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The Rules of Caring

At a recent meeting on trauma centers, a former Arizona Congressman, upon hearing of high rates charged by some doctors to be on emergency call, asked, "Whatever happened to altruism?"

To which a hospital administrator replied, "You can't beat the crap out of doctors, then expect them to be compassionate."

Indeed. It's one thing to be charitable and compassionate on a voluntary basis, giving freely of your time and skill to help others who desperately need it. It's quite another thing to be mandated to be compassionate by the new rules of caring: Get down to the hospital at 3 a.m. and patch up somebody who's drunk and blew off his hand with a shotgun. He's uninsured, you might not get paid, but you have to provide compassionate care because it's the law.

And by the way, Doctor: For every patient you treat who's on a managed care contract, we're going to reimburse you Medicare rates, if that. But not to worry. The president of the managed care plan is making $4 million a year, and you can still make $300,000 if you work 80 hours per week. Don't expect the average Joe on the street to cut you any sympathy. His health care premium is approaching 20 percent of his take home pay.

This isn't an apologia for physicians. It affects all of us. By mandating compassion, we run the risk of losing our capacity to care.

What started centuries ago as a tradition of voluntary charity care through almshouses, private homes, settlement houses and hospitals -- much of it faith-based -- has gradually morphed into a tangle of public laws, rules and regulations that mandates care on the principles of compassion and fairness, but then places the burden of that care unfairly on the shoulders of the "caregivers," and not on the rest of us.

So it is that the physician is required to be compassionate in the emergency room at 2 a.m., while the insurance executive who's home in bed isn't.

It's not surprising that some physicians and other health professionals choose to opt out of the system. It's not because they don't care. It's because they see others don't care, including spoiled citizens and lawmakers with a penchant for passing unfunded mandates. They become cynical and disillusioned. They think, why should we be required to care, and not others?

America is blessed with free clinics, community hospitals and volunteers -- including many nurses, physicians and other health professionals--who give generously of their time and talents to help those in need. But as marvelous as this web of caring is, it's a blip on the health care screen of almost 40 million uninsured, skyrocketing costs and cut throat competition driven by the rules of the marketplace and shareholder expectations.

Consider our own behavior. We buy health care stocks for our retirement portfolios. We expect them to do well and look forward to a cozy future with quality health care on demand and low co-pays, then wonder why doctors aren't feeling so charitable anymore, or why hospitals are thinking of getting out of the trauma care business.

We are seduced by the siren song of free choice and the market economy, yet the last thing we want is physicians who act like businessmen when our own health is at stake, and health organizations that allocate resources solely on the unforgiving scale of profit and loss.

Ironically, the best solution for the trauma and emergency room mess might well be even more mandates for compassion: a mandate for insurance plans to pay surgeons 200 percent of Medicare while on call, a mandate for the federal government to pay for EMTALA, a mandate for the state and hospitals to work together to integrate trauma care services, a mandate for auto insurance companies to pick up more of the tab for car accidents, a mandate for public funding for trauma centers, even a mandate for a base level of health insurance for all citizens.

Some of these mandates are about as likely as snow in July in Arizona. Short term, there are things we can do together voluntarily to integrate the system and make it more efficient. Long term, we need new rules that place the imperatives of compassion and caring on everyone, and not just the few.