensive is that doctors are extremely highly-compensated. A system that spends less money isn't certain to be a system in which they make less money, but there's some chance of it. Everyone feels much better, of course, attacking insurers and so forth, but if you really want to cut costs, it's actually doctors--not just profits but behavior--who are they key.

I should add that these progressive doctors are online friends who have never met me. Thus they overlook some logistical problems with their suggestion.

 As Ezra indicates, many doctors are risk-averse about the possibilities of reform. Oddly enough, that view is especially prevalent in the most lucrative subspecialties. Once upon a time, this was the dominant strand of medical opinion. Such sentiment accounted for the American Medical Association's role in defeating many health reform efforts, and the AMA's ambivalence or opposition towards public vaccination clinics and other steps to improve population health. Yet there is another side to this story.

In a previous column, I noted increasing evidence that doctors are a more varied and progressive group than they used to be. On the left, there are Physicians for a National Health Care Program. (I happen to dislike PNHP leaders' unhelpful stance in the current debate, but that is another story.) According to a 2007 national physician survey, 89 percent of physicians believed that "all American should receive needed medical care regardless of ability to pay." Two-thirds of physicians believed that the uninsured lack access to needed care. Prior surveys indicate that most physicians support some mechanism of expanded or universal coverage.

Hundreds of thousands of physicians belong to organizations that have endorsed the President's broad vision of health reform. These groups include the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics, the American Medical Student Association, the American Osteopathic Association, the National Physicians Alliance, and Doctors for America. (Full disclosure: I am an advisor to that last group.) The American Medical Association has endorsed the House bill, though some state medical societies have not gone along.

Many pro-reform physicians are primary care providers exposed to the daily irrationalities and cruelties of the current system. Others are emergency physicians who bear the strain of steadily rising demand for their services, even as increasing numbers of financially-strapped hospitals are closing their ERs. Disconcerting numbers of emergency physicians report first-hand knowledge of a patient's death arising from delayed care.

They are not the only voices in medical care. For physicians, as with insurers, cost-containment and delivery system reforms are far more difficult subjects than is universal coverage. The profession is divided across specialties, and within the hearts of individual physicians, who are at once members of our greatest profession and human beings with specific economic and political interests in play.

To a remarkable degree, physicians act with impeccable integrity and compassion in their treatment of individual patients. When I think about my old Princeton classmates and those with similarly privileged backgrounds, I would venture that the doctors are the only sizeable group who are out routinely helping disadvantaged people during their working day. Just last week, I spent the morning with residents training to serve patients with co-occurring substance use and psychiatric disorders. That's tough work, and the accompanying salaries don't blow me away, either.

Sadly, the profession does not always operate with the same ethical reflection in wielding its economic, political, and social influence in American society. Doctors have always been part of the solution, but part of the problem, too, in improving and reforming American health care.

These views are changing, not only regarding health care access, but also in reforming aspects of the delivery system and medical culture that make treatment less effective, more dangerous, and more wasteful than it should be. For example, practitioners have long dismissed evidence-based approaches as a form of "cookbook medicine." Doctors are coming to embrace these techniques as essential complements to the art of medicine in treating patients who may be helped or who may be harmed by powerful interventions. The strong physician response to Atul Gewande's indictment of bad and costly care McAllen, Texas, provides another positive sign.

If you want to find more doctors' perspectives, you might check out Hosted by Doctors for America, this website includes the perspectives of hundreds of physicians around the nation, such as Lauren Raimer-Goodman of Houston, Texas, who expresses frustration about uninsured children who cannot get needed services or medications, or Amir Arbisser of Davenport, Iowa, who complains about the inefficiencies resulting from dealing with multiple health insurers--each with its own separate rules and data systems that confuse both beneficiaries and providers.

By and large, these are progressive voices. They are also relatively young voices. It's easy to find another side to the story and to the profession. I am optimistic about the future. As for this current health reform season, I guess we will find out soon enough.