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The doctor walks into the basement room, the ER level of the hospital, a room empty except for you and the woman from your church you have just met. He tells her that her husband is dying, that only life support is keeping him alive, that the sudden heart attack he's just been brought in for has killed him, but his body doesn't know it yet. One thing the doctor cannot decide, though, is whether or not to remove life support. She has to make that decision; he won't.

And she turns to you and asks: "What do I do?"

The client walks into your office seeking legal advice. She tells you horror stories about her ex-husband, none of which arise to the level of actual child abuse, but none of them leave you very comfortable about how he behaves around their young daughter. And the problem is, he is trying to take custody of the child from her, because she works as a stripper. She has few marketable skills, and working as a stripper pays better than anything else she can do. She doesn't do drugs or bring men home from the club. She keeps her life separate from the life she leads with her daughter, at home. But she has no other source of income that pays the bills as well as this, and you know child support is a poor substitute for earned income. You do the best you can to represent her, but it's an uphill fight and legal representation is expensive and you have to always be aware of how much time you are spending on her case, because you have to pay your bills, too. In the end you lose, because of her job and her ex-husband's convincing manner (you are convinced by now yourself that the best liars are the worst parents, and wonder why judges never see that). You wish you had the money for investigators and time to build a serious case and present more facts about your client and her ex-husband; and you realize it may work that way on T.V., but this is real life. And you hope the daughter will be alright, and you try to put it out of your mind.

The patient comes to you with signs of gastrointestinal distress. Do you get them to change their diet, wait a few weeks to see if it resolves? Or do you order tests and refer them to a surgeon, reasoning the patient won't change their diet and it's better to be safe than sorry? According to Atul Gawande, the doctors of McAllen, Texas, one of the poorest communities in the country, generally choose the latter course. And the result, overall, is poorer healthcare against the national average, while healthcare spending in McAllen is nearly the highest in the country.

Most likely you've heard of the article, but if you haven't read it yet, you owe it to yourself to do so. Gawande's thesis is sound (and it's the one relied on by countries where health care is provided by the gov't, one way or another): unless costs are contained, nothing can be done to provide health care for an entire population. But it's when he tries to get down to the facts on the ground about McAllen that it gets interesting:

Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.

Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.

Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.

The "invisible hand of the market," of course, is supposed to take care of this, so we don't have to. But McAllen is the near-perfect example of why this doesn't work, and Gawande puts his finger on the problem in those three paragraphs. Just before that he visited the chief executives of the newest hospital in McAllen, one the other hospitals and doctors blame for raising costs without raising benefits. Why do they blame Renaissance, the new hospital? Because it is run by doctors, which means there is an inherent conflict of interest that makes those doctors order more procedures, the better to make money. Except the man who runs Renaissance doesn't see it that way:

So I asked him why McAllen’s health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, “are providing necessary, essential health care,” Gelman said. “We don’t invent patients.”

Then why do hospitals in McAllen order so much more surgery and scans and tests than hospitals in El Paso and elsewhere?

In the end, the only explanation he and his colleagues could offer was this: The other doctors and hospitals in McAllen may be overspending, but, to the extent that his hospital provides costlier treatment than other places in the country, it is making people better in ways that data on quality and outcomes do not measure.

“Do we provide better health care than El Paso?” Gelman asked. “I would bet you two to one that we do.”

Did you get that? Government is the problem because it doesn't pay enough, so the private sector has to make up the costs (I guess). There's lots of waste in government programs. But nobody at Renaissance is responsible, because they practice sound medicine. And finally, ultimately, it's not all about the money, or what can be measured scientifically.

Which doctor is ever going to say otherwise? Maybe you cheat, but I don't. Your costs are excessive; mine are reasonable and necessary. Your patients may get better, but mine get well! You can't measure that in dollars and cents! One can see easily how Gawande reaches his conclusion as to how we all miss the big picture because of our quotidian duties.

Which brings me back to my opening comparison. Two of those three scenarios I've lived through. All professionals face something similar, some point where they are responsible for the words coming out of their mouths, responsible in ways that go bone deep and provide a pivot point in some individual's life. Is it worse in the emergency room when you are the doctor, or the pastor? Is it harder to make decisions about a patient/client in your clinic, or in your law office? It's an impossible argument, ultimately. The burdens come with the territory, and you accept them or move on. But I will say this, about the financial side, speaking strictly from my personal experience:

The pastor gets paid whether he gives the right answer to the soon-to-be widow, or not. And whether he helps her or not, he may still lose his paycheck. The outcome is almost entirely personal and individual; it needn't affect your ability to pay your bills or have a place to live.

The lawyer gets paid only to the extent he can convince the client the work done was reasonable and necessary. Lawyers don't get paid by third-parties, generally. They don't get to insist extra work must be done, more pleadings filed, codicils to the will be drafted, pages added to the contract, simply because it might seem necessary and somebody will pay for it, so why not do all you can and then some? Indeed, I don't know of a profession where you could regularly charge any client more for doing what is arguably (according to Gawande) less; except for the practice of medicine.* Consider, again:

Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.

I worked for a large and wealthy law firm, before going to law school. The partners were always aware of every hour billed to their clients, and that included my billable time as a paralegal. The thought of what was in the bills was never out of their minds. When I entered private practice, this was equally true for the small firms I practiced in, and doubly true when I stepped down into family law, where only individuals hire you, and never even a small company. I couldn't be oblivious to the financial implications of my decisions, even when those decisions were regarding child custody or child welfare. I never had a third party paying my bill.

Is this to damn doctors, condemn hospitals, assault the industry? No. It's simply a fact. Doctors get paid for what they do, and that's the key difference between doctors and hospitals and almost any other profession: they get paid for what they do, and, as Gawande points out, that's part of the problem. There's nothing to keep them from getting paid, whether the outcome is better, or worse, or the same. Pastors get fired for displeasing the wrong people; lawyers get stiffed on their bills because the client didn't like the outcome, or didn't have the money to pursue the custody fight or to collect the past due child support (most people who really need a lawyer need a family lawyer; and they are least able to pay for those services). Doctors, if Gawande's article is to be believed, pass the costs on until someone picks up the tab. Does this make them evil? No. But it makes the system untenable, and unsustainable. I almost said "and liable to collapse," but in many ways, it has already collapsed. Michael Moore showed us that; but we just collectively shrugged our shoulders and went back to our quotidian lives, consumed with the details of our own existence.

Are we evil? Are the doctors?

It is worth pointing out that Gawande seems to disagree with my analysis:

When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.

Which takes us back to his thesis, actually, as I was saying. No, we can't take the third-party payor out of the equation. So we have put some kind of controls into the system, as Gawande points out in his conclusion. But that's merely saying what I am saying: without someone controlling the expense, without a system that works to control costs, there is no solution. We cannot make health care that unique in America, or it will fail more and more of us than it already does.

*I saw only one instance of a lawyer grossly abusing a client's pocket book, but the client was wealthy and the lawyer had obviously persuaded her the courtroom appearance was a necessity (it wasn't; I was trying to withdraw from the case because my client had quit paying me or returning my phone calls; he wanted nothing more to do with it). I cite it as the exception which proves the rule. No doubt it happens, but it is no more common than doctors who order extra procedures just for the money, not for the sake of the patient (many doctors in Gawande's article accuse other doctors of doing this; some give accounts of outright fraud. But is that the root of all the evil?).