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.”
Insensitivity in patient-doctor interactions has become almost normal. I once took care of a patient who developed kidney failure after receiving contrast dye for a CT scan. On rounds he recalled for me a conversation he’d had with his nephrologist about whether his kidney function was going to get better. “The doctor said, ‘What do you mean?’” my patient told me. “I said, ‘Are my kidneys going to come back?’ He said, ‘How long have you been on dialysis?’ I said, ‘A few days.’ And then he thought for a moment and said, ‘Nah, I don’t think they’re going to come back.’” My patient broke into sobs. “‘Nah, I don’t think they’re going to come back.’ That’s what he said to me. Just like that.”
Of course, doctors are not the only professionals who are unhappy today. Many professions, including law and teaching, have become constrained by corporate structures, resulting in loss of autonomy, status, and respect. But as the sociologist Paul Starr writes, for most of the twentieth century, medicine was “the heroic exception that sustained the waning tradition of independent professionalism.” It is an exception whose time has expired.
* * *
This book is not only about the midlife crisis in American medicine, but also about my own struggles as a middle-aged doctor, husband, and father to find equilibrium in my life and my practice. In my book Intern I describe the formative years of my medical training at a New York Cit
y hospital. Doctored is the further story of an education, about the loss of ideals and about midlife corrections and solutions. In fractal geometry, there is the concept of self-similarity, in which component parts resemble the whole. As in a coastline, reiteration of patterns occurs at progressively smaller scales. The premise of this book is that much can be learned about how to heal American medicine, forty years old in its modern incarnation, in a midlife portrait of one of its practitioners.
Everything that appears on these pages actually happened. However, most names and identifying details have been changed to preserve confidentiality; in some places, time has been compressed or the order of events has been changed for the sake of narrative cohesion; and in rare cases I have used composite sketches to better represent my experience. Dialogue is usually based on notes taken at the time, though some has been reconstructed from my memory.
The practice of medicine today is as fraught as it’s ever been, and the doctor-patient relationship is in serious trouble. One of my goals in writing this book is to understand why. These are not trivial problems. How they are resolved will in no small part determine the future of health care in this country.
PART I
AMBITION
ONE
Awakening
A young doctor means a new graveyard.
—German proverb
I had been pedaling furiously for nearly a decade—on a stationary bicycle. Medical school, internship, residency, and fellowship: my education seemed as if it would never end. So it was with no small measure of relief that in the late spring of 2004 I accepted a position as an attending cardiologist at Long Island Jewish Medical Center in New Hyde Park, New York. This was the last step in a long and grueling journey. After medical school I’d completed three years of hospital instruction in general internal medicine to earn the privilege to practice independently. After finishing this internship and residency, I’d elected to do a fellowship: three more years of study in cardiac diseases to further specialize. Now, with the fellowship concluded, I’d become an attending physician, the senior level of the hospital hierarchy, with ultimate responsibility for patients and junior doctors. Nineteen years after starting college and a few months shy of my thirty-sixth birthday, I finally had my first real job. The complexities of academic medical training had long since worn thin. I was ready to simplify, consolidate, and perhaps even reap some rewards for all those sleepless nights.
Cardiology was a natural career choice. I had trained as a physicist before going to medical school, and the heart, with its complex rhythms and oscillations, appealed to my predilection for patterns and logic. Heart disease was also no stranger in my family. Both my grandfathers had died of myocardial infarctions—one in his forties, ten years before I was born—so I had grown up with an awe of the heart as the executioner of men in the prime of their lives. Plus, the heart, with its symbolic meanings, had always occupied a special place in my (and the broader cultural) imagination. Take heart! Have a heart! He wears his heart on his sleeve.
Of course, I was nervous. Every new doctor should be. Cardiologists specialize in emergencies. The culture is fast-paced, pressured. I was going to have to learn to become quick and decisive in precarious situations. By nature I was slow and deliberate, and I had never felt comfortable acting on instinct—not exactly adaptive in a cardiac care unit where people can drop dead on you at any moment. In neuroscience there is the concept of the reflex arc, in which a threatening stimulus can effect a response without passing through the conscious brain—for example, when you see the taillight flash red on the car speeding in front of you and your foot automatically moves to the brake pedal. I was afraid that as a cardiologist I would now have to follow a similar reflex arc.
“Well begun is half done,” my father reminded me with his usual Aesopian wisdom. Dad possessed the annoying certitude that there were no more life lessons to be learned in this world, that whatever was worth knowing our forebears had already taught us. Traditional and moralistic, he liberally quoted proverbs and scriptures even if he didn’t always live by them. But when you think in axioms and parables, when the collective wisdom of the world can be distilled into the concentrated tonic of a few sayings, then you feel as though you have all the answers.
He had always wanted me to become a doctor—one trained at Stanford University, no less. That, he believed, would be the pinnacle of professional attainment. My family immigrated to the United States in 1977, when I was eight, to advance my father’s career as a plant geneticist, but in America my father never achieved the kind of success he felt he deserved—denied, he believed, by a racist university tenure system, which forced him to take postdoctoral positions with no long-term stability and left him embittered and in a constant state of conflict with professional colleagues. In medicine, my father explained, I would not be plagued with such insecurity.
One reason for my father’s struggles was that he always seemed to do things the wrong way. When I told him the mnemonic I had learned in school to remember the colors of the spectrum, he said: “Roy G. Biv? Oh, you mean Vibgyor!” He’d mow the lawn at night, waking the neighbors. He’d bring up controversial subjects like Sikh separatism or Kashmiri violence at low-key social gatherings. He’d trim our nails with a Gillette razor blade, twisting our fingers painfully so they wouldn’t get lacerated. As long as the nails got cut, it didn’t matter to my father how much we protested. That sort of encapsulated his personality: disciplined, unsentimental, focused solely on the task at hand.
My mother affectionately called him poottha, “awkward.” She accepted his idiosyncrasies with a kind of bemused resignation, as if they had been written in the stars. The eldest daughter of a wealthy New Delhi physician, she abided her station as the working wife of a discontented plant geneticist as though it had been ordained, just part of the deal of an arranged marriage, and she resolved to make the most of it. She didn’t believe in talk or analysis or drama, only in putting your best foot forward and grinding ahead, accepting your circumstances with dignity and grace. Yet for all her equanimity, she still regarded medicine as the hammer that would break her children out of the middle-class mold my father had set. She often told us she wanted her children to become doctors so people would stand when we walked into a room.
My apprehensions about my new job were only slightly mitigated by the fact that my older brother, Rajiv, an interventional cardiologist who performed invasive procedures, was already working at the same hospital. Rajiv was my parents’ firstborn, their pride. They had always favored him, and Rajiv demanded it, too. He knew the privileges of being the elder son in a traditional Indian family and guarded them closely, like a trust fund. Like most brothers close in age, we were fiercely competitive growing up, evenly matched at most things (Ping-Pong, chess, tennis), our rivalrous parity enforced by the unspoken fear that if one of us pulled away, we’d lose the other’s companionship. One sphere in which we were undoubtedly unequal was social relationships, however. Rajiv had the kind of gregarious and easygoing personality that I had always desired but somehow never could develop. The only time we had worked together professionally was during my internship at New York Hospital in Manhattan, where as a star senior cardiology fellow he unwittingly reminded me of my incompetence again and again. Toward the end of my own cardiology fellowship at NYU, he had invited me to apply to LIJ and had used his considerable influence to get me a job. Now he was in a position to guide me through another, perhaps more challenging apprenticeship.
At Long Island Jewish I would work as a cardiologist with a specialization in congestive heart failure. This was no small task: heart failure is the common final pathway for a host of cardiac diseases, including heart attacks, acute valve disorders, viral infections of the cardiac muscle, etc. There are many challenges in caring for these patients. They have multiple comorbid illnesses, such as diabetes and emphysema. Their symptoms—for instance, shortness of breath—are often nonspecific. They frequently have poor health literacy or cogn
itive impairment or are socially isolated because of their chronic disease. Despite these difficulties, I chose to specialize in heart failure because I wanted to develop close relationships with critically ill patients and provide long-term care, unlike my brother, who almost exclusively performs procedures and knows his patients mostly for the duration of an operation. I also wanted to be in a specialty where I would not have to perform surgical interventions. I’d never been especially good with my hands. Growing up, Rajiv had been the tinkerer and I had been the thinker. Of course, I knew this decision was going to involve a certain degree of monetary sacrifice. Heart failure is a money loser for most hospitals, which make most of their revenue from lucrative procedures like stents (wire mesh cylinders used to open blockages in the coronary arteries that feed the heart) and pacemakers, or hip replacements. In the American system doctors are paid much less for exercising their judgment than their fingers.
* * *
Dawn in July, a few weeks after starting my new job. Sirens puncture the early-morning stillness. I open my eyes. Twilight leaks through the window blinds, dissolving the gloom into tiny grains of black. I remain motionless, savoring the void. My wife, Sonia, is still sleeping—sleeping for two. I peer at the hazy sonogram framed on the windowsill. It is faded from the sunlight that beats on it daily, betraying nothing of the complications of the past few months.
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