Jonathan Zimmerman: Doctors can't write Rx for reform





[Jonathan Zimmerman teaches history and education at New York University. He is the author of "Small Wonder: The Little Red Schoolhouse in History and Memory."]

Should doctors make health care policy?

At first glance, the answer would seem obvious: of course they should. They’ve fought in the trenches, bearing personal witness to every fault of our medical system: uninsured patients, stingy HMOs and runaway costs. To reform the system, then, we should all pay special attention to what doctors think.

Think again. Personal experiences can skew our vision, blinding us to other ways of looking at the world. And seeing a problem up close doesn’t give us any particular insight into its solution.

Consider the American Medical Association, the nation’s largest and most influential physicians’ organization, which recently endorsed President Barack Obama’s proposal to provide universal health coverage.

Obama says the AMA is supporting his reform because doctors “have seen firsthand what’s broken about our health care.”

But so have the 14 physicians who serve in the U.S. House. And nine of them are Republicans, who will most likely vote against Obama’s health care package. Earlier this year, Rep. Phil Gingrey (R-Ga.), a Marietta obstetrician who has delivered more than 5,000 babies, called the Obama plan “a move towards socialism.”

Ditto for the two doctors in the Senate, Tom Coburn (R-Okla.) and John Barrasso (R-Wyo.), who host a twice-a-week Webcast — “The Senate Doctors Show” — about the dangers of Obama’s proposal. Their firsthand understanding of medicine lets them serve as “a kind of truth squad” on health care reform, as Barrasso recently bragged.

Nonsense. By pretending that personal experience gives doctors special authority over the reform, we ignore the crucial difference between technical and political knowledge. Just because you know how to deliver a baby doesn’t mean you know how health care is delivered.

Indeed, most doctors don’t. A recent University of Michigan survey of 58,000 medical students from 2003 to 2007 revealed that less than half of them believe they received adequate training about America’s health care system. By contrast, nine of 10 respondents felt well-prepared to make clinical decisions.

It’s been that way for a very long time. Like most professional training institutions, medical schools teach people to render service to an individual client. And most other things — including the social and political dimensions of professional life — fall by the wayside.

As early as 1921, the Association of American Medical Colleges recommended that medical schools devote 170 hours — that is, between 3 percent and 4 percent of total curriculum time — to “preventive medicine and hygiene.” But surveys soon showed that most medical schools fell far short of this target. Students learned how to make individual patients better, not how to improve medical care for everyone.

Listen to an AAMC report from 1942, which could have been written yesterday: “Deans and faculties of medical schools, though in general professing to consider it essential to provide sound instruction in preventive medicine and public health, do not actually regard this subject as important.”

Since then, to be fair, medical schools have revised their curricula to add more social and political topics. At George Washington University’s medical school, for example, classes have visited Capitol Hill to observe debates over health care. The school is also offering a policy track for students, who will study health economics and craft their own proposed reforms.

But fewer than 10 percent of GW medical students choose this program, which tells you something important about their priorities. And it also tells you that we should be wary of trusting doctors on health reform, unless they have made a special study of its complexities.

The same goes for other professionals, of course. What do lawyers know about the economics of tort reform, really, or engineers about the politics of public infrastructure? Not much, I’d guess, because they generally don’t have to learn it as part of their preparation.

My field, education, used to be an exception. From the 1900s into the 1980s, future teachers were required to take so-called “foundations” courses in the history, philosophy and politics of education. But at most schools of education, including mine, these classes have been scaled back in favor of more “practical” courses on skills and methods.

That’s fine, if all we want to do is prepare practitioners. But if we also want our teachers — or our doctors — to participate knowledgeably in public debates about their practice, we’ll have to give them the training to do so.

“If we don’t expect doctors to understand the health care system, who is going to?” asked one author of the University of Michigan study of medical students. It’s a fair point. And until our doctors answer it, they shouldn’t get any more authority over health care questions than you. Or than me.


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