TIME: Almanac 1993/TIME Almanac 1993.iso/time/073189/07318900.002

Text File | 1992-09-23 | 26.3 KB | 499 lines

                                                                                LIVING, Page 48

COVER STORY: Sick and Tired


Uneasy patients may be surprised to find their doctors are
worried too

By Nancy Gibbs


    "I do not know a single thoughtful and well-informed
person," George Bernard Shaw once said, "who does not feel that
the tragedy of illness at present is that it delivers you
helplessly into the hands of a profession which you deeply
mistrust."

    That sentiment is mild compared with some of today's
reviews. Doctor bashing has become a blood sport. To judge by
the popular press, which generally lacks Shaw's subtlety, too
many physicians who are not magicians are charlatans. The air
of the operating room, where once the doctor was sovereign, is
now so dense with the second guesses of insurers, regulators,
lawyers, consultants and risk managers that the physician has
little room to breathe, much less heal. Small wonder that the
doctor-patient relationship, once something of a sacred
covenant, has been infected by the climate in which it grows.

    All this means that it is simply harder to be a doctor now
than it was a generation ago: harder to master the art and the
craft, harder to practice, harder to savor the natural pleasures
of healing. Patients loudly long for the days of chummy family
doctors and personalized care, when Marcus Welby would make
everyone well. But it turns out that the distress is mutual, the
frustration shared. Many patients may be surprised to learn that
the doctors are suffering too. Listen to them tell it:

    "Once most people treated me as a friend and a confidant,"
recalls Boyd McCracken Sr., 65, a family practitioner from
Greenville, Ill. (pop. 5,000), who remembers making late-night
house calls. "These days the malpractice threat has created a
definite wedge between a physician and some of his patients."

    "I think patients have become consumers," says Robert
Rogers, an ophthalmologist in Pompano Beach, Fla. "They are no
longer interested in their doctor, who has perhaps been their
doctor for five, six, ten years. They are really interested in
what it's going to cost them. It's just like they're going
shopping at the local supermarket."

    "I get no sense they trust me," says Jonathan Licht, a San
Diego neurologist. "You tell them, `You're O.K.' They say, `No,
I'm not O.K. I think I have a brain tumor.' Then they keep
asking, `How do you really know?'"

    All across the U.S., among family doctors and brain
surgeons, in large cities and small towns, the tensions are
growing. Perhaps many doctors just miss their pedestals and the
days when their patients were more respectful and their
diagnoses unchallenged. But the soreness may also reflect the
stresses and strains of a profession in transition. Nothing in
medicine is stationary: the blinding speed of technological
advances, the splintering effects of specialization, the onset
of medical consumerism, the threat of malpractice suits have all
bruised the doctor-patient relationship in recent years.

    There are rich ironies here. Never have doctors been able
to do so much for their patients, and rarely have patients
seemed so ungrateful. Eighty years ago, a sick man who consulted
his physician had roughly a fifty-fifty chance of benefiting
from the encounter. The doctor's cheery manner and solicitous
style were compensation for the uncertainty of a cure. "Medicine
originally was mainly talk," says Sidney Wolfe, a physician who
directs the Public Citizen Health Research Group in Washington,
"and very little effective diagnosis and treatment."

    Compare that with the prospects of today's patient: what
was once miraculous is now mundane. The flutist has her severed
hand sewn back on. The man with the transplanted heart goes
skiing. As a society, Americans are living longer and well and
with less to fear from diseases that ravaged whole generations.
Life expectancy has jumped during this century from 47 to 75
years. And yet the physicians, victims of their own success, are
finding that however swift the advance of medical knowledge, it
is still outpaced by public expectations. "The public thinks
that all diseases should be treatable, all disabilities
reparable," observes John Stoeckle, chief of the medical clinics
at Massachusetts General Hospital. "And there should be no pain
and suffering."

    So naturally, the public is far from content. In part the
problem lies with the failure of the profession and the
government to police medicine adequately, since the stakes could
not be higher. If a stockbroker is incompetent, his client may
lose his savings; if a doctor is negligent, his patient may lose
his vision, his memory, his mobility or his life. Though the
public, the government and the physicians themselves have become
more vigilant, the persistent stories of medical mishaps
continue to take their toll on patient confidence.

    The anger and suspicion toward doctors are easy to measure,
even without reading the tabloids or watching Geraldo for the
latest tally of medical misdeeds. When the American Medical
Association conducts surveys of public attitudes toward
physicians, it finds a troubling loss of faith. Even people who
esteem their own physicians often deride the profession as a
whole. In 1987, 37% of those polled did not believe doctors take
a genuine interest in their patients. Only 45% believed doctors
"usually explain things well to their patients."

    A doctor's words may speak louder than actions, but every
patient hears them differently, and doctors end up feeling they
cannot win. When Cincinnati receptionist Doris Roetting had a
mastectomy in the fall of 1987, her surgeon assured her that
she was recuperating nicely. Her oncologist, however, was a bit
more explicit, to Roetting's dismay. He quietly explained that
she had a 90% chance of being alive in five years and an 80%
chance of surviving ten years. Some patients might have been
grateful for such candor; Roetting went home in tears. "I think
everybody who has cancer knows there is a chance they can have
it again," she says. "These doctors should show a little more
finesse."

    Tact and tenderness may be a lot to expect from someone who
must spend roughly twelve years learning the trade, work
impossible hours, be available to patients day and night, keep
abreast of changing technology and live a peaceable life while
constantly dealing with death. "The patient wants the best of
both worlds," charges Lester King, a Chicago physician and
medical historian. "He wants the knowledge and precision of the
most advanced science, and the care and concern of the
old-fashioned practitioner."

    For more and more doctors, that is just too much to ask.
They feel the wrath of their patients and realize the job is not
going to get any easier. A March 1986 survey of physicians in
the Minneapolis-St. Paul area found that nearly two-thirds of
them were "pessimistic about their professional futures," and
a like number said they would not want their children to go into
medicine. Applications to medical schools for the 1988-89 school
year declined 15% from 1986-87, reflecting a contagious concern
about the profession's future.

    As ambivalence and hostility divide doctors and patients,
medical experts are struggling to explain the troubled
relationship and find ways to revive it. Some of the conflict
arises from human nature. How can doctors feel comfortable when
patients come into the office prepared to sue them for
everything they own? How can patients trust a doctor who has a
clear financial interest in prescribing expensive, intrusive and
perhaps unnecessary therapies? When doctors disagree, how can
a patient know whom to believe? Both sides recognize that the
demands of treatment have changed in ways guaranteed to alienate
doctor and patient.

    The most obvious source of friction is the new technologies
that enter into every stage of treatment. Since the end of
World War II, as the science of medicine rapidly evolved, the
craft overtook the art. Many physicians regret that they now
spend far more time testing than talking, which may make for
more accurate treatment but less personal care. The race to stay
abreast of each new development can consume a doctor's every
waking moment. "Technologies have put a kind of emotional moat
between doctor and patient," laments David Rogers, professor of
medicine at Cornell University Medical College. Some tests,
particularly the CAT scan and colonoscopy, not only frighten but
dehumanize patients by reducing the body to an intricate piece
of machinery.

    Doctors often find they can do more but explain less,
leaving their patients with the impression that treatment is not
to be understood, rather to be suffered. The doctor, for his
part, may want to reassure the patient, but balks at taking the
time to deliver a discourse on molecular biology. "You have to
be tolerant," says Lake Forest, Ill., cardiologist Jay
Alexander. "You have to be able to answer questions, and it's
got to be an answer that the patient is able to understand.
Twenty years ago, I imagine, less explanation would have been
necessary." The suspense and confusion weigh heavily on patients
and their families. Author Norman Cousins and his followers
believe lack of concern for the patient's state of mind can
actually cause physical harm. "At its worst," argues Cousins,
"it's a form of malpractice."

    Yet keeping patients informed becomes ever harder when each
test is performed by a different technician in a different
building, with no one wanting ultimate responsibility. For
Josefina Ponce, a day-care worker in Los Angeles, it took four
visits and twelve doctors to have one gallbladder operation. "I
saw one doctor in the emergency room, then a second doctor," she
recalls. "On my second visit, I saw three different doctors who
knew nothing about my case. I was told what my surgery date
would be, and I said I wanted to meet my doctor. But I was told
there would be five doctors, and it could be any one of them."

    Those who, like Ponce, lament the anonymous quality of
their treatment reflect a second revolution in patient care: the
rise of the medical-industrial complex. Every bit as important
as the advances in technology are the means of delivering them
and deciding who should pay. Instead of an individual doctor
seeing his regular patients in the privacy of his office, the
typical encounter now occurs in the thick of a vast corporate
hierarchy that monitors every decision and may weigh in against
it. Marketing medicine has become very big business.

    As costs have risen, the past decade has seen an explosion
in prepaid, "managed" care. More than half of all physicians
work in some kind of group practice, most commonly a
health-maintenance organization. Patients pay a flat annual fee
in exchange for care that is provided by HMO member doctors. As
private corporations, many HMOs can be quite profitable -- so
long as their patients do not get too sick. The number of
patients enrolled in HMOs has doubled in the past five years,
to 32 million, often at the urging of cost-conscious employers.
The goals: efficiency through greater competition, lower costs,
accountability and better preventive care.

    But the results may be mixed. Patients relinquish much of
their freedom to choose who will treat them, and can be lost in
a shuffle between rotating doctors. The physicians, meanwhile,
are transformed from professionals into employees, with a duty
to serve not only the interests of their patients but the
demands of the corporation as well. "They're asking physicians
to pay for their decisions," says internist Madeleine Neems in
Lake Bluff, Ill. "That's a terrible concept. When you analyze
whether or not a patient needs an expensive test, a lot of times
it's not a clear-cut yes or no. I don't want my finances tied
into those decisions."

    Doctors resent spending extra time with patients who demand
exhaustive explanations or who merely exercise their
hypochondria. "If you have to spend twice as much time because
a patient's assertive and he wants to ask questions, it's
certainly difficult to bill for that period of time," says
cardiologist Alexander. "Lawyers and accountants don't have
third parties or government agencies looking over their
shoulders to determine whether their billings are fair."
Patients understandably take a spare-no-expense attitude toward
their health, but that is not a philosophy likely to keep a
medical company in the black.

    Physicians and patients who are not part of an HMO have
found their lives affected too. The government (as the largest
health insurer) and the private insurance companies have tried
to cap medical costs by deciding in advance how much a
particular treatment should cost and balking at anything above
that amount. Many doctors can no longer decide how often they
see a patient, when one can be hospitalized, or even what drugs
may be prescribed. Those decisions are now in the hands of third
parties, hands that have never touched the patient directly.

    Medicare and insurance-company guidelines, for example,
forbid cardiologists to hospitalize patients for a coronary
angiogram unless the patient is desperately ill. Otherwise, it
must be done on an outpatient basis. As a result, Los Angeles
cardiology consultant Stephen Berens sometimes has his frail or
elderly patients take a room in a nearby hotel the night before
the procedure. If he decides the patient needs a temporary
pacemaker during the angiogram, he often implants the device but
does not charge for it, because the Medicare system denies
payment except in cases of very obvious need. "To make them
approve it, I'd have to exaggerate the risk of going without
it," he says. Berens would once have charged $200 for the
pacemaker; now he absorbs the cost.

    More than a doctor's pride and cash flow may be at stake.
Some physicians warn that the need to make rapid decisions, see
more patients and control costs could result in faulty
diagnoses. Promising but expensive treatments cannot be provided
to everyone who needs them, so what is to prevent reserving such
care for the rich? The new pressures on hospital care have also
affected the way young doctors are trained. Doctors lose the
sense of satisfaction that comes from having a personal
relationship with patients and helping them through crises,
since hospital stays are shorter, patients are sicker, and
treatment time is more rushed.

    Not only have the scientific and organizational landscapes
of medicine changed; so too has the social and economic climate
in which physicians practice. In order to sustain public support
and federal funds, the medical community trumpets triumphs with
abandon. Hospitals spent more than $1.3 billion last year on
marketing and advertising. Small wonder that even the
desperately sick are surprised when they are not cured. "The
whole idea is false," argues author Richard Selzer, a retired
surgeon in New Haven, Conn. "No one has ever got off the planet
alive. The natural course is to be born, to flourish, to dwindle
and to die. Yet the medical profession has encouraged people to
think of the natural course as an adversary, to be fought off
until the bitter end. Of course, doctors cannot live up to the
expectations they have aroused."

    Physicians certainly cannot hope to satisfy patients who,
instructed by the consumer movement, have come to view medicine
as a commodity like any other, despite the fact that it is
unlike any other. Once people would no more price-shop for a
doctor than they would for a church. But today some patients
switch doctors for as little as a $5 saving on the price of a
visit. "You can be a mediocre doctor and discount your fees
enough to have all the business you want," observes James T.
Galyon, an orthopedic surgeon in Memphis, "rather than trying
to be a very fine doctor and achieving a professional reputation
that will cause other doctors to refer patients to you. The
loser in the long run is the patient."

    Other patients are shopping not for savings but for status.
This inspires physicians to spend valuable time on
self-promotion and merchandising, not skills that contribute
materially to patient care. "My feeling was that if you're a
decent physician giving decent service, that's really all you
should have to do," says Florida ophthalmologist Robert Rogers,
who has hired a business consultant to help manage his practice.
"But patients don't seem to want that. They like the flashy
stuff. They like to see your name in print. They like to see you
lecturing."

    In an effort to be educated consumers, today's patients
read books with titles like What Your Doctor Didn't Learn in
Medical School and Take This Book to the Hospital with You. The
message is that a smart patient is an informed patient, who
challenges a doctor's authority rather than submits uncritically
to the physician's will and whims. Yet that approach rubs raw
against a basic instinct. Patients want to trust their doctors,
to view them as benign and authoritative. Even those who
privately question a doctor's decisions may be loath to express
dissent. Doctors admit that an aggressive or challenging patient
can be very irritating. "When you can, under certain
circumstances, play God, you sometimes tend to behave like you
are God," says Cornell's David Rogers. "The enormous
satisfaction of being able to help a lot of people makes you
impatient with those who question your judgment."

    The ultimate price of inflated expectations and consumerist
attitudes is the treacherous legal reality that confronts
doctors today. Anything short of perfection becomes grounds for
penalty. And once again, while it is the doctor who must pay the
high insurance premiums and fend off the suits in court, the
patient eventually pays a price. The annual number of
malpractice suits filed has doubled in the past decade and
ushered in the era of defensive medicine and risk managers. No
single factor has done more to distance physicians from patients
than the possibility that a patient may one day put a doctor on
the witness stand.

    Manhattan cardiologist Arthur Weisenseel remembers the
elderly woman who arrived in Mount Sinai Hospital's emergency
room having suffered a heart attack and battling pneumonia. A
man and a woman hovered by her bedside, and the emergency staff
assumed they were worried relatives. Then the man pulled out a
yellow pad, asked for the correct spelling of Weisenseel's last
name and identified himself as the family lawyer. "I kind of
lost it that day, and I told him to get out," Weisenseel
recalls. "That may have been the most distressing situation I've
had in 22 years of practice."

    The impact of possible litigation is felt long before a
patient sets foot in the doctor's office. Some physicians, like
Linda Bolton, a pediatrician in Birmingham, Mich., try to screen
out potential problems. "It really dictates what happens at the
office. If I feel I have people who are litigious, I prefer not
to take them as patients." In the past, she has fixed her rates
only after she has been notified how much she will have to pay
for malpractice insurance.

    The costs of practice have driven out hordes of doctors
altogether. According to a 1987 survey by the American College
of Obstetrics and Gynecology, 1 out of 8 U.S. obstetricians has
left the field because of the malpractice threat. Those who
manage to stay in business may feel forced to practice a kind
of medicine that assumes every patient is a prospective
litigant. Such defensive tactics are antithetical to
compassionate care: the doctor ends up being afraid of someone
he or she wants to help, cautious about trying attractive new
treatments and emotionally aloof from someone in need of
emotional support.

    Doctors recognize a vicious circle here, but there are
indications of a possible break. Last year, for the first time
in more than a decade, medical malpractice suits abated. Claims
settlements were down $100 million from the 1987 high of $4.2
billion. In response, several major insurers have reduced their
premiums. On the basis of studies showing that physicians who
know their patients well over a long period are less likely to
be sued, more doctors are looking for ways to avoid the fearful,
adversarial climate that prompts them to retreat emotionally --
which ends up making a suit more likely. "Many malpractice suits
come because people are angry at their doctors for not
communicating," says Cornell's Rogers. Consumer advocate Michael
Rooney of the People's Medical Society agrees: "It's when they
feel they've been hurt or betrayed that they sue."

    The relationship is actually poisoned on both sides.
Patients may insist on the most conscientious care and yet balk
at the battery of tests that doctors order to cover themselves.
"You come in for an ingrown toenail, and they turn you inside
out giving you all kinds of tests that you don't need," says
columnist Ann Landers, who receives complaints from all
concerned. "The bill is horrendous. The doctors want to be able
to prove that they didn't miss anything. It makes people mad,
and I don't blame them."

    Even as natural a procedure as giving birth has been
greatly distorted by the epidemic of lawsuits. "Mothers believe
that all babies should be born perfect," observes Massachusetts
General's Stoeckle, and here the bond of doctor and patient may
be most fragile. Doctors order expensive tests and uncomfortable
procedures as protection against future suits. The costs to
expectant parents are exorbitant, and discomfort during delivery
is heightened: nearly one-quarter of all U.S. births are
currently by caesarean section, which can be less risky to the
baby than vaginal delivery and makes the doctor less vulnerable
in court.

    Finally, there are those who argue that litigation actually
slows the progress of medicine. "Innovative techniques don't
get used very often for this reason," says George Miller, an
orthopedic surgeon in Washington, N.C., who last year won a
malpractice suit that had dragged on for "eight long years."
Doctors find themselves taking a more rote approach, what some
call "cookbook medicine." By following standard procedures as
much as possible, the physician may hope to avoid any
controversy that might arise in court -- and thus steers clear
of promising, if less proven technologies and treatments.

    The combination of these factors -- the welter of
technology, the intrusions of corporate medicine, the high
expectations of patients and the threat of malpractice -- has
cast a pall on the practice of many older physicians. "I detect
a certain despondency among doctors my age, in their later 50s,"
says Memphis surgeon Galyon. "They will frequently say something
to the effect, `I'm glad I'm this far in my profession and not
starting out.'"

    Oddly enough, many young physicians do not feel the same
way and still see in medicine a career of compassion and
challenge, despite its loss of luster in recent years. Their
attitudes may reflect new priorities in many medical schools.
Traditionally, med school, internship and residency were a
notorious, competitive ordeal that all but guaranteed less
humane doctors. "It makes book learning and grade getting their
yardstick, not kindness, gentleness and taking care of people,"
says Dr. E. Grey Dimond, founder of the School of Medicine at
the University of Missouri at Kansas City and a leader in
humanistic medicine.

    That may be changing, thanks to some innovative programs
that are challenging the conventional curriculum. The most
visible experiment, following an example pioneered at Missouri,
was launched at Harvard Medical School in 1985. The goal of
Harvard's New Pathway Program was to focus from the very first
day on the doctor-patient relationship, rather than rely solely
on textbook learning. "Even in an era that is overlaid by
science and technology," says Harvard Professor Ronald Arky,
"doctoring still involves an intimate, close contact with the
patient, and somehow that was being pushed out." Small groups
of students work closely with a physician and meet with patients
on hospital wards almost immediately, in an effort to mix basic
science with clinical decision making. Course work draws not
only on science but also on literature, history, anthropology
and sociology.

    As more hospitals and universities increase the emphasis on
the doctor-patient relationship, there are signs that attitudes
are changing. When humanistic courses were introduced in the
1970s, high-powered students resisted what they viewed as soft
science. "Now the students see that the shine on their shingle
is affected by what people think of them as human beings," says
author Cousins. The profession is attracting a different kind
of student: many are less concerned with accumulating wealth for
its own sake and more comfortable with patients who ask
questions and challenge authority. "It's a much more difficult
field now," says Dr. Matthew Conolly at UCLA. "I think we'll see
a different set of motivations."

    Doctors and patients alike may look forward to the day when
better relations mean better care. A strong bond makes it
easier for doctors to craft their therapy to the patients'
needs. More cynically, some experts predict that competition
among doctors will force a more humane approach as a selling
point. Finally, the problem of reimbursement could be relieved
if insurers came to value a good doctor-patient relationship and
were willing to allow doctors more discretion. Says consumer
advocate Rooney: "It's a recognition that, in the long run, it
may be more important to talk to someone at age 28 than it is
to clean out their arteries at 78."

    In the end, however, the struggle between caring and curing
is not likely to be resolved by invention or innovation. The
next generation of doctors may appreciate that medicine is a
fine art of human care; their patients may accept the
constraints on physicians and resist the temptation to blame
them for an absence of miracles. But even if relations ease, the
challenges to patients and doctors will still grow. The practice
of medicine, though it may become ever more precise, will never
again be simple, never cheap and never magic.


-- Barbara Dolan/Chicago, S.C. Gwynne/Los Angeles and Janice C.
Simpson/New York