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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.
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Paul Schrodt is a writer living in New York City. He has contributed to New York magazine, Radar, and Esquire.com.
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Abraham Verghese is a Professor of Medicine and the Senior Associate Chair of the Department of Internal Medicine at Stanford University. He is a graduate of the Iowa Writers Workshop, and his work has appeared in The New Yorker, Atlantic Monthly, The New York Times and many other venues. He has written three books, most recently the novel Cutting for Stone, which was just published by Knopf. His web site is Abrahamverghese.com.
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Abraham Verghese is a Professor of Medicine and the Senior Associate Chair of the Department of Internal Medicine at Stanford University. He is a graduate of the Iowa Writers Workshop, and his work has appeared in The New Yorker, Atlantic Monthly, The New York Times and many other venues. He has written three books, most recently the novel Cutting for Stone, which was just published by Knopf. His web site is Abrahamverghese.com.
Granite
What about the stranglehold the AMA has on medical schools to limit the number of future doctors? Keeping doctors scarce increases doctors incomes.
What about predatory lawyers who advertise relentlessly on television to sue for millions over the slightest medical error? Malpractice insurance is so expensive that doctors are almost forced to go into high-paying specialties, or safer (malpractice resistant) specialties like dermatology.
I don't know that this mess will be solved anytime soon.
Embers
Granite, I was going to say the same thing about the AMA. Everytime someone wants to open a new medical school, the AMA squelches it. Medical school might cost less if there were more schools and more competition.
When healthcare is too expensive for people to afford, you've got to question the morals of a lot of doctors. They shouldn't make a high salary just because they went to school so many years or have so much debt. A lot of people go to school for years and graduate with debt, and they don't demand these huge salaries.
Even the doctors who mostly see Medicare patients are still making pretty good money.
When a doctor charges you these enormous fees, of course you're going to be angry if that doctor makes a mistake, and you're going to sue the crap out of him. Duh!
cleo123
I am a nurse practitioner. There is no mention here of how we can help in this healthcare crises. We provide great primary care, are empathetic and willing to listen to our clients. Research has shown that they perform just as well as general practitioners. Problem for us is that the AMA fights us at mostly every opportunity for trying to take over primary care, something they are not interested in anyway.
amragar
Dr. Verghese :
I'm so thankful you wrote this. I thought about the same "year of service" idea during the Obama campaign.
Not only do the specialiteis draw away much needed financial resources, but the lucrative salaries also attract the best and the brightest medical students/residents. Instead, the best and the brightest should be going into primary care!
Jstyxx
I'm sorry, but the above posts show a complete lack of the concept regarding physicians and pay.
Do you feel teachers (K-12) make too much? Personally, you cannot begin to put a price on the cultivation of a young mind because don't know what that person will accomplish. So what's worth to you for your child's education. I know I would pay whatever it takes to get the best for my child which is why most people would prefer to send their children to private school.
The same is true for health care. If you think Physicians make too much then learn about the most complex machine ever, then try to figure out how to correct the problems that arise. Wouldn't you want the best person? Well, the way this world works the nicer the nice, the higher the price and you do get what you pay for.
I agree medical school is expensive and tuition needs to be come down. That would allow future physicians to choose specialties they like versus ones that can repay their student debt in the least amount of years. However, you need to think clearly about the rationale physicians make too much money because most people only think about that after they are well and they receive the bill.
SalamaSeed
"Even the doctors who mostly see Medicare patients are still making pretty good money." -- Seriously? Go talk to a doctor that acutally spends more than 15 minutes with a patient on Medicare, and see if he/she is surviving.
Medicine is unlike any other profession. The product that is being produced is health. Doctors are dealing with PEOPLE. Not cell phones, car engines, or a burger and fries. They are held to a higher standard because of this, but mistakes will still be made. Only when you make a mistake with a person's life and health it can't be sent back to be cooked a little more.
Johnnorth
That's a brilliant idea for Peace Corps type of assignment. Will any of those clowns in Congress take it up? People like Barney Frank and Chris Dodd are too busy covering up their own role in the financial bust to pay attention to the big issues Dr. Vergehese raises
ryokisan
This is a little bit ridiculous. As someone who works in this environment I can tell you that the purpose of electronic medical records is NOT to take the physician or the caregiver out of the equation in any way. It is to allow the information gathered during a patients visit to be legible and durable. In the long term, interoperable so that if the patient is seen in several places that providers can easily access their previous record quickly and get information they need to treat.
I believe this is also generational. Studies have shown that older people do feel that they computer is a distraction from the care they are recieving whereas younger people feel that the hosptial/office is 'behind' or 'old fashioned' if they don't have a computer. Yes, it can be an issue when the computer gets in the way of personal interaction and communcation but that is not the purpose nor the fault of the electronic record.
Furthermore, maybe this wouldn't be such an issue if so many doctors weren't going into speciality care fields b/c they can make so much more money at them than primary care. I agree we need more primary care physicians and support for them but that has nothing to do with the electronic health record. They should be our allies in it.
tibca1
Funny thing-the LAST thing I need is a Primary Care Physician. Mine never writes referrals to specialists, makes me wait 45-60 minutes, and when I went to the ER and was diagnosed with Diabetes, wanted to stick me on insulin. Luckily, I went to the Internet, found a good Diabetes specialist and kickec my A1C from 13 to 5 in 6 months-no thanks to my primary doctor! I would love to switch, but most of the docs in my area do not like my insurance.(Pacificare) How I wish for a single-payer plan, where I can see my Diabetic doc more than 3 times a year.....
stevecaplan
As a physician, I am amused by the idea of "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". Apparently, Dr. Verghese isn't aware that this has existed for more than a century: it is called an internship. Generally, one works for subsistence wages (barely enough for room and board, not enough if you have children), due to the massive loan payments that become due the moment one graduates from medical school, but is not allowed to practice for one to several years more, depending on the field (primary care generally requires three years of internship/residency).
Embers
Well saleema whatever, I have worked with doctors and for doctors and I know what I'm talking about.
I didn't say anything about K12 education either. I am a teacher. I went to school for many years and we don't get bonuses or 100k salaries. Even the crappiest doctor in town here makes at least 100k. And if a doctor is able to pay for their office, equipment, staff, etc. and STILL take home over a hundred thousand a year, then perhaps doctor's fees are too high.
People always get upset when you dare to question doctors.
Embers
Jstyxx:
"However, you need to think clearly about the rationale physicians make too much money because most people only think about that after they are well and they receive the bill."
Uh, no. If you're sick and try to get care without insurance, see how you're treated. Doctors DO NOT deserve to earn a high salary simply because they are doctors. What about healing people and helping their fellow man? Someone who earns a lot of money isn't necessarily the best doctor. Grow up.
AndreainNY
Doctors are among the brightest in our population. They are entitled to earn more based on the expertise they acquire in school and in practice. There is a significant barrier to entry in the medical profession -- ex., admission to medical school -- unlike the few barriers to entry in teaching.
It is foolish to say that doctors shouldn't make more than teachers.
shreward
As a primary care PA I can agree with much of this article. Many of my classmates are making at least 1/2 again of what I am making. I have thought about these higher paying specialist positions and have considered switching. Growing up in rural south alabama I saw a need for primary care and choose to enter this field.
As for the 'peace corp type' program...It already exists. It called the National Health Service Corp. I was awarded this during my first year of school. It provided me a stipend during these years and paid for 100% of my medical education. In repayment I serve 2 years in medically underserved areas in a 'primary care' speciality. This is internal med, ob/gyn, family practice, or peds.
With this existing program, I could move to the area that I love, practice what I love to do, and afford to do so. These programs exist if medical students wish to do the repayment. Not everyone gets them, but they do exist.
LindaA1
Generally, doctors make between $160,000 to $200,000 a year. Speciallists in certain fields make much more. I can't lose a lot of sleep over the plight of financially poor doctors.
As for electronic medical records, the good side is the access it gives caregivers to our histories. The two obvious downsides are the loss of privacy (what's not already lost) and the natural reliance of doctors to treat by computer instead of utilizing the irreplaceable hands-on care.
It's a done deal and we may as well get used to it. Younger doctors are going to do as much as possible on the computer. I've had occasion to be in the emergency room on several occasions lately - and in our local hospital, each patient has a clear view of the nursing station.
I've watched doctors and nurses spend the vast majority of their time at the computers, not in the rooms dealing with patients one on one. My own doctors and nurses would pop into the room almost only to verify that the info on the computer was correct (often it was not).
It's impossible to miss what's happening to medicine with the institutionalization of more and more electronics. Unless we train doctors to keep their patients on the par of real sick, hurting, often cantankerous people instead of the more appealing antiseptic computer screen, we can kiss our medical standards even further goodbye that we already have.
Thank you.
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