Doctored (2 page)

Though he worked in a different country, my maternal grandfather led such a life. As a boy in India I used to watch him at work in the iodine-stained clinic on the ground floor of his palatial three-story flat in an upper-crusty neighborhood of New Delhi. Pitaji's clinic always smelled pungently of medicine, as did he. Through the drawing room window I'd spy him examining patients with boils or sepsis while lizards clung motionlessly to the limestone walls. He'd look so distinguished in his three-piece suit and spectacles, sitting cross-legged in an armchair beside books with titles such as
Diseases of Women
or
Treatment in General Practice.
His patients showed up at all hours, even during meals, and always without appointments: first come, first served. My grandmother functioned as his secretary and nurse. Grandchildren would be running around, playing cricket on the veranda, interrupting examinations, stealing his cystoscope or his magnifying glasses or the special otoscope with the brass earpiece. My grandfather was deeply proud of his knowledge. He fancied himself a mainstay of the community. He received fair compensation from those who could afford to pay and provided charity care to those who could not. Though it was a different time and place, this tableau matches well that of the American physician knight.

Indeed, American doctors at mid-century were generally content with their circumstances. They were prospering under the private fee-for-service model, in which patients were covering costs out of pocket or through fledgling private insurance programs, such as Blue Cross/Blue Shield. They could regulate fees based on a patient's ability to pay and look like benefactors. They were not subordinated to bureaucratic hierarchy. So when nationalized health insurance plans were proposed, doctors opposed them, perceiving an attempt to undermine income, autonomy, and, ultimately, patient care. They were afraid that the introduction of Medicare in 1965 would be the end of medicine as they knew it. It turned out they were right, but not in the way they imagined.

After Medicare was created as a social safety net for the elderly, doctors' salaries actually increased, as more people sought medical care. (Charity care also dwindled, as the federal government started to pick up the tab.) In 1940, in inflation-adjusted 2010 dollars, the mean income for American physicians was about $50,000. By 1970 it was close to $250,000, nearly six times the median household income. Doctors' purchasing power had never been greater.

But as doctors profited, they were no longer seen as knights. They were increasingly perceived as knaves bilking the system. Year after year, health care spending grew faster than the economy as a whole. Premiums for insurers like Blue Cross, whose reimbursement rates were determined by doctors, increased 25 to 50 percent annually. Meanwhile, reports of waste and fraud were rampant. A congressional investigation found that in 1974, surgeons performed 2.4 million unnecessary operations costing nearly $4 billion and resulting in nearly 12,000 deaths. In 1969 the president of the New Haven County Medical Society warned his colleagues “to quit strangling the goose that can lay those golden eggs.

“The temptation to get rich while the getting's good is powerful,” he said. “A lot of our group have payments to make on their apartment house complexes [and] shopping centers … [But] you can't blame the average patient for thinking that we doctors are living much too high on the hog.”

“It was a free-for-all,” recalled a senior physician at my hospital who had worked through that era. “Before Medicare,” he said, “doctors were not so focused on making money. Professional attainment still meant something. But if you call attention to this [change] you are considered a…” He struggled for the right word.

“Troublemaker?” I offered.

“Yes, a bad apple. There were so many unnecessary procedures. But all those doctors were board-certified,” he said disappointedly. “Who was I to tell them what to do?”

If doctors were mismanaging their patients' care, someone else would have to manage that care for them. Beginning in 1970, health maintenance organizations (a term coined by Paul Ellwood, Jr., a physician and an aide to President Richard M. Nixon) were championed to promote a new kind of health care delivery built around price controls and fixed payments. Unlike with Medicare or private insurance, doctors themselves would be held responsible for excess spending. There were other novel mechanisms for curtailing health outlays, including greater cost sharing by patients and insurer review of the necessity of medical services. The Health Maintenance Organization Act in 1973 supplied grants to start new HMOs to provide such “managed care” and required businesses with more than twenty-five workers to offer an HMO option, if available, thus ushering in a new era of health care financing.

The transition from knighthood to knavery had major consequences for doctors. In 1973 fewer than 15 percent of physicians reported any doubts that they had made the right career choice. By 1981 half said they would not recommend the practice of medicine as highly as they would have a decade earlier. Public opinion of doctors shifted distinctly downward, too. Doctors were no longer unquestioningly exalted. There were journalistic and media critiques of the medical profession. On television, for example, physicians were portrayed as more human—flawed or vulnerable (
M*A*S*H*
,
St. Elsewhere
) or professionally and personally fallible (
ER
).

As managed care grew (by the early 2000s, 95 percent of insured workers were in some sort of managed care plan), physicians' confidence plummeted further. In 2001, 58 percent of about two thousand physicians questioned said their enthusiasm for medicine had gone down in the previous five years, and 87 percent said their overall morale had declined during that time. More recent surveys have shown that 30 to 40 percent of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even higher percentage would not encourage their children to pursue a medical career.

There are many reasons for this disillusionment besides managed care. An unintended consequence of progress is that physicians increasingly say they have inadequate time to spend with patients. Medical advances have transformed once terminal diseases—cancer, AIDS, congestive heart failure—into complex chronic conditions that must be managed long term. Physicians also have more diagnostic and treatment options and must provide a growing array of screenings and other preventative services. In a study of sixty-seven hundred patients in twelve metropolitan areas, researchers found that the medical care for a host of ailments, including diabetes, alcoholism, and pneumonia, met national guidelines only slightly more than half the time. A paper published a decade ago in the
American Journal of Public Health
estimated that it would take over four hours a day for a general internist to provide just the preventative care—scheduling mammograms, arranging screening colonoscopies, and so on—that is currently recommended for an average-size panel of adult patients (this on top of the regular workday managing acute problems and emergencies). “The amount of time required is overwhelming,” the authors wrote. If anything, the problem has worsened since then.

However, the dissatisfaction probably would not have reached such a fever pitch if salaries under managed care had kept pace with doctors' expectations. But they have not. In 1970 the average inflation-adjusted income of general practitioners was $185,000. In 2010 it was $161,000, despite a near doubling of the number of patients that doctors see per day. While patients today are undoubtedly paying more for medical care, less and less of that money is actually going to the people who provide the care. According to an article in the journal
Academic Medicine,
the return on educational investment for primary care physicians, adjusted for differences in number of hours worked, is just under $6 per hour, as compared with $11 for lawyers. As in the rest of America, there is serious income inequality in the medical profession. Some doctors, especially procedure-based specialists, are probably paid too much. Others, such as primary care physicians, are not paid enough. (Yet almost every doctor feels the world owes them more for what they've been through.) Doctors today are working harder and faster to maintain income, even as staff salaries and cost-of-living expenses continue to rise and medical school debt approaches $200,000. Some have resorted to selling herbal supplements and vitamins out of their offices to make up for decreasing revenues. Others are limiting their practices to patients who can pay out of pocket without insurance company discounting. Private practices today are like cars on a hill with the parking brakes on. When you look at them, you don't realize how much force is being applied just to maintain stasis.

“I am very dissatisfied,” a doctor wrote online. “My father was a family physician … We discussed how maybe the practice of medicine should be reserved for the independently wealthy or a religious order. Seriously, I fear that these pressures will drive suicide and mental disease sky-high within our group of colleagues, who for the most part went into medicine due to the size of their hearts with minimal consideration on the impact of the size of their wallets. We all thought we would be comfortable and be able to pay our bills. All I have to say is, thank God my wife works.”

The time crunch and reimbursement cuts are only a small part of doctors' woes, however. Other factors include a labyrinthine payer bureaucracy (American doctors spend almost an hour on average each day, and $83,000 per year—four times their Canadian counterparts—dealing with the paperwork of insurance companies); fear of lawsuits; runaway malpractice liability premiums; and finally, the loss of professional autonomy that has led many physicians to view themselves as pawns in a battle between insurers and the government. A doctor lamented on
medscape.com
: “The public policy forces acting upon us are pushing us into being technicians on an assembly line with less and less time to relate to our patients as people and sometimes hindering us from even giving the best technical care. But we can only work so hard and so long, and if our patients aren't willing to pay for better time and attention, then we have to change with the times.”

The growing discontent has serious consequences for patients. One is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners. Try getting a timely appointment with your family doctor. In some parts of the country today, it is next to impossible. A report published by the Association of American Medical Colleges projected a shortage of as many as 150,000 physicians by 2025. Aging baby boomers are starting to become patients just as aging baby boomer physicians are getting ready to retire. The nation is going to need new doctors, especially geriatricians and other primary care physicians, to care for these patients. But interest in primary care is at an all-time low.

Perhaps the most serious downside, however, is that unhappy doctors make for unhappy patients. Patients today are increasingly disenchanted with a medical system that is often indifferent to their needs. There has always been a divide between patients and doctors, given the disparity in power inherent in their relationship, but this chasm is widening because of time constraints, malpractice fears, decreasing income, and other stresses that have sapped the motivation of doctors to connect with their patients.

People used to talk about “my doctor.” Of course, you had other doctors as the need arose, but you had one doctor you could call your own, and when you were sick, that doctor would be at your bedside. The archetype of a loyal, empathic family physician persisted in our culture for decades.

Today care is widely dispersed. In a given year, Medicare patients see on average two different primary care physicians and five specialists working in four separate practices. For many of us, it is rare to find a primary physician who can remember us from visit to visit, let alone come to know us in depth or with any meaning or relevancy. Many primary care physicians are no longer able to care for their patients who have been admitted to the hospital, relying instead on hospitalists devoted to inpatient care. It has become prohibitively inefficient for primary care physicians to leave the office for several hours—to drive to a hospital, examine a patient, check laboratory tests and vital signs, talk to a nurse, and write orders and a note—for just one or two patients. The economic calculus is such that if they did this on a regular basis, they wouldn't have enough revenue to pay their staff, their rent, and their malpractice insurance. The upshot is that the doctor who knows a patient best is often uninvolved in her care when she is hospitalized. This contributes to the poor coordination and wanton consultation that are so common in hospitals today. “Years ago you had one or two doctors,” a hospitalized patient told me. “Now you've got so many people coming in it's hard to know who's who.”

Not long ago I took care of a woman with an abdominal mass who had been transferred to my hospital for a preoperative evaluation. No one knew exactly what the mass represented or even whether she had had a biopsy—including the physician at my hospital who had accepted the transfer. The paperwork from the other hospital was a mess, incomplete; no one could make any sense of it. And the doctor we reached at the transferring hospital knew next to nothing about the patient. I told my patient that there were some things we needed to figure out before sending her to the operating room. “Like what?” she asked.

“Like what is this mass,” I answered. “Is it cancer? Has it spread?”

“Do you know if it has?”

“I don't, ma'am. I'm just meeting you for the first time.”

Tears filled her eyes. “No one knows what is going on,” she said, and she was right. I was eventually able to tell her it was a benign mass, but not before she had been tortured by worry for two days. It is hard to imagine such a thing happening in the era of “my doctor.”