I must admit I’m a little weary of the entire debate on health-care reform. But something still haunts me. And that something is accountability. Of course, over the almost twenty years that I have borne the title ‘MD,’ I’ve learned a few things about accountability.

I understand that, almost without fail, the buck stops with me. The nursing home director knows the elderly lady wasn’t seriously hurt in that fall, but he sends her to the ER ‘just to check things out.’ That is, just to make sure that if a problem does crop up, someone else is accountable for finding it.

The surgeon wants me to see the post-op patient because she’s busy, and it’s just too risky to make a decision by phone.

The private physician admitting the very ill pneumonia patient has that patient stop in the ER, ‘just so someone else can lay eyes on them.’ In other words, to share the blame for complications.

The patient with chest pain in the cardiologist’s office is sent to the ER ‘to stabilize him before he goes to the ICU.’ To wit, so that the cardiologist needn’t leave the office to see the potentially sick person who could easily go to the ICU.

The sick child is sent from the pediatrician’s office, so that the emergency physician can arrange the transfer to the teaching center, and so that the icky parts of pediatrics, like frightening resuscitations, can be kept at arm’s length. So that someone else can be accountable for that part.

I understand accountability. We all try to share it when we can. I consult people when I’m uncertain. But the fact is, everyone wants someone else to bear accountability. As someone said to me in medical school, ‘Focus the Glory, Diffuse the Blame!’

Unfortunately, accountability in person isn’t very popular. However, anyone in America can feel good about themselves simply by saying, ‘well, I don’t know, but if I were you I’d go to the ER!’ They feel good, but I’m still the one making decisions and signing forms.

Fair enough. I figure, that’s one of the things I went to school to be. Accountable! Physicians, particularly young ones, should learn to embrace it and bear it up like real men and women. I guess at least half of my income is simply for being willing to take the blame as well as the praise.

But when this health-care reform package passes, and if it does to the economy and to medical practice what many of us fear, will anyone be accountable? Will they step up and say, ‘yep, that was me! Sorry, I’ll try to fix it!’ It’s unlikely. That’s not how politics are conducted.

I suspect we’ll see what we always see in politics. The positive feedback loop. More money spent, more money fails to help the problem, thus, more money must be spent. If money does appear to help (whether or not it actually does), also spend more money. We’ll see the same with climate change. Increase taxes and fees and clamp down on industry. If it seems to work, apply more harshly. If it doesn’t, apply more harshly.

Imagine the same in medicine. The clot buster didn’t help the stroke? Well, heck, give more of it! We’ll teach that stroke! The antibiotic gave you diarrhea and didn’t make the urinary tract infection better? Here’s a bit of the ‘hair of the dog.’ More of the same is always better!

And I wonder, will the physicians who pushed so hard for this package suddenly be willing to see more uninsured or under-insured patients? Will they open themselves to new Medicare patients, despite cuts? Will they extend their hours to allow more access to primary care? Will they hire more partners and dilute their income, to improve everyone’s health? Doubtful. But they may seek more sweeping health-care reforms!

Maybe it will work! Maybe health-care will all be vastly better! Although I disagree with the entire monstrosity, I hope no one is hurt by it. I even understand the motivations of those who, in good faith, just want to help the downtrodden.

All I want is for someone to be willing to take the blame if it all goes to pieces.

All I want is for others to share in the accountability. The same way I have to when I make a decision…and find out the next morning it was the wrong one.

I don’t think that’s asking too much, do you?

Edwin Leap is an emergency physician who blogs at edwinleap.com.

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