AMA Journal of Ethics^®

The date was September 5th, 2005. Catastrophic devastation surrounded me. I sat on the steps of my office building and gazed upon a formerly fully occupied parking lot that had been transformed into a makeshift triage center for the American Red Cross relief effort in New Orleans. We had no electricity and no clean drinking water, and heinous images of dead bodies were far too often on the news. I was scared and worried that New Orleans as I had known it was gone forever. How could a city and its people rebound from this level of destruction?

My own healing process began by working to improve the health of the children and families who still called New Orleans home. Many others began their healing process much the same way—by getting down to the business of rebuilding the city brick by brick.

Fast forward 5 years. A Super Bowl victory, NBA playoff appearances, a blossoming independent school system, educated young entrepreneurs everywhere you look, and construction underway on state-of-the-art VA and teaching hospitals to rival those anywhere in the world. What was needed in New Orleans is what we need in medicine: renewed engagement. Doctors today need to care about their patients and their profession as much as New Orleans’ citizens care about getting their city back on its feet.

As New Orleans was brought low after Katrina, the culture of health care in America today is broken. Our payor-payee system is dictated by financial motivations, not concern for the patients. Our hospital systems overlap and duplicate services, wasting millions of dollars on obsolete routines. Our medical institutions of higher learning have forced the best and brightest to shun primary care as a practice area for fear that they may not be able to pay back their student loans. The United States now faces a shortage of primary care doctors, and huge numbers of our patients suffer from preventable illnesses—childhood obesity, hypertension, and diabetes. The profession—not the mere job of medicine, but why it all matters—is in danger of being lost. Organized medicine can do for the profession what rebuilders did for New Orleans; all we have to do is bring people back to it.

First, New Orleans had to improve communications between local and state governments, the lack of which resulted in catastrophic and deadly logistical failures. Without good communication all systems fail. The medical profession is suffering from insufficient communication on many levels. There is a poisonous lack of respect between members of the different health care professions that keeps everyone from working together. And the proprietary, commercial nature of electronic medical record systems mean that communication among hospitals and other care delivery sites, especially across state lines, is patchy at best. A cohesive, reform-mindedcenter to the profession could demand better coordination among commercial interests that would bring together the disparate parts of the health care delivery system.

The next step New Orleans undertook was repairing the physical surroundings. As Malcolm Gladwell chronicles in The Tipping Point, the crime rate in New York City dropped precipitously due in part to a concerted effort to cover the graffiti that plagued the city. This project was undertaken according to the Broken Windows theory, which holds that “crime is the inevitable result of disorder. If a window is broken and left unrepaired, people walking by will conclude that no one cares and no one is in charge. Soon, more windows will be broken, and the sense of anarchy will spread…sending a signal that anything goes” [1].

The city center of medicine is the hospital—the hub of both the care of patients and the training of new physicians. And our medical facilities—especially those that serve the most vulnerable people in America—are in disrepair; they are not fit for the worst of our enemies. Let’s examine what doctors trained in these surroundings are learning. They see the poorest, most marginalized people waiting enormous lengths of time only to be pushed through like cattle. The staff is often overworked, underpaid, and not particularly respectful of the patients. I believe this is leaving trainees with the view that it is fine to give underserved people sub-par care because they have no choice, and the medical profession doesn’t have any responsibility to make conditions better. Upgrading the physical surroundings in which doctors learn and underserved patients are cared for will send the message that these missions are important and worth investing in.

Which brings me to the third step that had to be taken to revitalize New Orleans: the recruitment of visionary leaders to help rebuild the city. This very critical move has put New Orleans in the forefront of the charter school movement, the movie production industry, and cutting-edge entrepreneurial action. The medical profession needs strong, honorable leadership to make progress. And organized medicine has been that force in the past. The model works, but the profession is turning away from it. Wariness that it might hamper individual physician autonomy, concerns about the time commitment and the cost, and just plain apathy have made physicians reluctant to be a part of organized medicine. This will not do. Young, enthusiastic, visionary, and idealistic physicians must work within organized medicine to make the health care system honorable once again.