TIME: Almanac 1990/1990 Time Magazine Compact Almanac, The (1991)(Time).iso/time/073189/07318900.002

Text File | 1990-09-17 | 27KB | 470 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