Letter to the Editor: Editorial: The Goal is Health, Not Surgery

To the Editor,

I want to thank Drs. Ring and Leopold for their excellent editorial [2], and I cannot agree more with their premise that our goal is health, not surgery.

I suspect most of us feel this way. Therefore, I wondered why this resonated with me so much. Then I remembered one of Charlie Munger’s maxims: “Show me the incentives and I will show you the outcome.”

What are my incentives? I work in a fee-for-service system. I get paid for surgery, not for health. Every day, I can login and see my tally of procedures.

Every month, I receive patient satisfaction summary score cards. I have come to realize that the unhappy patients leaving my office are much more likely to answer this survey than the happy ones are. And all too often, their unhappiness seems related to my inability to communicate well when I thought not having surgery, shots, or additional tests was in their best interest.

Every quarter, my practice receives an update from the hospital on our room utilization. How many blocks go unfilled, and how many blocks end too early? How do we compare to other specialties?

When I go to annual meetings or read the latest research, I notice that a substantial proportion is about the newest, marginally tested surgeries. And a lot of social credit seems to be given to the people who propose these debatable treatments and diagnoses, as they travel around the world talking about them.

I will note that, beyond the potential harms I’ve alluded to already, there is some good rationale for each of these examples. People should get paid for their work. Doctors should try to treat patients in ways that leave them satisfied. Not using up all that expensive operating room time is wasteful. And a small proportion of novel surgical procedures are, indeed, breakthrough treatments.

I don’t have a good solution for any of these things. I have worked in different systems—at one point, I was salaried, for example—and for every problem that is solved, another one gets created. It becomes easy to lose track of the real goal: health. I am grateful that Drs. Ring and Leopold regularly take the time to emphasize this [1-4]. The actionable advice they provide helps me stay grounded and focused on the patient in front of me.