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Tuesday Jan 09, 2018

Why Are We Eager to Save One, Reluctant to Help Many?

I woke up to an intense snowfall and ice fog. We were scheduled to fly out of Valdez, Alaska, to a conference that evening, but flights in Valdez are frequently canceled when the weather is bad. My wife and I had to decide whether to drive to the Anchorage airport or attempt to fly out of our local airport.

[car pulled over in snow with triangular reflector sign]

This was a complex decision because I live 300 miles from Anchorage across sparsely populated terrain. The temperature this time of year is often well below zero, and there are also risks from ice and moose. We wear warm clothing while driving in case of trouble, but it is disquieting to know that conditions may not be survivable if there is an accident or car trouble. We recognize that should there be difficulties, we would depend on the help of others, and that in return, we may be someone else's salvation. When faced with the uncaring cold of an Alaskan winter, strangers rely on each other. If you are an Alaskan and a car is stopped on the side of the road, you try to help.

As Michelle and I made our way past snow-covered peaks, glaciers and frozen waterfalls, we discussed health care financing and how to communicate the AAFP's position about universal coverage to lawmakers who may not share our values. Our academy is engaged in advocacy on multiple levels, trying to achieve high-quality care for all Americans while at the same time reducing costs and improving physician well-being. I have been appalled at how the national discussion devolved into self-righteous indignation about who deserves care and who does not. Perhaps this is an expression of human nature, a tribal sense of "us" versus "them."(www.joshua-greene.net) And yet human nature is such that when there is an emergency, most of us will help, often risking our lives to save a stranger.

On one occasion while driving home from skiing Thompson Pass, my son and I saw a car slide on a patch of ice, hit the shoulder, flip into the air, and disappear into a river that flowed alongside the highway. Without thinking about our own safety, we stopped and jumped into the river. I was still wearing my ski boots, which helped me keep my footing in the swift, waist-deep water, but in retrospect, wading in a near-frozen river with heavy boots was not without significant risk.

The car was upside down with the wheels still turning. I could hear a young woman and a baby screaming inside. To my intense frustration, I couldn't get the door open because the handles had been broken off on the car's way down the riverbank. I had one foot on the side of the car and both hands gripping the lip of the door trying to pull it open like an ineffectual, human Jaws of Life when my son -- who had joined me in the river -- said, "Hey, Dad, you want me to kick the back window in?"

He was also still wearing ski boots, which made short work of the rear window. He reached in and came out with a baby that he carried to a group of people who had gathered on the riverbank with warm blankets. We then helped the child's mother to safety, as well.

I would love to say that as we watched the car in front of us go into the river, I made a conscious decision to try to rescue the occupants, but I can't. Jumping into a swiftly flowing Alaskan river in December wearing ski boots may not have been a smart choice, but it was a human one.

The frustration I felt when I wasn't immediately able to get the mom and baby out of the car was familiar. I feel this on a regular basis when my patients can't get the care they need due to lack of insurance or resources. To politicians and insurance administrators, my patients in need are just numbers. To me, they are people I have known for years, whether it be the child with severe developmental delay, the young mother in tears with unexplained pain and fears of cancer, or the elder who needs services but cannot afford them. I could go on and on.

Why is there such a difference between our response to one person in need and our response to many? The nation reacts to a single child stuck in a well, but has difficulty addressing childhood hunger. This is the crux of the problem in the health care policy debate. We can all imagine one child in need, but our eyes glaze over when discussing the nearly 9 million children covered by the Children's Health Insurance Program. Behavioral research has shown that the desire to help decreases when the number of people who are in need rises.

Our brains are still wired from a time when we lived in much smaller groups, and we get blind-sided by biases in our decision-making that made sense then, but are less useful now. You can see this play out daily in examples of self-righteous indignation. We have difficulty thinking in terms of large communities and have a natural inclination to think in terms of us and them. Whenever there is this dichotomy, we have a biased sense of fairness that benefits the group we identify with.

What is needed is a pragmatic approach to health care financing that maximizes value. In order to accomplish this, we must be aware that we have biases that influence our actions and our decisions, and that these biases can cause harm. They come from a different time and context and may not translate to optimal health care policy. We can have a health care system that is more equitable and less expensive for our country, with greater physician satisfaction and better outcomes.

It is easy to think dispassionately of numbers, to blame people we feel have made poor choices, or even to give in to self-righteous indignation for being forced to help others. But beneath the numbers or the faceless strangers, there are real people who may live or die based on our decisions. It is our job as physicians to advocate for the people behind the numbers, to make them real. These are the same people we would help -- perhaps risking our very lives -- if we found them individually on the side of the road.

John Cullen, M.D., is president-elect of the AAFP.

Posted at 12:54PM Jan 09, 2018 by John Cullen, M.D.

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