Doctored
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For my mother
For Sonia
And for Mohan and Pia—always, always
Contents
Title Page
Copyright Notice
Dedication
Epigraph
Prologue: Storm
Introduction: Medicine at Midlife
PART I: AMBITION
1. Awakening
2. Odd Conceptions
3. Learning Curve
4. Good Intentions
5. Do the Right Thing
6. Double Effect
7. Hatching a Plan
8. Pact
PART II: ASPERITY
9. Stress Test
10. Moral Hazard
11. Devotion
12. Denial
13. Deluge
PART III: ADJUSTMENT
14. Deception
15. Ticktock
16. Follow the Money
17. Speed Dating
18. Diversion
19. A Country Husband
Epilogue
Notes
Acknowledgments
Also by Sandeep Jauhar
A Note About the Author
Copyright
Wholly unprepared,… we take the step into the afternoon of life; worse still, we take this step with the false assumption that our truths and ideals will serve as before. But we cannot live the afternoon of life according to the program of life’s morning—for what was great in the morning will be little at evening, and what in the morning was true will at evening have become a lie.
—Carl Jung
Prologue: Storm
I am walking on a muddy path. The rain has ceased, and puddles are shimmering in the moonlight. I am wearing olive green Gap pants, beat-up Hugo Boss shoes, and an orange Patagonia Windbreaker. I am the picture of success.
I start to run. Trees and poles hurtle past me as head down, eyes fixed, I sprint down the trail. Wet leaves scrape against my face as I swat them away. Shadows oscillate. The wind is swirling like a loud yawn from heaven. I stumble on roots, but I keep on going.
Sleep has been hopeless. I haven’t been able to nod off for more than a few hours at night, and sedatives leave me even groggier the following day. A strange feeling has taken hold of me, and it won’t let go. “It isn’t anger,” I told Dr. Adams, my psychiatrist, “as much as butterflies in the stomach.”
“Why the anxiety?”
“I don’t know, but I am waking up with it and the workday hasn’t even begun. How do I make it stop?”
My pants catch in nettled bramble. The cloth rips slightly as I struggle to free myself. I finally stop and gaze into the still blackness. A faint light glows in the distance, refracting through my spectacles into an array of crystals. In the damp weedy grass around me, crickets chirp in angry unison. A nearby branch quivers where a creature must have just departed. I begin to jog again. Misty droplets, heavier and more urgent, peck at my face until the sky opens up to release a downpour. I sprint home. You can speed up after an accident, but you never make up for lost time.
Introduction: Medicine at Midlife
A certain amount of dissatisfaction may be inherent, even necessary, to the practice of medicine.
—Abigail Zuger, The New England Journal of Medicine, 2004
When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic. Many of my colleagues are similarly struggling with the loss of their professional ideals. Of course, the relinquishment of one’s ideals is standard fare in the midlife phase. In this period, fundamental questions about life often arise: What is its purpose? What is my ultimate aim? Depression and nostalgia can take hold as middle-aged adults struggle with responsibility, regret, and the nagging awareness that their lives are half over.
I used to think that my life would settle down when I got to this stage, but I was wrong. The insecurity and ambivalence of my youth have persisted, though in different forms. In my twenties, hamstrung by my passions, I yearned for consistency in my core beliefs. I obsessed about what I was going to do with my life. Those ruminations now seem like luxuries. The challenges I face now—supporting my family, navigating the precarious domains of job, marriage, and fatherhood while trying to maintain personal and professional integrity—seem so much bigger (if no less insoluble). As a young adult I believed that the world was accommodating, that it would indulge my ambitions. In middle age, reality overwhelms that faith. You see the constraints and corruption. Your desires give way to pragmatism. The conviction that anything is possible is essentially gone.
It occurs to me that my profession is in a sort of midlife crisis of its own. In the last four decades, doctors have lost the special status they used to enjoy. In the mid-twentieth century, at least, physicians were the pillars of any community. They made more money and earned more respect than just about any other type of professional. If you were smart and sincere and ambitious, the top of your class, there was nothing nobler or more rewarding that you could aspire to become. Doctors possessed special knowledge. They owned second homes. They were called upon in times of crisis. They were well-off, caring, and smart, the best kind of people you could know.
Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented, and anxious about the future. In surveys, a majority of doctors express diminished enthusiasm for medicine and say they would discourage a friend or family member from entering the profession. In a 2008 survey of twelve thousand physicians, only 6 percent described their morale as positive. Eighty-four percent said their incomes were constant or decreasing. The majority said they did not have enough time to spend with patients because of paperwork, and nearly half said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether. American doctors are suffering from a collective malaise. We strove, made sacrifices, and for what? For many, the job has become only that—a job.
Consider what a couple of doctors had to say on Sermo, the online community of more than 125,000 physicians:
I wouldn’t do it again, and it has nothing to do with the money. I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients. Working up patients in the ER these days involves shotgunning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don’t need them, and being aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a money-making game for hospital administrators. There are so many other ways I could have made my living and been more fulfilled. The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade.
Another wrote:
I loved what I did, running an ICU. But I was on call 11 of every 14 days for more than 25 years. Over a third of my work weeks were 100 hours. I quit when I was 56 because my wife developed a terminal illness and I wanted to return all the lost hours I had promised her “when we retire.” In my last year of practice I asked the billing department to collect all the actual money we had collected on one particularly long and difficult weekend on call … After overhead, I was actually paid $11.74/hour. Who would do that again? Fool that I am, I probably would, but my wife and I brought up our sons from an early age t
o be totally against the idea of medical school. They were clearly bright enough, with full academic scholarships. And while they respect physicians, they are not doctors. And I am glad they are not.
The discontent is alarming, but how did we get to this point? This book, chronicling my experiences in my first few years as a new doctor, is my attempt to answer this question.
* * *
A decade ago, the economist Julian Le Grand developed the idea that public policy is grounded in a conception of humans as “knights,” “knaves,” or “pawns.” Knights are motivated by virtue. They want to make the world a better place. Knaves are selfish. They desire to extract as much as possible for themselves. Pawns are passive. They follow external rules and regulations rather than an internal code of conduct.
In a 2010 essay in The Journal of the American Medical Association (JAMA), Dr. Sachin H. Jain and Dr. Christine K. Cassel apply these concepts to medicine. Knights, they write, practice medicine to save and improve lives. The best thing government can do is to get out of their way and let them do their jobs. Knaves, on the other hand, put their financial well-being before their patients and often order tests for personal gain. Government needs to guard against their malfeasance. Pawns are ruled by the environment in which they practice. The role of government is to incentivize them to do what is right. As Jain and Cassel write, “A society’s view of human motivation influences whether it builds public policies that are permissive, punitive, or prescriptive.”
The history of American medicine over the past half century can be interpreted through this lens. In the halcyon days of the mid-twentieth century, physicians were viewed as knights. They were among the most highly admired professionals, comparable to astronauts and Supreme Court justices. American medicine was also in a golden age. It was a period when life expectancy increased sharply (from sixty-five in 1940 to seventy-one years in 1970), aided by such triumphs of medical science as polio vaccination and heart-lung bypass. Doctors largely set their own hours and determined their own fees. Depictions of physicians in the media (Marcus Welby, General Hospital) were overwhelmingly positive, almost heroic. Doctors were able to trade on this cultural perception for an unusual degree of privilege and influence.
“Doctors were God,” Harry Steinberg, the white-haired retired chairman of medicine at my hospital, Long Island Jewish Medical Center, told me. “They had the corner house in the neighborhood with the shingle out front. In the hospital they had their own private service. Everybody knew who you were. You walked around with a black bag, interns in tow. There was almost no regulation. We didn’t have case managers telling us what to do. There weren’t these interdisciplinary teams.”
Suburban doctors in this period led a gentlemanly life. They’d go on rounds in the hospital in the early morning and then go to their offices—often attached to their homes—to see patients till noon. During their lunch break they might return to the hospital to eat in the doctors’ lounge or to check on a sick patient, or they’d make a house call. In the afternoon they’d often go back to the hospital to check laboratory tests or X-rays or to meet with a patient’s family, and get done with the bulk of their workday by 5:00 p.m. Evenings were spent at home with their families or at the social club or lodge. On Saturday nights they might have taken their wives out to dinner or even to the opera. In general, they weren’t seeking patients. They desired respect and status in their communities. They worked hard but also lived with dignity and high-minded purpose.
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.