article

03.24.09

Health Care's Next Crisis

Digitizing medical records may be a cornerstone of the Obama health-care plan but Abraham Verghese argues it misses a far greater problem: the shortage of primary-care physicians.

President Obama’s proposal to solve the nation’s health-care woes includes a plan to commit billions of dollars to “digitizing” medical records. Incredibly, there is much more money flagged for that goal than for easing the critical shortage of primary-care physicians. That suggests to me that there’s a voice not being heard in this debate. It’s not the voice of Medicare or insurance companies or organized medicine--it’s the patient’s voice.

If health-care reform puts billions of dollars into programs that add more computer screens and create more iPatients, but does nothing for the true care of the patient, things will only get worse.

The patient’s voice, alas, is difficult to hear even in our hospitals, because the patient in the bed is overshadowed by machines and activity; the anxious soul under the covers has become a mere icon for the “real” patient in the computer. Indeed, the “iPatient” (my term for this virtual patient entity) has never been better cared for: buffed up and polished, with pop-up flags telling physicians when to feed and bleed and send postcards to bring them back to the office. And if health-care reform puts billions of dollars into programs that add more computer screens and create more iPatients, but does nothing for the true care of the patient, things will only get worse.

Real patients will tell you they want real, live physicians. Most diagnoses can be found in the patient’s history, in the story the patient has to tell. But you can’t hear it if you aren’t listening, and you can’t listen if you’re staring at the computer screen. You have to be with the patient to hear their story; the telling is important. Real patients want someone whose examining skills, when combined with common sense and sound judgment, can spare us the costly, blind, shotgun, ‘tick-all-the-boxes” kind of testing and imaging that has come to be the American brand of medicine. We want a doctor who orders tests judiciously, who calls in specialists sparingly, and who rides herd on them and weighs and translates what they say. What we want, in other words, is a primary-care physician.

A bank collapse, an auto-industry collapse, hurts the pocketbook and is easily measured. But the dwindling numbers of primary-care physicians is just as devastating and will cost us even more in the health of our nation. That‘s the crisis we are facing. Instead of pouring money into “digitizing the medical records,” we need to rescue primary care.

Medicare (and therefore insurance companies) reimburses doctors in a way that creates a disincentive for listening to the patient, a disincentive for thinking. Doing, by contrast (cutting, poking, probing, scoping, scraping, freezing, inserting, shaving, biopsying, lasering, tightening, injecting, imaging), pays a lot more than thinking. Our graduating medical students carry huge college debts and are forced to be pragmatists. If they go into primary care, they know it means long hours, vanishing amounts of time per patient, and an income that is one-fifth to one-tenth of a classmate who picks a procedure-based specialty. It’s not much of a choice. It explains why dermatology has become hugely popular as a specialty. But the earning incentives continue to corrupt long after graduation. I am amazed that we physicians can own MRI and CAT-scan facilities and infusion centers, yet really think we can be objective in ordering tests or prescribing infusions that send patients to our own facilities. We are likely to resist solutions that better the lot of patients if it means taking our fingers out of the pie and money out of our wallets—in that sense we’re part of the problem.

In most European countries, the government subsidizes medical education. Even if doctors there don’t make supersized American-style incomes, they also don’t finish training in their thirties with a mountain of student loans, feeling pressured to earn as much as they can as quickly as they can to pay down the debt.

Instead of pouring billions of dollars into programs that add computer screens, here’s my suggestion: Let’s put in place a mandatory year of national service for graduating medical students, a Peace Corps-like initiative where students work in areas of America that have the greatest need for primary-care physicians. In return, the government will erase or substantially reduce their debts. This will do two things: First, it will provide a critical annual infusion of primary-care physicians into our health-care system, and second, it will cause a few young physicians to discover that caring for a small community is the kind of medicine that suits them. Those students who choose to could be allowed to buy their way out of this year of service, but they will find that students who did the year of primary-care service are given priority when applying for postgraduate training (particularly in dermatology!).

Health reform must take away the incentives to do to and replace them with incentives to do for the patient, to be with the patient. As the debate heats up and the lobbyists warm to their tasks, let’s listen to the patients, because they can tell us what’s wrong. Yes they can.

Abraham Verghese MD is Professor of Medicine, and Senior Associate Chair for the Theory and Practice of Medicine at Stanford University School of Medicine. His latest book, a medical epic, is Cutting for Stone , published by Knopf.