The Good Doctor (29 page)

And while I grumbled a great deal about Medicaid and HMOs, which forced me to make phone calls and write letters to get my patients various procedures, medications, or consultations with specialists, I appreciated why they were hassling me. The fact was that my father’s generation of physicians, particularly after the passage of Medicare in 1965, embraced fee-for-service medicine with too much passion. Ordering tests was easy, and when the person or institution ordering them got paid to do so, there were no brakes on the system. Patients, too, reflexively assumed that more testing and treatment—regardless of the price—was better. The costs associated with health care had not been a major issue when my father began his practice in the early 1960s, but it had become an emergency when I began mine thirty years later, and Bill Clinton tried unsuccessfully to pass major reform legislation. So while I had no great love for insurance companies, I understood how physicians like myself needed help in determining which of our efforts were cost-effective.

I also rejected, to a large degree, my father’s disdain for physicians who were willing to delegate patient care to their colleagues once they had left their offices or the hospital. This was, of course, tricky turf for me, as so much of my respect for my dad stemmed from his utter devotion to his patients. But my sheer exhaustion during my residency had opened my eyes to other models for covering one’s patients. Even my father, who had essentially lived in the hospital during his training, characterized my internship as “absolutely ruthless and demanding.” And, in retrospect, it had not been good for him, my mother, my sister, and me that he had never found ways to detach from his medical work, pursue other interests, and, potentially, reinvigorate himself. In some instances, perhaps, it might not even have been good for his patients.

As of 1993, when I returned to Columbia, my general medicine colleagues and I still followed our clinic patients when they required hospitalization. But there was a new phenomenon on the horizon: hospitalist medicine, a specialty made up of physicians who covered
other
doctors’ patients when they were in the hospital. Many of us initially rejected this idea. After all, general internists strove to know their patients inside and out and liked being in charge of their cases. I could think of many instances in which I had discovered errors or misperceptions in the care of hospitalized patients because I had known them longer than anyone else involved.

But over the next decade, internists gradually began to admit our patients to hospitalists. It made sense for a lot of reasons. Hospitalists not only were experts in in-patient medicine but knew how to work the system to get patients expeditious and more cost-effective care. Those of us who showed up in the hospital only periodically were, frankly, lost at times.

The potential downsides of this new type of arrangement were obvious. Concepts such as professionalism and humanism, which medical schools and residency programs were increasingly emphasizing, had once been synonymous with total devotion to medicine and the care of patients. Now, patients were handed off from doctor to doctor, not only from general internist to hospitalist but from one hospitalist to another. Meanwhile, the house officers who helped us care for patients had their own confusing schedules; their chief residents sometimes even sent them home in the middle of the day so they would not work too many hours. Care for their patients could pass through several different doctors, including night floats, before they returned the next day. Indeed, in 2013 a physician wrote an article praising one of her mentors, Joseph Lieber, who came to the hospital seven days a week, was a highly skilled diagnostician, and was “always nice” to his patients, and the
New Yorker
found it interesting enough to publish in its “Annals of Medicine” section.

Many physicians—not just old-timers like my father but some from my generation—bemoaned these new developments. One surgeon proudly recalled one of his mentors standing in the way of a resident trying to leave the hospital and telling him, “Once you lay your hands on a patient, that patient is yours.” Another physician termed the eighty-hour workweek “pathetic, embarrassing, and paltry.” “Calling,” another wrote, “isn’t a word you hear much anymore.” Similarly, writing in 2002, a residency program director stated that limiting hours produced unsafe doctors. “Learning medicine,” he wrote, “is different and requires physical effort that may seem inappropriate to those in other professions.”

On rounds at Columbia, my longtime nephrologist colleague Jay Meltzer taught physical examination and differential diagnosis on each admitted patient in the thorough, even painstaking, style that he had been taught. But the Department of Medicine eventually informed Meltzer that he needed to speed things up. House officers had complained that he was picking up too many new findings on his examinations. “Unable to teach badly,” Meltzer told me, “I had to resign.” Meltzer’s and my colleague cardiologist William P. Lovejoy was nearly apoplectic when he read an op-ed piece written by a physician in the
New York Times
stating that the only reason to do physical examinations was to provide patients with a “hands-on” feeling. “I can think of a thousand diagnoses she’s missed,” Lovejoy railed.

But much to the chagrin of these venerable physicians, this way of practicing and learning medicine has largely ended. Sad to say, physicians are much less likely now to spend time with patients, make provisional diagnoses, and then revisit those diagnoses as the clinical situation evolves. Rather, doctors now send patients for CT scans and MRIs that reveal the diseases in question. Many modern physicians now have tablet pockets sewn into their white coats to ensure easy access to their iPads on rounds. Nor is exhaustion on the wards a badge of honor. Physicians—both women and men—are eager to have outside interests and be more active parents than their predecessors were. When Meltzer retired in his eighties he wrote a heartfelt letter to his patients saying that medicine had structured his life “for daily learning and discovery,” a goal that few modern physicians likely seek. Even Louis Weinstein’s fabled Monday-evening journal club, which my father had so avidly attended during his years in Boston, could not survive in this new era. Weinstein’s trainee and colleague Sherwood Gorbach tried to keep it going, but the infectious diseases fellows had rebelled at spending evenings away from home. Some of them even preferred to watch
Monday Night Football
!

As a historian of medicine and my father’s son, I well understood the pull of this old model of medical practice. But I also sincerely believed that spending time away from the hospital potentially
enhanced
one’s ability to be a skilled professional—by broadening one’s horizons and lowering the likelihood of burnout. And, as I suggested to my students and residents, these new arrangements actually freed up some time that could be used to directly improve patient care. For example, my using the hospitalists’ services did not prevent me from visiting my hospitalized patients. Even if I was no longer writing daily notes in their charts, I could speak with my patients, eyeball the situation, and, if necessary, provide some suggestions to the other doctors. These visits were analogous to the second looks that my father and Weinstein liked to make on their sickest patients before they left the hospital for the day. Extra time could also be spent phoning discharged patients at home to check on their progress and confirm follow-up appointments. Or doctors could promptly call outpatients with the results of major tests, so such individuals did not have to anxiously wait until their next appointment. The fact was that being a good doctor no longer necessarily meant knowing every last detail of patients’ cases or completely understanding the biological basis of their diseases, but rather using one’s training and skills to supervise their care and make sure that their basic wishes and goals were elicited and respected. Part of this effort, I had to admit, involved using UpToDate and other computer-based tools that provided quick and reliable information. Some might see this as cheating, but even my father, toward the end of his medical career, had thrown up his hands and admitted there was no other way an infectious diseases specialist could keep up with the expanding amount of knowledge within his own field, let alone in all of internal medicine. The days of his reading twelve weekly or monthly medical journals from cover to cover had ended.

Among the authors whose works my father read and admired was the writer and critic Anatole Broyard, who penned a series of essays about medicine after being diagnosed with terminal prostate cancer in 1989. Perhaps more so than any author, Broyard identified a series of qualities that made for a good doctor—even in a world of technological medicine and time constraints. Several of these reminded me of my dad. One was being a physician who viewed a serious illness as a crisis for the patient in question, not simply as a routine incident in his or her medical practice. Another quality was being a doctor who—even if only for five minutes at a time—would genuinely bond with patients, brooding on their situations and seeing the comedy and tragedy of their stories. These humble and perceptive insights are why I often assign a Broyard essay when I teach.

Of course, I still cringe at the notion of doctors doing shift work. I have encountered some physicians who, unfortunately, see their commitment as ending as soon as the clock says that it does. And I am well aware that fragmented patient care may lead to more medical errors, worse outcomes, or patient dissatisfaction. Fortunately, to this point, studies have not corroborated such concerns. Looking at house officers who are actually awake during noon conferences and seem relatively happy and well adjusted, I continue to believe that the changes have been for the best. And there remains, at least at the medical schools and hospitals where I have worked, evidence of great devotion and compassion. Perhaps this notion was best conveyed by an anonymous medical student responding to a surgeon’s blog post that celebrated the days of the giants: “I am in medical school, and I could not imagine or design a class more full of energy or brilliance,” the student wrote, pointing out that many of his classmates showed a special commitment to medicine, having started out in different careers and then spending years completing premedical work.

For me, a particularly vivid demonstration of commitment to patient care came in the wake of Hurricane Sandy in November 2011. I had just moved from Columbia University to New York University and the Bellevue Hospital Center in July. When Bellevue’s patients needed to be evacuated after the storm damaged the electrical equipment, many of my new general medicine and primary-care colleagues stayed in the building for days, even carrying patients down darkened stairwells. When the hospital and its clinics remained closed, the Bellevue internists attempted to contact all of their clinic patients to see how they were faring and to get them medications and medical care. I cannot remember how many times I heard someone say, “These are our patients.” It was inspiring and a throwback to my father’s era, when house officers essentially lived in the “house.”

Unfortunately for my father, things had continued to deteriorate at the Mount Sinai. In 1996, Primary Health Systems, a for-profit organization, purchased the hospital. Although my dad admitted that PHS had probably saved the hospital from total collapse, he believed that it made all decisions based only on costs. In 1997, the new administrators dismissed the chief of pharmacy in what my father termed a “ruthless” manner. Later that year, several neurologists and cardiologists, including my father’s own cardiologist, defected to University Hospital. Members of the Mount Sinai’s Infection Control Committee, which my father led, either resigned or were fired, leaving him as the only person on the committee.

In March 1998, things reached a crisis. The hospital’s census and consultations were way down. Massive layoffs were planned for the next few weeks. Most worrisome, from my father’s perspective, was a plan to change him and other full-time faculty members from a guaranteed salary to a stipend system, where doctors were paid per patient seen. Meanwhile, these physicians were still expected to teach for free. My father already believed that patient care at the hospital had sunk to an unacceptable level, and now it was sure to become worse.

“This is it,” he wrote on March 28, 1998. “Push has come to shove!” His symptoms of anxiety and depression had increased, as had his baseline insomnia, heartburn, and vertigo. Plus, his misery was adding to my mother’s burden of caring for Jessie.

“I see no other choice but to retire,” wrote the man who had devoted his life to the practice of medicine and little else. He was not “emotionally ready for retirement” but it had been thrust upon him. “Now don’t feel sorry for me,” my father wrote to his imagined reader. He was only one of the many victims of the upheavals in medicine. My dad was especially grateful that all of this was happening when he was in his mid-sixties, nearing the end of his career. Younger physicians like me were not so lucky.

By April, my father had put a plan into place. On June 30, 1998, he would resign from the Mount Sinai Hospital. Fortunately, two infectious disease physicians from University Hospital had approached him about moving to their facility. Although he planned to do so, he would be acting mostly in a teaching capacity and not as a provider. “I’ve had it with patient care,” he wrote. This decision made particular sense, as he had just reached two important milestones: it was forty years since his medical school graduation and twenty-five years since he had joined the staff of the Mount Sinai.

I was thrilled that the opportunity to move to University Hospital had arisen. I knew that my father was still an extremely talented physician and teacher who had an enormous amount to offer to patients and students. Plus, my mother was understandably dismayed at the notion of having my dad around the house all day. Aside from a brief interlude in which he had made sculptures from rocks, he had no hobbies. His life, he admitted, had been one of “fanatic involvement with medicine, my own field and medicine in general.”