Sunday, December 21, 2014

How do we restore appropriate doctoring?

kw: book reviews, nonfiction, medicine, ethics, doctors, memoirs

In all the various stories I have gathered of troubles I have had with or about medical doctors over the years, the problem has always been competence, not ethics. If the experiences Dr. Sandeep Jauhar has described are truly typical, it seems I've been quite lucky. His new book is Doctored: The Disillusionment of an American Physician. The main title is a reflexive jest, because he was the one "doctored", or taught, through his experiences. He got an attitude adjustment, and not one that I would applaud.

General Norman Schwarzkopf said (I paraphrase), "Hardly anyone goes to work daily expecting to do a bad job." In the same way, very few begin a medical career intending to do harm or to get rich off the poor. In his former book Intern Dr.Jauhar described his trials after completing medical school and entering residency. There, he was the abused one, and he harks back to those days a few times in Doctored, when he meets residents and interns who callously take advantage of new ways of doing things, going home at the end of a shift, regardless what is happening, seemingly without caring a whit for the patient being handed off to the next shift's physician. While he never saw one stand up in the midst of CPR because "it was time to go home", but it almost came to that.

To become a family doctor these days is the fastest way to get into practicing on one's own, but it still takes a good while: four years of medical school and at least two years of residency, and perhaps a year or two of fellowship. At the earliest, a newly minted family physician can begin practice, whether privately or with an organization, by age 28 or 29. Dr. Jauhar is a cardiologist. The residency was longer—I am not sure whether he did one or two—and he performed a few years of fellowships before being hired as the attending cardiologist at Long Island Jewish Medical Center at age 36. This accords with the experience of a family friend who also got free of his "education" at age 36 and is now in practice as an orthopedic surgeon.

When you are pushing 40 and have a quarter-million in education loans to pay off, it's hard to make ends meet, even if your pay is well above the national median of $52,000. The book covers a period of about eight years, just the right span of age for most of us to get around to having a midlife crisis. Dr. Jauhar didn't really have time for a midlife crisis. He had a career to jump-start, and soon found the jumper cables were badly frayed. We read a lot about his wife's increasing distress as their savings dwindle after one child is born, and then when another is on the way.

Urged, berated, and nearly bludgeoned by his wife and by circumstance, he began to work part time for another doctor who is in private practice. He soon learned that is it all about business. He didn't have the heart, or the right way of thinking, to do well in business. Ask a doctor why there are so many tests ordered these days, and why nearly everyone gets the same tests regardless how sick they are. The standard answer you'll get is likely to be something about "defensive medicine", the need to "cover all the bases" to avoid litigation. The answer you won't hear is that the insurance companies pay better for some tests than others, and it is the high-dollar ones that are the most overused. Dr. Jauhar found himself "doing scut work for peanuts", to use a phrase he doesn't use, but that I've heard from others. Though he could now make ends meet, he felt he was beginning to lose his soul, helping a doctor game the system and get rich at the expense of the American public.

Make no mistake about it, we all pay for unethical medicine. Most of Medicare is paid for by a payroll tax, and its losses are covered out of the general Federal budget, from taxes we all pay. Insurance companies are not in business to subsidize health care, and must indeed make a profit, so premiums increase and increase to cover the actual costs they incur. Don't pay any mind to a few blind guides who boast that American medicine is the best in the world. Yes, there are a few areas in which treatments in America are the most effective, but in general we pay more than twice as much per capita as in any other developed nation for the thirtieth or fortieth best medical system.

The book is in three parts, titled "Ambition", "Asperity", and "Adjustment". In the end, he adjusted. That, I find rather sad. He got doctored all right. I remember once remarking that a good subtitle to the musical Grease would be "The corrupting of Goody Two-Shoes." Here, I cannot say Dr. Jauhar has been corrupted, not quite, but he has to admit there is a stain on his soul. The incentives built into moderm American medicine, which will be only partly relieved and otherwise exacerbated by the Affordable Care Act (AKA "Obamacare"), practically force a doctor to defraud the system to make a living, and yield incredible riches to those most adept at doing so.

I recall the "traditional" insurance plans called "Major Medical." Patients were expected to pay out of pocket for all the ordinary stuff: doctor visits or office visits (in a day when the doctor visited you a third of the time), and most pills or shots. If you needed something less ordinary such as setting a bone, or sutures, or an operation, the Plan paid 80%, and rates were such that most middle-class Americans could afford their 20%, maybe with a little short-term loan. Now that insurance plans purport to "cover everything" (It's not true, but that's what they advertise), where is the incentive for anyone to economize? When everyone pays thousands and thousands yearly for their medical plan, they feel entitled to go to the doctor for every little thing, and they're OK with the doctor ordering dozens of tests of all sorts, because "the Plan will pay for it". The next year, premiums go up, and the few who are wise realize that once "the Plan" has paid, it has to get the money back, and premiums are its only source of income.

Our system isn't just broken, it is devastated. Dr. Jauhar doesn't have much in the way of solutions to offer. I do. Vote with your feet. Get your "ordinary doctoring" from a local physician. If you need something major, assuming you're capable of travel, go to India or England or somewhere else with one of those 30-40 medical systems that outperforms ours, where you'll pay less at full price, including your travel costs, than you would for the "Co-pay" demanded by the hospital here. Medical tourism is on the increase, for good reason. If enough of us do so, the American medical system will respond to the only force mighty enough to change it: Competition.

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