Can you be a good physician without a basic understanding of economics? Yes, of course you can: all the professional needs to do is to use a little common sense, the rationality of ‘oikos nomeia' in their decisions, and they are sure to make the right choice. The problem is that, in much of medical practice, the context in which clinical activity takes place does not encourage that rationality.

Why should I consider the costs of what I do if I don‘t have take responsibility for the results? What motivates me to be careful about the resources I use if it could give rise to doubt and uncertainty (regarding what I don't do) rather than recognition (regarding what I do)? Since I receive a salary that I am guaranteed regardless of the effort I make, what can motivate me to be aware of any squandering? At the end of the day, they are things that do no harm, even though they may not do any good either.

And as analysts, what could lead us to think that a public health system will find a balance when those who decide, demand or evaluate do not bear any of the consequences? Can we expect anyone to evaluate the profit margin from devoting time and resources to one patient, regardless of the costs involved, bearing in mind that failing to do so will mean fewer resources for other patients, whether one's own or not, under treatment or on a waiting list, or who even as a result of a lack of health education do not recognise that their ailments are treatable?

At this point, more than one reader may have already been upset by this sermon on health economics. And professionalism? Or medical ethics? What about the Hippocratic oath? Is this not a form of ‘economicism' by those who seek to know the costs while ignoring the value of what is being done? Let us say right from the start that these are reactions of confusion, with some empirical truth and a lot of normative lies, and in any case they generate asystematic responses… The goodness of a system that is based on the demand for good men cannot be expected today. There are necessary conditions, perhaps not sufficient, but the first are necessary to achieve this. And one of them is rationality!

Hence, the cross-cutting nature of economic rationality, of the management of one's own, ‘oikos nomeia', plays a relevant role in medical training. A reminder that our decisions, in whatever context (hence sometimes the lack of the condition of sufficiency!), must be disciplined. Health economics as a discipline in clinical management is offered as an element to help ‘format' medical decisions; assessing what we are going to do in terms of the alternatives, the benefits versus the costs, not in terms of ‘the whole', but in terms of the additional impact our decision has on the margin. We are not really going to do, in any case, ‘whatever it takes for our patient', regardless of the costs we incur; at least not in the time we devote to him/her or in the leisure time we sacrifice for that desired benefit. We sacrifice effort and resources, allocating them to the best of our ability. In this regard, there is no ethics without efficiency (with squandering). If we don't do it at home, on our own budget, or in the case of private practice, we should do it even less when the resources we use belong to the community!

If competence in that knowledge is to be cross-cutting, it is logical that we do not advocate the ‘colonisation' of medicine, from corporatist standpoints, in favour of a subject in the degree course, an easy subject perhaps to be taken as a potion of adherence, forced by the financing politician. Horizontality is best achieved from case studies in all branches of Vesalian knowledge. The idea is to visualise the virtue of incorporating rationality, the assessment of the timeliness of the decision, given the alternatives, including waiting to obtain, if possible, better knowledge of the matter. It is unacceptable to do so as a device attached to the morphological division of medical studies, to the super-specialisation of current areas of science; it is as unacceptable as when in micro-management we talk about profits while ignoring costs, ignoring the fact that the budget has to balance the expenditure and income sheet, about the taxes with which we finance public health expenditure and the remaining income for the welfare of families, necessary for other orders of life. And the fact is that we all trade health for income, even though we know that if the first is lost, the second becomes worthless.

In short, core competence implies that rationality must be permeating studies in all the different fields. Health economists must step out of the ghettoes of economic management and, side by side with clinicians, work in partnership and complement each other to ensure the efficiency of the system, while respecting the equity so desired by the public authorities. An economics department in a medical school should not be there to ‘teach', guide, direct… but to accompany and support the clinical decision-makers.

Today I already see evaluation staff in some hospitals, in the health system, in clinical consultancy, who share this position. This is the way to go. And, in turn, to awaken in undergraduate medical degrees, the idea that without efficiency it is impossible to be a good professional. The motivated intuition of some may not need to resort to ‘the wisdom of the gnomes'; but, in general, the discipline of health economics, as a discipline, offers a way forward, ensuring the rigour and robustness of decisions that might otherwise be lost in improvisation, prejudice and inertia.