Over the last several weeks, I have written about the epidemic of over treatment and unnecessary testing. To pin down a reason for this excess, I wrote about defensive medicine, our fee for service system and greed.
But there’s another force at work. The math does not add up. Yes, we order tests to protect ourselves against litigation. Yes, we certainly like the money. But, I couldn’t indict raw greed as the primary reason we are profit driven. Just last week an article noted that doctors in HMOs who don’t profit, still order CT scans. They order them with almost the same abandon as those who have a financial interest in getting you to sign up and then lie down for one.
In the last post, I noted that greed is not what I see, feel, hear or experience my day to day contacts with colleagues. No doubt there are some, and perhaps many, doctors who are cynical outliers who knowingly order tests that are not in your interest. And paraphrasing Lincoln, “all of us do it some of the time; some of us do it all of the time; none of us do it none of the time”. And yes, you should be aware of this and maintain an attitude of mannered skepticism in the face of medical advice. But the math does not add up. There’s something in the air. A missing force that closes the circle on all the excesses of our medical care delivery system.
So where is the wellspring, that continuous force, lying just below the surface that provides the stimulus for all the needless testing, invasions and prescribing?
Quoting from Luke.”The Force will be with you, always.”
It’s deep in our doctor psyches. It’s a behavior called money primed. Physics has been looking for a Unified Theory of Causality for a century. Einstein became lonely in his futile attempts to find it. Well, for medical economics I have found our Universal Theory of Medical Causality. Thank you, it was nothing really. The Nobel awaits.
Priming is a concept that plays a key role in human behavior. There are stimuli, lurking in the background that never reach conscious awareness. Despite this, their presence influence what we do and why we do it. It could be just a word, a picture or even barely audible background music. They make an impression and alter our thoughts and deeds. For example, experimental participants were exposed to words that were evocative of kindness as part what they were told was a ‘language test’. When they subsequently made contact with a target subject, they viewed him as kinder than other participants who were not exposed to ‘kind words’. Kind words do make kind deeds.
So, the passive receipt of subtle influences that occur in one context can go on to influence our behaviors in unrelated settings. Racism, hostility and aggressive traits can be primed all without our knowledge or our direct participation. Cognitive scientists “know that such effects are ubiquitous and pervasive across the major forms of psychological phenomena: appraisal and evaluation, motivation and goal pursuit, social perception and judgment, and social behavior.”
Sometimes these priming stimuli don’t just pop up in our environments…they saturate them. And rather than just influencing our thoughts, they, in part, control them.
Enter Money Primed
Money is an emotionally-charged subject that profoundly effects how live our lives and how we live with others. Above, I quoted Luke’s mission. No, not the Bible’s Luke. I’m talking the Star Wars Luke. But the Bible does weigh in. The New Testament 1 Timothy 6:10 says, “For the love of money is a root of all kinds of evil. Some people, eager for money, have wandered from the faith and pierced themselves with many griefs.”
Others disagree. “Money itself is not evil. But if we ignore the powerful effect that money can have on our attitudes and behaviors toward one another, we risk falling under its corrupting influence and allowing love of money to trump love of one another.” No one discounts the importance of money.
Doctors are Money Primed
Pre medical students worry about money and live in debt. Medical students hope for money and live in debt. Doctors-in-training earn very little money and live in debt. But all around them are their mentors, teachers and their seniors. These are the monied class that drive expensive cars, live in costly homes and go on extravagant vacations. Money, entitlement (and yes, wisdom) ooze from every pore.
When we finally are able to ‘get out and get ours’, we do. We live well, travel well, raise our children well. It’s just that we don’t always behave well. And sometimes it makes us not feel well. Many of us labor under an increased incidence of anxiety, depression and substance abuse.
Money saturates our lives from our colleges to our clinics. And when it does, it changes how we see the world.
Time Is Money
In our fee-for-service world, time is money. And when people who work at ‘doctor level’ hourly wages get the time to think, they think about how valuable their time is. It’s been shown that “when people paid by the hour think about their time in terms of money, they are more likely to adopt an economic evaluation lens when making decisions.”
Earnest While Earning
And think about money we do. But we don’t do it consciously. Money primed, we make subliminal decisions based on our economics. Even when ordering things that don’t help you, we money primed doctors could pass lie detector tests. We look earnest because we are earnest . Earnest while earning.
Money isn’t in our brains. It’s in the air we have breathed since college days. Our concepts of self are related to the economic evaluation of what our time is worth. Money primed people are more self reliant and solitary. More self sufficient, they view the world differently than those who are not. Experimentally money primed subjects sit farther from other people than those who were not primed for pesos, pounds or pengos.
Priming makes us more self reliant, independent, socially isolated protectors of the status quo…kind of sounds like doctors..right? “Kind of sounds like me. Yikes!”
Kathleen Vohs, is a pioneer whose experiments revealed some of the traits of the money primed. She says, “Money has been said to change people’s motivation (mainly for the better) and their behavior toward others (mainly for the worse).”
Despite this, most doctors believe (really believe) that what counts are skills, advocacy and a pure intent, borne from our professional codes and ethical norms. And it’s true. It’s just that money gets in the way.
A Boston Globe article a couple of months ago, reported on wealthy politicians. It may have just as well been speaking of doctors whose net worths are greater than most congressmen and senators. ” As a mounting body of research is showing, wealth can actually change how we think and behave—and not for the better. Rich people have a harder time connecting with others, showing less empathy to the extent of dehumanizing those who are different from them. They are less charitable and generous. They are less likely to help someone in trouble. And they are more likely to defend an unfair status quo. If you think you’d behave differently in their place, meanwhile, you’re probably wrong: These aren’t just inherited traits, but developed ones. Money, in other words, changes who you are.”
Our attitudes, our preferences and our motives are all influenced by ingots. And please don’t blame us. It’s the system of fee-for-service. We become what our medical-industrial behemoth turns us into.
When that test is ordered and you look into your doctor’s eyes you will see, reflected back at you, all the Hippocratic honesty that is also primed into us. It’s just that money gets in the way.
And that’s the problem. You see us with halos and offer your kudos for our professionalism. We, with full hearts, we are sublimely unmindful of our full wallets. You should though, be mindful.
Next week…it’s your fault too, you know. Hey I fessed up now it’s time to shine the light on you guys!