Health Care Reform Reflection

Doctors in the crosshairs…

Let’s start with a disclaimer:

I am not complaining; I’m just stating the facts.

Honest fact: The morale of doctors in the real world is low–and sinking lower.

I know what you are thinking. “Come on Mandrola, you are nuts if you expect us to feel sympathy for doctors–of all professions.”

Well…you can think that if you wish, but I’m calling it as I see them. And here is why it matters:

Because when you are sick, an available, rested, un-rushed and talented doctor is really important.

You know this: quality health care–real quality, not spreadsheet or Internet quality–stems from basic human-to-human interaction, between patient and doctor. Healthcare reform, with its emphasis on metrics, prevention of fraud and cost-cutting measures has forgotten the basics. Namely, that humans, who have dedicated their life and committed their self-esteem, practice medicine. To take care of people well, doctors need things:

  • We need face time with the patient–not with a computer screen.
  • We need time to listen, to examine and to treat.
  • We need to feel trusted.
  • We need our self-esteem.
  • We need leeway to be human.
  • And of course, we need to be paid a fair wage for the years of training that it took to acquire these skills.

In support of this view, I’ll call your attention to four posts from real doctors:

–My colleague Doctor Wes Fisher talks of the growing culture of hostile dependency towards caregivers. Wes is rightly disturbed by a sensational and one-sided book review (WSJ) of surgeon-author Dr Mark Makary’s Unaccountable. Agree or not with Wes, his words come from the heart of a man who hangs a lot of his self-esteem on the doctoring peg. Wes is a guy I would want to have as a doctor. If healthcare reform keeps going in this direction, patients will have fewer Wes Fisher’s around to pull them out of fires.

–Here’s a quote (via email) from an esteemed colleague–another guy you would want as your doctor.

We doctors are absolutely being demonized.  Every day something new is written pinning our healthcare crisis squarely on our shoulders.  It’s really affecting me emotionally.  I’ve actually started to think it might be a good idea to take a media holiday for a while.  I appreciate that you still have the energy to fight.  I’m getting pretty tired.

–One of the most obvious unintended consequences of cutting healthcare costs on the backs of doctors providers is the flight of good primary care doctors to concierge medicine. One of the best posts I have read on the topic of Dropping Out comes from Dr Rob Lamberts. Dr Rob is a beautiful writer and another passionate practitioner of Medicine. I’ve been reading his stuff for years, and it is clear that Dr Rob has unequivocally mastered the obvious.

–Finally, there’s me. I wrote an In the Prime post today about the two sides of the canvas of healthcare reform. It was in response to a nicely written opinion piece in the Courier-Journal. A local doctor pointed out that we must not settle for anything less than universal insurance coverage. He’s right; but there is also the important question: What good is universal coverage if there are not enough caregivers?

Doctors don’t expect sympathy. That’s not what we want. We want the people–our patients–to know the consequences of hostility towards caregivers–be it in mistrust, hyper-regulation or lower pay.

We welcome reform, but we can’t sit still and watch it destroy the practice of Medicine.


14 replies on “Doctors in the crosshairs…”

“You Didn’t Cure That!”
I agree there seems to be a growing hostility and dependency on doctors, as well as pharmaceutical companies, investors, and business people who “make it”. “Hostile”. “Dependent”. Both of those two words are important to the discussion. Maybe “entitled” and “resentful” should be added to the list. All the hard work, risk and resources the aforementioned people put into getting an education and building their practice or business is not entered into the expected business profit or healthcare cost equation. Or the fact that these people are human like the rest of us. Of the group above, doctors are the most compassionate in my experience. I cringe when I think that if a doctor makes one mistake, or selects a treatment plan that turns out to be not the best in hindsight, that someone is going to jump into the “sue” mode. I also can’t understand how people think that everyone is going to pay healthcare premiums that are always less than their treatment costs. Someone has to wind up paying. People are taking on a child to parent role with their doctors. Expectations are rising and treatments are constantly evolving, warts and all. I used to think my parents were going to keep me safe from all disease and dying. I thought I was entitled. What a great illusion. Obviously, I found out that wasn’t true. My reaction was fear. I never reacted well to fear. My parents weren’t perfect either. They even died and passed on their genetic code to me… good and bad. I had resentments. I eventually came to accept them as humans. I also came to realize I had to take responsibility for my own actions, health, and future. I was ultimately responsible for the consequences of my actions. I wasn’t entitled to good health. And taking responsibility certainly didn’t come without great cost. That was the hardest thing for me concerning this thing called maturity. I’m okay with, I mean, tolerant of it now. But the illusion was great while it lasted.


Concierge medicine, or ‘Doctor, Your Patient Will See You Now’. Steven Z Kussin, M.D. My doctors are at war…with each other. This doesn’t bode well for me, a frequent flyer. At a recent annual physical my family dr went into a meltdown at my answer to the statement “It is time for you to have a bone density scan.” “Already had one at my sports med facility”… amidst various presurgical MRI scans. Apparently, my PCP’s practice had acquired a bone density scanner, rarin’ to use it…a lot. As if any patient is supposed to know this? His tone became irate and he forgot to email-submit several refill prescriptions to my pharmacy…had to take an extra 5 minutes to redo. All of this affected my ‘care’ experience yet had nothing to do with me. The first night of hospital stay for major surgery the night nurse shoved a ‘comments’ card into my hand and was offended that I couldn’t remember her name…while I was still on Dilaudid pump. I enter every medical facility with the hard won understanding if I’m lucky I’ll sail through controlled chaos rather than a zoo. I thirst for evidence-based answers and treatments in return for the deeply exhausting never-ending appeasement required to get effective measures from every doctor I must encounter. I have excellent health insurance and still remain hyper-vigilant in any medical setting guantlet.

Very aware the quality of my care is #4 on the priority list. Hostility is a learned response. It doesn’t seem realistic to expect patients (people under some sort of physical duress) to welcome having to drag themselves from doctor to doctor without reaching an emotional tolerance critical mass. 10 minutes with a doc means hours out of the patient day combined with the entire human context traveling along with the body. The disparity between doctor-patient experience is vast.

There will be apps for much of this in the future. A welcome relief to all parties.

Hey Jaynie,

Here’s one thing that I struggle with when writing about ‘health’ topics: I try to stay mindful that I am writing from the perspective of one blessed (thus far) with good health. It’s important for doctors and policy-makers to place themselves in the shoes of those without perfect health. I call this parallax–meaning that an object looks differently depending on the perspective of the observer.

Thanks for your perspective.

Ok. Once the pity party is done, we can go back to reality. Like doctors who have conflicts of interests, like needing to meet procedure rates or becoming spokespeople for drug companies and testing firms. Or the arrogance that every doctor shows when a patient questions why a treatment is necessary or when the patient tells them he or she wants to get a second opinion. Or the crux of the WSJ article that said that you cover for the Dr. Hodads. Sorry, Dr. John, usually you see both sides, but the reality is that your profession has had little scrutiny for a very long time. And at the first push for accountability, the pushback is full of rage against what is so clearly the right thing to do.

No pity my friend. Just the facts of what’s happening out there in the real world. On arrogance: There’s one thing that caring for real patients teaches good doctors: No hubris. Never hubris.

Dr. Lamberts piece I applaud. I wish I had a doctor like him to trust my family’s care to.

But Dr. Wes is in denial. His piece attacked the messenger. Questioned his credentials. But never addressed the issues the WSJ article brought up? What is it that you found commendable about Dr. Wes’s piece? I read Dr. Wes and all I could see was someone feeling sorry that a world of enormous privilege, status and entitlement, that doctors have enjoyed is being taken away?

My doctors (GP and Specialist) do not share information.
When are patient records going to be shareable (with patient permissions of course)? That would prevent mistakes and repeated tests and repeated patient inputs. No wonder patients are frustrated. Doctors frustrated as well by walking into patient meetings with no “chart” to guide them…for their 5 minutes of listening and recommending.

I’m for accessible medical records. I try to write every note as if the patient would be reading it. This seemingly simple concept, however, isn’t as simple as it looks on paper. There’s a lot in the medical record that isn’t important and a real risk would be that a patient gets derailed by insignificant things in his or her medical record. I face this in dealing with complicated arrhythmias like AF. We don’t have time for review of systems stuff. We need to get to the heart of the matter.

As if on cue, I just saw this in the WSJ

In my regular follow-up visits at our Regional Pain Clinic (ongoing issues with chest pain of coronary microvascular disease), my pain specialist dictates the upshot of our appointments while I am sitting there in front of him at the end of each visit. The first time he prepared his report for my GP in this fashion, I was shocked – had never heard/seen this practice before. He told me at that time that his new protocol allows him to review our discussion/treatment planning/test results immediately, and if he overlooks/forgets anything, he likes to know that his patients are sitting right there to remind him of what was just said. I don’t get “derailed by insignificant things”, and I have what most would consider a highly complex chart.

Thanks, Dr. John.

These are my medical records and I expect to know exactly what’s in them.

Replace each instance of Dr. with ‘patient’ and almost all if your post would still ring true. The system grinds on everyone.
I wonder if Docs realize how much support staff problems undermines trust.

During my last office visit to an EP, the records people lost test results (I had a copy), the wrong script was called into the pharmacy, and the bill was wrong. Not a situation that breeds trust or patience. I expect 1 or 2 screw ups for each visit, at a ‘world class ‘ facility.

Maybe my experience has been different than others. It is based on various doctors in New Jersey for over 30 years. I have always been given a copy of my records and tests after I requested them once. I was also given all notes for the last 30 years… a very thick file including notes from visits. My current PCP works closely with my electrophysiologist, gastroenterologist, orthodontist, and dematologist. My electrophsiologist and PCP share files (I had to fill out some forms). My PCP was actually at the my physiologists office when my nuclear stress test was done. My electrophysiologist and PCP are very friendly, understanding, and take all the time I need to explain things. I value that.

I have to admit that I don’t feel as comfortable in a hospital setting. The only other complaint I have is that while my doctors are great, sometimes the people out front don’t say “Hello” when I walk in… they say “Copay?” That also matters to me.

Add to the list the difficulty for doctors to establish a credible digital presence, how technology impacts the medical practice, and how both of these are expected by patients and you’ll see where a lot of challenges arise.

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