What David Sedaris Can Teach About Health Care

David Sedaris had a comic piece in the New Yorker about socialized medicine that is, as you’d expect, pretty funny. While it’s not exactly a policy wonk piece chock-full of statistics, I do think it’s worth thinking about. One of the important flaws that policy wonks focus on in the American health care system is the incentive structure—the claim is that fee-for-service incentivizes the system to push for more care rather than better care. I think that’s important, but the role of culture is not unimportant here.

Here’s Sedaris describing a visit to the doctor:

There’s a pharmacy right around the corner, and two blocks further is the office of my physician, Dr. Médioni. Twice I’ve called on a Saturday morning, and, after answering the phone himself, he has told me to come on over. These visits, too, cost around fifty dollars. The last time I went, I had a red thunderbolt bisecting my left eyeball.

The doctor looked at it for a moment, and then took a seat behind his desk. “I wouldn’t worry about it if I were you,” he said. “A thing like that, it should be gone in a day or two.”

“Well, where did it come from?” I asked. “How did I get it?”

“How do we get most things?” he answered.

“We buy them?”

The time before that, I was lying in bed and found a lump on my right side, just below my rib cage. It was like a devilled egg tucked beneath my skin. Cancer, I thought. A phone call and twenty minutes later, I was stretched out on the examining table with my shirt raised.

“Oh, that’s nothing,” the doctor said. “A little fatty tumor. Dogs get them all the time.”

I thought of other things dogs have that I don’t want: Dewclaws, for example. Hookworms. “Can I have it removed?”

“I guess you could, but why would you want to?

It’s easy to see how this encounter with the doctor could’ve gone differently—he could’ve ordered a test on that eyeball, or done something to remove that fatty tumor. Instead there’s an “enh, whatever” attitude that prevails and seems to serve Sedaris quite well, insofar as nothing has happened to his eye and as far as we know he is not cancerous.

And there’s little with the structure of the system to discourage a more activist stance—the visits are conducted along fee-for-service lines, and yet the results are strikingly different than the prevailing results in many regions of the United States. Some of the cultural difference is because of the patient (Sedaris writes, “For my fifty dollars, I want to leave the doctor’s office in tears, but instead I walk out feeling like a hypochondriac, which is one of the few things I’m actually not” and elaborates that he wants to hear fancy technical terms and whatnot. A more pushy patient might demand that “fatty tumor” get removed forthwith), but much of it is the doctor also.

So it’s probably a mistake to assume that changing the incentives will do the entire job. But what changed incentives might do—if announced loudly and persistently enough—is help signal that a change in culture is necessary.