Wednesday, August 05, 2009

Let Them Eat Prestige

Over the course of a decade and a half (and corresponding with my time as an undergrad and a law student), clerical and technical workers at Harvard struggled to form a union. Their most potent slogan was "we can't eat prestige," which was later turned into the title of a book recounting the period. The slogan was powerful because it captured a deep truth. Underpaid workers at Harvard were still underpaid workers, even if Harvard was a prestigious institution.

The slogan was also, perhaps deliberately, misleading, for there was little prestige attached to being a secretary at Harvard. The prestige accrued largely to the faculty, students, and alumni. (The non-faculty administration are an intermediate case which I'll put aside.) What the clerical and technical workers were saying was that they couldn't eat the prestige that other people affiliated with Harvard were getting. And they were right.

But what about the prestige hogs themselves? Could they eat prestige? I think the answer is yes, or at least sort of. Let me explain.

In my experience, academics are very much driven by the desire for acknowledgment. This can come in the form of affiliation with a prestigious institution. I know of couples who have lived hundreds or thousands of miles apart for decades because each partner had a "better" position far away from the other than would be available were they to live closer to one another. Just the economic cost--travel, maintaining two households, etc--are enormous, so that such couples could enjoy a higher standard of living if one or both took a less prestigious appointment. And that's to say nothing of the strain on their relationship and, in the instances of couples with children, the strain on that relationship.

Meanwhile, I should say that nearly every responsible academic I know is almost constantly turning down opportunities to make money so that he or she can instead do work that will earn acclaim from peers. My own calculus is illustrative. I consult a bit for paying clients, and I enjoy the work a great deal. Working on real cases keeps me in touch with the legal profession and exposes me to a range of legal developments that teaching and research wouldn't necessarily cover. I could probably do more consulting, consistent with my obligations as a professor, but I don't because I take the view that excelling as a legal academic means writing well-regarded scholarship, and I don't want to cut down on my time for scholarly pursuits any more. In this respect, I think I am very much in the mainstream of legal academics, and of academics more broadly (except that academics in some fields lack opportunities for well-paying non-academic work).

What this tells me is that in the professional world I know best, people are motivated less by dollars (although that would cease to be true below a certain comfortable minimum) than by the desire for something like prestige. And that brings me to medicine.

I am sure that a great many doctors are motivated primarily, or even exclusively, by a desire to heal what ails their patients. But that's surely not the whole of the story. As I noted last month, in an article that should be very influential, Atul Gawande has described much of the phenomenon of rising health care costs as due to locally specific cultures of profit-maximizing medical practice. For seemingly random reasons, in some communities doctors regard patients as a kind of ATM, leading to cost ratios between these and other communities of 2-to-1, without any resulting health benefit. The doctors in these high-cost places (McAllen, TX is Gawande's main example) are basically involved in a business.

I don't have anything I'd call a "plan," but I do have an idea: What if there were some way to get the doctors in the high-cost areas to value something even more than money? Ideally, what they would value is the health of their patients, but asking them to do that directly may be difficult. Paying doctors for keeping their patients healthy might work, but many doctors who are already making thousands per procedure on a fee-per-service model would likely resist that approach. What we need to do, somehow, is to make it prestigious to have healthy patients. That could be accomplished by a cultural shift, but it would take some shaking up. Given the connection between prestigious medical schools and some of our best hospitals, we have the infrastructure to change the culture. If doctors could be persuaded that they can eat prestige, we could go a long way towards addressing the fast rise in health care costs.

Posted by Mike Dorf