The young patient was dying right before our eyes, and most of us around him in the ER that day who had a clue as to what was wrong had the wrong clue. Amongst all of the frantic chaos was one cool head belonging to a family doc in training who reached for the biggest needle he could find and drove it through the patient’s upper chest wall. Air from the chest hissed out of the needle, decompressing the punctured lung and struggling heart underneath, and saving the patient.

God wore a white coat that day, I remember thinking.

That event in a New Jersey emergency department 23 years ago reminds me why, if health care is a pack of snarling, snapping dogs, physicians are still leaders of the pack. While there are lots of contenders for top dog, health care remains first and foremost about patient care; when it comes to that, physicians continue to know the most, decide the most, and have opinions that often count the most in health care debates.

If that’s the case, who better to lead us in the future of health care reform than physicians, one might think. Yet the record of the physician profession to date in such a leadership role has been … well, let’s just say if that record had been a patient, life support might have been withdrawn long ago.

Despite a philosophical dedication to the interests of patients, and individual physicians who have stepped forward, I think my profession collectively has failed miserably to lead on most hot issues of health care reform. It has not, for example, led efforts to get all Americans health insurance, to reduce medical errors, or to reduce waste in health care in order to help make it affordable for us all.

What’s ahead in health care reform, however, presents new opportunities for the medical profession to lead. Almost every issue of substance in reform represents a crossroad for America’s disparate community of physicians; the question is, will they take the self-sacrificing leadership road to progressive importance or the self-serving low road to progressive impotence?

Which road will they choose when it comes to redistributing health care spending away from procedures and into primary care for all patients? Primary care is the cost-effective, fundamental care that every American must have to live as long as possible, as physically and emotionally well as possible, and as inexpensively (from a health care perspective) as possible, but it is the poor cousin of American health care where procedures, tests and surgical specialists make the big money.

Which road will physicians choose when it comes to reducing the number of wasteful procedures they perform and for which they get paid? We do countless colonoscopies, heart catheterizations, MRI scans, joint scopings, office visits and much more that waste billions of dollars and cannot be eliminated without physician leadership of a “whack out the waste campaign.”

Where will we stand on this — in front, leading this charge, or in back, being dragged kicking and screaming to a more economically sustainable model of patient care?

Physicians show great courage when the long needle has to be picked up and stuck into the patient’s chest; can we “screw that same courage to another sticking place” and stop ordering far more health care than Americans need? Will we stand up to our colleagues and to patients, and say, “Enough with the over-prescribing of antibiotics and other medications, enough with the over-ordering of cover-our-ass CAT scans, enough with surgeries of marginal value?”

Will we have the courage to stop defending our over-ordering of tests on the grounds we might get sued, and so on?

In the good old days of medicine, physicians could lead by simply being heroic when the needle needed to be driven home and the patient saved, but that does not cut it any more. We can now only lead Americans through the chaos of health care reform by being leaders outside the exam room and the operating room.

The selflessness, dedication to patient interest, and leadership through chaos we have shown in the care of individual patients is now required in the care of a nation of patients.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems.