Outside In | Our health care would benefit from this fix in how we pay doctors

Atul Gawande, surgeon, author and advisor to President Clinton on US health care reform, has a dark secret: as he paved his brilliant medical career, he was seduced by the glamour or “heroism” of surgery compared with the humdrum banality of what he calls “incremental care”.

Today, he complains that the US medical system is skewed and wasteful because of bias in which doctors flock to those areas of medicine in which dramatic, heroic interventions make them look like saviours and attract the majority of public attention, and most of the medical dollar.

“When illness was experienced as a random catastrophe, and medical discoveries focused on rescue, insurance for unanticipated, episodic needs was what we needed,” he said in a thoughtful paper, “The Heroism of Incremental Care”, in January’s Annals of Medicine: “Hospitals and heroic interventions got the large investments; incrementalists were scanted.”

He noted that the five highest-paid medical specialties in the US are orthopaedics, cardiology, dermatology, gastroenterology and radiology – these earn an average of US$400,000 a year: “All of these are interventionists,” he said: “they make most of their income on defined minutes- to hours-long procedures – and then move on.”

By contrast, doctors attracting the lowest pay – about half the average earnings of the top five – are all “incrementalists” – paediatricians, endocrinologists, family medical practitioners, geriatricians, immunologists, headache specialists, psychiatrists, rheumatologists – who “produce value by improving people’s lives over extended periods of time, typically months to years.”

His point is that it is these humdrum “incrementalists” that actually contribute most to our communities’ wellness – in short, who do most good – rather than the adrenaline-fuelled gladiators engaged in charismatic, glamorous “rescue medicine”.