There's one story in Sandeep Jauhar's new memior Doctored that I can't stop thinking about.
Jauhar, a cardiologist in Long Island, writes about a 74-year-old patient named Mildred Harris who was "frail and virtually bed-bound." Harris had been referred to him for an examination prior to surgery, by another cardiologist who didn't have admitting privileges at his office. That cardiologist had referred Harris for surgery and needed Jauhar's sign off. But after examining the patient, he decided the procedure was too risky for someone so frail and called the procedure off.
It happened anyway — mostly because it was good for business. The other cardiologist (the one outside the hospital) had asked the surgeon to go ahead — and the surgeon, who got lots of referrals from that cardiologist, didn't want to tarnish the relationship by declining this one. "Adelman [the other doctor] sends me a lot of business," the surgeon explains to Jauhar. "I don't want to lose it."
It's scary to think about being that patient; I certainly wouldn't want to have a surgery my doctor thought was unnecessary only to solidify another doctor's financial relationships. It's scary, but also not unique: there are dozens of examples like this in Jauhar's book that he argues are leading to a collective malaise among America's physicians.
"In the mid-20th century, physicians were the pillars of any community," Jauhar recently wrote in the Wall Street Journal last week. "If you were smart and sincere and ambitious, at the top of your class, there was nothing nobler or more rewarding that you could aspire to become.
"Today, medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future."
Jauhar and I spoke Friday about why American doctors are frustrated, what role their salaries play, and whether Obamacare can alleviate some of the problems. What follows is a transcript of our discussion, lightly edited for clarity and length.
Sarah Kliff: One of the most impactful statistics you cite in your book is that only 6 percent of physicians say they have positive morale. Do you think that's different from other time periods and, if so, why?
Sandeep Jauhar: Satisfaction in medicine has probably been somewhat variable and even cyclical. I think we happen to be at a very low point right now. If you look back in the 19th century, there were moments when dissatisfaction was very high. People were unhappy with doctors, and their business was being cut into by quacks peddling snake oil.
American medicine went through a hallowed period in the 1950s. Doctors were not only incredibly well-respected but there were so many tangible improvements in medicine with the advent of technological innovations like coronary bypass surgery.
In the Wall Street Journal, I trace some of what you're seeing now back to the advent of Medicare. Medicare didn't end up cutting into doctors' income; their income actually skyrocketed. But that lead to a backlash against fee-for-service, and that lead to managed care. And that led to all the restrictions we have now on doctor's autonomy.
SK: This was something that jumped out at me right away in the book, that you almost seemed a bit nostalgic for the world of fee-for-service medicine, where doctors got paid for each service. But in the health care world, there's a lot of thinking that this is a terrible way to pay doctors, because it encourages unnecessary care.
SJ: It was nostalgic in the sense physicians were undoubtedly happier in that era. There were also, obviously, a lot of downsides to that way of practice. There wasn't as much evidence-based medicine, and there weren't the technological innovations that we have now. Also, the vast majority of patients were not insured.
You can't go back to that model. Health care is too expensive today, and you have to have insurance. But I think that today, patients are suffering from different problems, equal or greater in scope. Now, they're benefiting from the pacemakers and defibrillators and stents, but they have chronic illnesses handled by a team of physicians that don't coordinate their care. This has created a highly fragmented environment.
One of the things I always get asked by my patients is, are you going to talk to my other doctor? Because a lot of time you have specialists for each body part, but they're not talking to each other.
SK: One of the parts of your book I found most disturbing is about how referrals work. Your experience seems to suggest that referrals are a lot about money and relationships, and that a lot of follow-up care and tests are unnecessary. Why do doctors accept referrals for procedures that they don't think are necessary?
SJ: There's an etiquette. If someone asks you to see a patient, and you refuse, you're never going to get a referral again. Your business could dry up. I'm not under nearly as much pressure as an interventional cardiologist [who does surgeries]. What are you supposed to do when you feel like the patient doesn't need the care? It's a conflict that has to get resolved, and sometimes the physician who is being referred to just acquiesces.
SK: The case that jumped out at me in your book the most was the old woman who you didn't think should have surgery, but she did anyway, mostly because another cardiologist seemed worried about losing out on the surgeon's business. It's a scary situation to think about as a patient.
SJ: It is scary. That case did have a discretionary element. I wasn't 100 percent sure I was right and that the surgeon was wrong. I, as a cardiologist, was saying, we shouldn't do anything, but we ended up doing it. She did end up fine with the surgery, in the end.
Would she have done the same, or better, without the surgery? We don't know. That's another thing about medicine. So much of it is discretionary now. We don't have strong evidence in many situations about the right way to do things, and you can argue it either way.
SK: One of the things you write about in your book is the financial pressures that doctors face, and how it's not a cushy profession.
When I was reading that part, I couldn't help but think of a study I'd seen earlier this summer, showing that nine of the top paying professions in the US are all in health care. So I'm curious how you reconcile those two things, the type of financial pressures that you describe facing and the fact that doctors do earn more than pretty much any other profession?
SJ: I think that income is a small part of doctors' woes. Theres no question that doctors earn healthy incomes. What they have to do to earn that income is often appalling. To earn a $150,000 to $200,000 salary, which is a healthy salary that primary-care doctors make, you have to run on a treadmill. You're seeing 25 to 30 patients a day.
These figures don't include the educational debt that some of my colleagues have, which can be nearly $500,000. The amount of pressure and risk that you take seeing patients for eight to 10 minutes per session, the educational debt, the fear of getting sued, all of that has created a climate of dissatisfaction.
I agree with you that doctors generally make healthy incomes. They certainly make more than European doctors, but European doctors don't have all the educational debt, and they don't work as hard. I've had friends go abroad, and they talk about taking hour-and-a-half lunches. They don't do that here.
SK: This might be a really simple question but, why not? It sounds like if doctors worked less, they would earn less, but be more satisfied with their profession.
SJ: That's what I'm doing. I decided to take a salaried position, because I didn't want to compromise my ideals. There was a time in my life when, with debt and with a new family, I just couldn't make ends meet.
You can argue why can't you make ends meet with your salary? I couldn't, and I had to look for a second job [moonlighting on nights and weekends in a private cardiology practice]. I personally think that the way out of this mess is to focus less on money, less on the bankers making millions, and really focus on our professional ideals. I personally think that doctors would be happier on salary.
SK: Are you optimistic that things will move in this direction? Or that the treadmill will just speed up, and force doctors to see even more patients in shorter time periods?
SJ: I'm optimistic. Like with my own personal crisis, I had to hit rock bottom that got me out of the mess. That is a metaphor for medicine. I think we're at the low point.
I'm surprised that I've had a lot of colleagues who applauded the book, who have stopped me in the hallway and said, "You wrote exactly what I'm thinking." The book paints a system that is really bleak and broken. When you get into a highly broken state, things can only improve. And my hope is people will read it and understand some of the drivers of disease in the system.