A middle-aged professional acquaintance of ours needed an operation to remove a cancerous tumor.62 A friend asked him, “How do you like the guy who’s going to be cutting you open?” The man replied, “I feel the same way about the surgeon as I do about the pilot who flies an airplane that I’m on. Whether or not I like her is irrelevant. What is relevant is that she knows what she’s doing and does it really well.” Doctors, especially surgeons, must be decisive at times and they have to be convinced that what they are doing is the right thing or they won’t do it well. And you won’t do as well unless you believe that your doctor makes good decisions and is skilled at her job.
One of us was once described by a Yale professor as being “unencumbered by knowledge.” While we are quite sure that the Yale professor didn’t intend that as a compliment, there is a sense in which knowledge can get in the way of understanding; the Canadian environmentalist, Farley Mowat, admonishes, “never let the facts get in the way of truth.”63 And it’s not only, as Alexander Pope says in his famous poem, a little learning that is dangerous. We fear that those in medicine who drink most deeply of Pope’s Pierian spring are sometimes the scariest. That’s because there can be a false sense of certainty that comes from memorizing what for the time being pass for answers, forgetting how ephemeral answers can be—losing one’s sense of maybe. On occasion, knowledge can close the mind to new possibilities. That is no excuse for failing to learn from the available information; you don’t want a dumb doctor. But you don’t want a doctor who doesn’t know when he is wrong either. If we pay attention we can learn by being wrong.
So how can you avoid getting involved with a know-it-all doctor and realizing it too late, after something goes seriously awry? Here are some things to look out for:
This doctor is not at all interested in partnering; she is completely in charge and has no patience with any challenge to her authority. She pays little attention to what you have to say. She might respond to your question with, “I am the doctor here, don’t tell me how to do my job!” Or she might say, “Just do what I tell you to. There’s a reason we call them doctor’s orders.”
The doctor is disrespectful to staff and/or other health care professionals. Although this doctor’s worst behavior will likely happen elsewhere, there may be clues in how she talks to nurses, aids, and other personnel while tending to you. How members of her staff behave in her presence can also betray less than amiable relationships. Are they overly deferential? Do they appear frightened of the doctor? One of the staff may make an apparently off-handed comment when the doctor’s not around about how difficult she is to work with; that’s a red flag.
The doctor appears sleepy or seems to have trouble concentrating. Sleep deprivation can cause even the most well-intentioned doctor to be impatient and short tempered, to act like a jerk. Doctors may be more likely than most people to have their sleep interrupted by the demands of a busy practice, and paradoxically, they may not realize how seriously chronic loss of sleep is changing their behavior for the worse. A tactful observation that your doctor seems tired might call her attention to the problem and could even help to change her behavior. However, if the problem persists, you will just have to admit that this person may be incorrigibly arrogant whether or not she is sleep derived.
The doctor is disrespectful to other patients. While you shouldn’t deliberately eavesdrop, sometimes you may hear the doctor talking to another patient or discussing a patient on the telephone. If that happens, pay attention to how the patient is addressed or referred to. The know-it-all doctor doesn’t always show appropriate respect for her patients even when they are face to face and commits even worse offenses when discussing a case with a colleague.
Reflecting on a visit to the doctor, do you feel that:
You were dealt with as a mature and reasonably intelligent adult?
Your problem was the central issue?
The doctor adequately explained what she thought was wrong and how she planned to proceed?
You and the doctor talked to, not at, each other?
Remember, you choose your doctor, not the other way around. While your choices may be limited, you do not have to accept poor treatment—at least not without exploring all of the available possibilities. You should make every effort to create a good working partnership, as discussed earlier, but if the relationship still isn’t working you should do your best to find a better situation.
We can only hope that the next candidate in line is not the chronically unhappy person whom we are about to meet in the next chapter.
Trisha Torrey, “Trisha’s Misdiagnosis Story.” Every Patients Advocate, http://everypatientsadvocate.com/who-is-trisha/misdiagnosis/.
Richard Hayward. “Balancing Certainty and Uncertainty in Clinical Medicine.” Developmental Medicine & Child Neurology 48 (2006): 74–77.
“My Friend’s Story,” The Fecal Translant Foundation: Patient Stories, September 23, 2014. http://thefecaltransplantfoundation.org/patient-stories/.
Laurie Tarkan, “Arrogant, Abusive and Disruptive—and a Doctor,” The New York Times, December 1, 2008.
Sandra G. Boodman, “Doctors’ Diagnostic Errors Are Often Not Mentioned But Can Take A Serious Toll,” Kaiser Health News, May 6, 2013.
Laurie Tarkan, “Arrogant, Abusive and Disruptive—and a Doctor,” The New York Times, December 1, 2008.
personal recollection, KB.
Laurie Tarkan, “Arrogant, Abusive and Disruptive—and a Doctor,” The New York Times, December 1, 2008.
Confidential personal communication to MMEJ
Personal recollection, KB
Farley Mowat, Wikipedia https://en.wikipedia.org/wiki/Farley_Mowat.
CHAPTER 7
The “Poor Me” Syndrome
You don’t want a doctor who is unhappy with the job and the odds that you may wind up with one appear to be increasing. Perhaps you can understand the situation better by looking at the size of the problem, some reasons for it, and some of the potential consequences. While understanding the situation may not overwhelm you with sympathy for the doctor suffering from this “poor me” malady, it might help you to avoid some real health risks on your way to finding a doctor who better appreciates uncertainty.
Most doctors claim that they chose their career for noble reasons, although definitions of nobility vary. The claim to care for one’s fellow humans is pretty common, but expectations of a higher than average income, prominent social status, general respect, and admiration of family and peers are also pretty high on many doctors’ lists of reasons for choosing a medical career.
Whatever their expectations were when they started out, a lot of doctors no longer like their job. There is a catalogue of complaints—overwork, underpay, lack of respect, fear of lawsuits, pressure to over-test, bloated schedules, cumbersome electronic medical records, etc. In a survey of twelve thousand physicians only six percent described their morale as positive.64 Sandeep Juahar, author of Doctored, says, “American doctors are suffering from a collective malaise. We strove, made sacrifices—and for what? For many of us the job has become only that—a job.”65
Many doctors feel that they are victims of a failing system, forced to compromise their practice standards, and pressured into a profit driven style of health care that they do not enjoy and is different than what they expected. Those feelings are proliferating; there are more and more unhappy doctors. Fifty-eight percent of two thousand physicians surveyed several years ago said their enthusiasm for medicine had been on the wane for five years; eighty-seven percent said their morale was sinking.66 Over one eight-year period the number of doctors who doubted that they were in the right profession increased from around ten percent to nearly half. A lot of a thousand-plus doctors questioned in 2009 said they had
moderate to severe problems with feelings of isolation, work-life stress, or dissatisfaction.67 The long list of reasons given for disintegrating doctor job satisfaction is readily condensed to just two—time and money.
There are two parts to the time problem—too little of it and too little control of how it’s spent. Doctors complain that the excessive commercialization of health care has turned their lives over to managers. Doctors are providers, a resource to be optimally deployed to maximize efficiency. Terms and phrases like those are relatively recent additions to the health care conversation. Demands to get more patients through the system faster have dramatically shrunk the amount of time a doctor actually spends with a patient. Couple that with the time spent documenting virtually everything, contracting with a variety of payers, and desperately trying to establish a meaningful relationship with a clunky electronic medical record, and one might start to feel like a lot of physicians who said to Jay Crosson, vice president of professional satisfaction for the American Medical Association, “I used to be a doctor, now I’m a clerk.”68
When doctors are asked what about their practice other than money gives them the greatest feeling of satisfaction, most answer things like, “relationships with my patients,” “making a difference in peoples’ lives,” “providing good medical care.” But those things take time, and there is a pervasive notion that the basic principle driving medical practice is, “time is money” and so a commodity that must be doled out with careful attention to the economics. It’s not surprising that around half of 7,200 doctors surveyed by the Mayo Clinic in 2012 reported at least one symptom of burnout (formally defined as a combination of emotional exhaustion, feelings of depersonalization, and decreased sense of personal accomplishment).
What are these thieves of time that rob doctors of the satisfaction they expected from their profession? As we said above, one is the demand to see more patients faster; half of practicing primary care physicians spend less than sixteen minutes with each patient they see.69 Many think that number is shrinking. Some visits don’t require much time, especially for a patient whom the doctor knows well. But establishing that critical relationship starts with a thorough history and physical examination. It’s not obvious what kind of a history and physical examination can be done in less than sixteen minutes, but it is virtually certain that such an effort would not have met with Professor Osler’s approval. Stanford physician and author Abraham Verghese makes the point most elegantly in his TED talk “A Doctor’s Touch.”70 The process of taking a history and doing a physical exam is about more than getting information. It is an essential part of creating that “relationship with a patient” that doctors claim is a main source of their job satisfaction. And it takes time!
Then there is the eternally proliferating “paperwork,” the requirements for highly specific and complete documentation of absolutely everything that a doctor does or thinks. That, too, takes time. Two-thirds of primary care providers spend ten hours or more each week doing paperwork and administration. One could do at least ten Oslerian-level patient histories and physical exams in ten hours. The electronic medical record and other wonders of the information age that promised doctors freedom from the burden of paperwork have turned out to eat up even more time. There are many reasons for that and, in the long run, electronics will make doctors more efficient, but the growing pains are excruciating.
The “poor me” doctor also believes that she is being underpaid and strongly suspects that the lion’s share of the patient care dollars that she generates goes to administrators, managers, and other business types. All but five percent of the explosive growth in the health care workforce in recent years has been more administrators, not more doctors.71 That may be one reason why half of practicing doctors do not feel “fairly compensated” for what they do.72 They think that they are being ripped off by the suits. In fact, some believe that the serious time problem driving doctors to burnout is at root a money problem. Has medical practice metamorphosed from a caring activity with doctors’ relationships with patients as a core value into an essentially commercial enterprise managed by generously compensated suits and driven more by the health of the bottom line than the health of the people responsible for paying the bill?
Some people think that’s true (other books have been written on the subject), but let’s focus on doctors’ incomes. Are the half of practicing doctors who feel underpaid all suffering from the “poor me” syndrome? Well, there are almost certainly doctors who are not fairly compensated for what they do, and some fraction of those who believe that to be true no doubt have a case. But consider some facts. In 2015, the average annual salary of a primary care doctor was $195,000; for specialties the number was $284,000. Incomes exclusively from patient care ranged from $189,000 for pediatricians to $421,000 for orthopedic surgeons. Data from 2009 indicate that cumulative lifetime earnings were about $6.5 million for primary care doctors and more than $10 million for specialists. Granted, doctors spend many years and many dollars (often borrowed dollars that must be repaid) getting educated and trained, and there are plenty of people in our country who invested a lot less time and money preparing for their job and yet make a lot more money than doctors. Sandeep Jauhar, quoted earlier, points out in Doctored that people who choose medicine have a lot of other career options where they could make more money and there is some truth to that. However, median household annual income in the U.S. is currently about $50,000.73 That means that there are plenty of people whose income is less than that. And unpaid medical bills are the leading cause of this year’s two million bankruptcies.74 You will probably have trouble feeling a lot of sympathy for a doctor complaining about a $200K salary, not to mention for the half million dollar a year orthopedist. We agree with Dr. Jauhar that if minimizing educational requirements and maximizing income are very high on one’s list of criteria for choosing a profession one should probably look somewhere other than medicine. But doctors are assured plenty of income to support a very good life regardless of their areas of practice; they live better than most of their fellow countrymen. You should be wary of the doctor who complains too loudly about the salary that goes with the job.
There are a lot of reasons why you don’t need to feel too bad for the doctor who doesn’t like her job, no matter how miserable she sounds. For one thing, a secure and well-paying job these days is not to be taken lightly. And, after all, doctors are not indentured servants. Medical skills are marketable and there are still many professional options in this country. If a doctor feels that her practice is demeaning, insensitive, and over-demanding, perhaps she should consider looking for another job.
Martin Karnovsky and Janis Finer both did that.75 Dr. Karnovsky, a sixty-one-year-old internist in Chevy Chase, Maryland, was seeing patients every fifteen minutes. He hated it. He worried that he was missing important things and knew that he was short-changing the people he was trying to care for. He worked with a consultant who helps doctors switch to a concierge model and reduced his patient load from 1,200 to four hundred who pay more for longer visits and twenty-four-hour access to him; both he and his patients are happier. Dr. Finer, a fifty-seven-year-old primary care doctor in Tulsa left a busy practice for full time work in a hospital (she became a specialist known as a hospitalist) with predictable hours, every other week off, and increased pay—more time, more money. There are many such examples. Doctors have skills and knowledge that are valuable in the marketplace and they can take control of their professional lives if they choose to.
There are some other, perhaps more unusual options. If a doctor who is unhappy with the profession really wanted a job where she could take the time to practice medicine that connected with people and favorably affected her life, she could check with Dr. Victoria Sweet at the Laguna Honda hospital in San Francisco.76 Slow medicine, Dr. Sweet called it in her memoir, God’s Hotel. Dr. Sweet took as much time as she needed to care for the penniless drug addicts, schizophrenics, and ailing elderly at Lagu
na Honda. And it worked for both Dr. Sweet and her patients. She felt good about her job and she saw things other doctors had missed.
For example, there was an elderly patient who had had recent hip surgery and who was diagnosed with Alzheimer’s disease at another hospital. She was given antipsychotic drugs and taken from her home and her mentally disabled daughter. Dr. Sweet took some time with the patient and realized that the problem was not mental deterioration, it was pain from her replaced hip slipping out of its socket. Serious pain can occupy so much of one’s brain that normal functions don’t work as well. But it takes time for a doctor to discover that.
So a position at a place like Laguna Honda might be good therapy for the “poor me” syndrome. It could solve the time problem. The salary might not meet expectations, but it would be plenty to live on well enough and, hey, nobody ever promised Utopia. If more doctors tried slow medicine they might discover something good about themselves and their profession and all of us might benefit.
There are several practical reasons why you don’t want any of the chronic complainers for your personal doctor if you can avoid it. For one thing, visits to such a doctor will not make you happy and that matters to your health. Both your attitude and that of your doctor affect the outcomes of your interactions for better or for worse. Danielle Ofri, author of What Doctors Feel: How Emotions Affect the
Practice of Medicine, says that patients of high empathy doctors have 40 percent fewer severe complications of their diabetes than patients of low empathy doctors.77 Forty percent! That’s as good as you can do with intensive medical therapy. So, you would do well to avoid an unhappy doctor because that relationship will make you unhappy and your health will suffer as a result.
Unhappy doctors also make more than their share of mistakes. The last thing you need is a consequence of a medical error, and avoiding that is hard enough even with a happy doctor. Somewhere between fifty thousand and two hundred thousand people die each year in American hospitals of preventable medical errors;78 patient harm has been said to be the third most frequent cause of death in the nation. Those errors are not committed by institutions; they are committed by people. Some of those people are doctors and it is very likely that many of the guilty parties are prone to being distracted by worries about the things that are wrong with their job; distracted doctors make mistakes.
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