ASLEEP AT THE WHEEL
Why Your Doctor Doesn’t Listen to You
Assembly-line patient visits, poor care for the chronically ill, stacks of paperwork, and endless red tape: This is the life of the American physician.
Victoria* was a teenager when a car struck and almost killed her. A major surgery requiring plastic mesh sewn into her belly saved her life. Soon after, her skin erupted in painful rashes that refused to heal.
She consulted specialists all over the country, but they couldn’t help her. They told her they didn’t know the cause of her rashes, but there was no evidence for rashes related to implants. At one point they even told her she was delusional, despite her diffuse ulcerating lesions. After a decade of searching, Victoria found a physician who’d seen patients with unusual symptoms under similar circumstances. After he removed the plastic implant, her skin cleared up completely.
As Victoria spoke, my heart broke as it does every time I hear stories of patient neglect. The week before, a young man named Jack* told a similar story: an accident, then an illness followed by years of debilitating symptoms that forced him to travel the country consulting specialists looking for an answer that never came—until he found a doctor who listened and she began to work with him to find a way to heal.
These stories will come as no surprise to anyone with a chronic illness. All too often, we conventional physicians dismiss patients with unusual complaints or simply ply them with medicines. Of course, the medical community can’t develop a new “evidence base” if we ignore our patients. It’s an insane medical Catch-22, and patients are getting fed up. Now, instead of turning to the once trusted physician, many Americans are spending billions on alternative and complementary medicine.
Is the medicine we practice simply no good, or are the doctors to blame? The answer might be both.
It’s widely accepted that conventional medicine frequently fails to help people with chronic ailments. It’s set up to fail, as most clinics function as dehumanizing assembly lines better suited for manufacturing cars than treating people. While health care consultants insist on finding ways to enhance “efficiency,” efficiency and assembly lines only make sense if we know everything there is to know about how the body functions—but we don’t.
It’s a well-known fact that many patients don’t fit our heuristics. Instead, they have weird, unrecognizable constellations of symptoms—and most doctors don’t have the time to deal with it. If we do anything for them at all, we might scan or scope them, send them for referrals, and then finally send them away with a printout explaining fibromyalgia or irritable bowel syndrome or other similar diagnoses. Doctors are then on to the next patient, and between patients they are distracted by a towering mountain of non-clinical tasks. Doctors aren’t dumb. They know this is a rotten deal and they are demoralized, running faster and faster with no hope of catching up.
Now The New York Times best-selling book Doctored, The Disillusionment of the American Physician, by Sandeep Jauhar, MD, explores this dismal state of affairs. The book is a memoir that highlights the problem of physician burnout in the midst of our by now decades-long health care crisis. In a recent Wall Street Journal feature, Jauhar neatly details how we got here—how corporate and government intrusions turned a once intellectually stimulating profession into a mind-numbing enterprise. One physician who commented on Jauhar’s article even likened it to slavery. In another recent Medscape article, one physician described himself as a “beaten dog.”
If doctoring these days is akin to a kind of humiliated servitude—and many physicians in their private moments claim that it is—then it’s axiomatic that we need less centralized control and more freedom in order to be more responsive to patients. But Dr. Jauhar, who is a cardiologist and director of the Heart Failure Program at Long Island Jewish Medical Center, seemed to be calling for more centralized control and something he calls “bundled payments” to control costs, akin to the ill-conceived Accountable Care Organizations that many people justifiably believe are doomed to fail.
Many doctors were disappointed—including me. Jauhar is clearly an intelligent doctor and writer who has garnered the attention of important decision-makers. He was putting a spotlight on a problem that needs addressing badly, and yet he seemed to be summoning up the same tired solution we’ve already been trying for 30 years. I concluded that Jauhar had to be another out-of-touch East Coast academic physician.
But I was wrong. When we spoke, I found Dr. Jauhar to be a deeply thoughtful physician whose experiences were remarkably similar to mine, even though we practice on opposite sides of the country. “The last thing I intended was to call for more bureaucratic entanglements or more regulations,” Jauhar said. “I am also a practicing physician and I deal with this stuff all the time.”
During the course of our conversation, Jauhar spoke about doctors burdened with unnecessary paperwork and how it takes away from patient care. In one amusing coincidence, we had both recently been tasked to write a letter attesting to a patient’s need for oxygen. For both of us, it took several iterations—requiring rewrites and multiple faxes— to get the wording precisely right for the oxygen to be delivered. The medical equipment companies, under increased scrutiny of the Affordable Care Act, insist on elaborate documentation to protect themselves in the case of an insurance or Medicare audit.
I point out this trivial example exactly because it is trivial—and it was common to both of us, although Jauhar is a specialist and I am a primary care physician. This is a reckless misuse of physician time and energy. A country that is serious about health reform would not take a limited, valued resource and waste it on nonsense like this. It shouldn’t be a surprise then, when a patient presents with unusual symptoms, the overburdened physician is simply not listening. He may be worried if the fax went through or that a desperate patient can’t get an oxygen tank, and he may give the patient in front of him the usual thoughtless response: “That’s not in the evidence base.”
Physicians are overwhelmed because we are in the middle of a collision of powerful unrestrained forces. In the last 30 years, there’s never been the political will to take on pharmaceutical pricing, exploitative insurance contracting with physicians, tort reform, administration and CEO salaries, payments to home health companies, cost shifting to ERs, the overpricing of imaging services, or patient demands for unnecessary care (a major driver of spending).
Instead of dealing with any of these politically sensitive items, every single one of them has become part of the physician’s to-do list. Overpriced drugs? Make the doctor call in for a “prior authorization.” Concerned about fraud? Make the physician fax over a carefully worded note—three times if necessary. Worried about lack of supervision of physical therapists? Make the doctor sign an illegible six-page treatment plan that he has no expertise in or ability to evaluate. Worried about hospital re-admissions? Dock the physician’s pay. Worried that with all of this stress your doctor may not always be so nice? Arm the patient with a patient-satisfaction scorecard.
To be sure, patients should have some guarantee that when they see a doctor, they will get a basic level of acceptable care—and certainly the instinct to control costs is an honorable one. But does anyone think this litany of tasks is an appropriate use of physician time? If you do, please tell that to the seriously ill woman I met recently who can’t get in to see her doctor until next May.
So, how can we right this ship, given the politically powerful, well-financed parties who are profiting from the way things are now? “If I am to call for anything, it would be a greater emphasis on professionalism. It would be great if doctors could do it themselves, but it’s very hard to incentivize professionalism,” Dr. Jauhar said. “We need to return to a professional core where we put the patients first.”
I think he’s right. But the patient is not “put first” when it comes to corporate medicine. There are too many patients like Jack and Victoria scrounging around for years until they find a doctor who will listen. Indeed, turning all doctors into employees is quite a dangerous proposition. Doctors will be too busy to do anything but mindlessly write whatever prescriptions they tell us to write—while assuring us that it is “evidence based.” And corporations will squeeze the patient visit more—now they are even promoting the absurd notion of the “group visit” to increase physician “productivity.”
Physicians will regain our professionalism when we stop participating in this circus. For most primary care physicians, that will mean turning to direct pay or concierge medicine—because all this interference with the doctor-patient relationship has ended up putting the patient last.
*Names have been changed.