A System of Incentives?

May 21, 2007 at 1:42 am (Michael's Posts)

I’m reading this book Hospital by Sydney Lewis (as I mentioned previously) and it’s raising interesting questions. One of the things that came up today is how we get doctors to take care of poor people. The doctors’ testimonies in the book seem to indicate that the only way they got the system of care to work at County (at least in the 60s and 70s and 80s) was to employ a large number of interns and residents whose goal was to further their education by working at County. The idea was that if you could make it through County, you could make it anywhere. In the most sceptical light, it was a super resume boost. The overwhelming majority of them didn’t remain in practice at County and they didn’t remain in practice in the service of poor people, either. Now this may be the bias of the interviewed doctors (because they often did spend a lot of time there) but it also raises an interesting question: without plenty of money, how can you get quality people to provide care to poor people? What other incentives might draw people to these situations? Is the incentive of an education-in-the-trenches morally okay? I mean, are the people who are providing care in those circumstances doing so for the right reasons? Does that matter?



  1. Eli said,

    Since I now work for a public hospital, albeit not in patient care, this is something I think about too. I personally take pride in working for the hospital that attracts the “difficult” cases: the gunshot wounds, the child abuse cases, the HIV cases, and the largest share of uninsured patients. Clearly not everyone sees their training here (we’re an academic medical center) with the same public service dimension. I’ve heard third and fourth year medical students say that our hospital get the most “interesting” cases, i.e., expressing the “if-you-can-make-it-here, you-can-make-it-anywhere” attitude.

    I don’t think that attitude is necessarily in conflict with the public service attitude. Just because the residents use the “if you can make it here” reputation to their advantage doesn’t mean it’s the sole or primary reason they’ve chosen to work here. Plus, I think the public/profession should give them this respect. I mean, if the hospitals that serve the rich (i.e. the neighboring hospital here) had the reputation of being “the toughest,” then maybe we’d have to face the prospect of fewer people wanting to work for the poor people’s hospital. This reputation for toughness compensates for our hospital’s lower figures when compared to other area hospitals
    . Hospitals that take people who haven’t had regular preventative care tend to have higher death rates. That’s why our neighboring private hospital isn’t interested in seeing certain kinds of cases. So I say, give them the incentives. It makes the residents happier, and keeps them working for the poor.

  2. msoule said,

    That’s what a lot of the people in the book seem to be saying and I guess as long as quality care is being provided, it shouldn’t matter all that much. The challenge to survive in the environment of such hospitals does provide an incentive to residents to work there. It may also expose people to situations that awaken a response to the plight of the poor people they treat that might not otherwise be stirred. Following this idea, shouldn’t all health centers for the poor be operated by, or under the aegis of, university health programs? If they were, then this exposure factor would be raised many-fold. This idea was set forth by Rolf Gunnar, one of the former chiefs of Medicine at County, in Hospital.

  3. Mesothelioma said,

    poor people should be helped by providing them cheap health facilities!

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