TOHL: What impact are lobbyists and special interest groups having on health care today?
They are accomplishing very successfully what they are paid handsomely to do: maintain the status quo–and their own vested interests–in a health care system better designed to churn patients through its turnstiles (and maximize providers’ profits) than to care for individual patients (or improve the health of the U.S. population). Remarkably, the special interests of insurers, hospitals, physicians, drug and medical device manufacturers, nursing homes and other health care providers are special because, all too frequently, they conflict with the best interests of patients. In any other industry this business plan would fail: how can a business hope to succeed if it doesn’t satisfy its customers? But health care, astoundingly, is the exception to this rule. That’s one of the reasons I wrote One Doctor: in our fragmented, commoditized health care system, patients need to learn more about how to achieve their own best interests.
TOHL: Why has there been such a decline in medical school students pursuing family medicine?
Because, when compared to the lucrative medical subspecialties, careers in family medicine and other primary care specialties (pediatrics and internal medicine) don’t pay. This may seem crass until one realizes that most medical students amass enormous educational debts before they can even begin their careers; not surprisingly, most of them follow the money and spurn careers in primary care. Insurers have always valued subspecialists more highly than primary care doctors–as does, increasingly, the medical profession itself–but these discrepancies in reimbursement and prestige have grown in recent years. (Most patients don’t know that these discrepancies are often unwarranted and sometimes counterproductive to cost-effective medical care.) The result is an “inverted pyramid,” the metaphor often used to describe our inefficient, lopsided physician work force: too few primary care doctors at the base of our health care system and too many subspecialists at the top. In contrast, every high-performing health care system around the world has a strong primary care base as its foundation.
TOHL: Your book is filled with stories of patients and your journey to find correct diagnosis for them. Does one story stand out?
For internists like me–who are, first and foremost, diagnosticians–the stories that stick out are the ones that got away, the patients whose diagnosis we missed. In One Doctor, readers meet several of my own diagnostic misses, most notably a tragic cold case from long ago that haunts me still. In a very real sense, diagnosticians seek the “truth” about patients–constantly questioning, reexamining and second-guessing the facts (and ourselves). In the process, we learn even more from our failures than our successes, one reason we remember them so well. Diagnosticians (low-tech “cognitive” doctors who use their heads) tend to get less credit–notwithstanding TV shows like House–than proceduralists (high-tech doctors who use their hands and machines). But, regardless of who gets the credit, the reality is that surgeons or other proceduralists can’t help a patient unless a diagnostician first discovers that patient’s “truth.” In the end, this is the biggest reason why diagnosticians don’t forget their “misses”: when we miss, the patient loses.
TOHL: The chapters where you look back at your time in the ‘80s spent in New Hampshire would make a great television show–filled with a lot of local characters, some brutal winters, and a special kind of doctoring on your part. What was so influential about this time in your career?
That was when I became a “real” doctor, when I learned to love being there for patients whenever, wherever, and however they needed my help. It was also a time when I, previously a lifelong New Yorker, expanded my horizons and learned that life looks different when viewed from other places or others’ eyes. But, at the same time, getting to know and care for those fine, colorful, salt-of-the-earth New England folks taught me that good doctoring is, fundamentally, the same everywhere. This helped me not only at Dartmouth but also when my career took me to other places, different patients and new challenges–and then, eventually, back home to New York.
TOHL: Why are Friday nights “cursed” in big city hospital ERs?
The death rate for patients admitted to hospitals on weekends tends to be higher than for patients admitted on weekdays. (The precise causes of this “Friday night curse,” a well-known problem in the U.S. and other countries, are uncertain.) This doesn’t mean that you shouldn’t go to the hospital on a Friday or Saturday night if you’re very sick. But you should know that hospitals often schedule less experienced staff to work weekends; many also reduce staffing on weekends to cut costs. In addition, you should know that many doctors “hand off” their patients on weekends to “on-call” doctors who, as a rule, cannot know these patients well. As One Doctor illustrates, weekends are just one of many holes in the “Swiss cheese” fabric of U.S. health care.
TOHL: Emergency rooms today account for 11% of all outpatient visits in the U.S., 28% of all acute care visits and 50% of all hospital admissions. What explains this phenomenon?
If you build it, they will come–not only the “real” emergencies (which constitute only a small minority of all ER visits) but also the uninsured, the homeless and mentally ill, the Medicaid patients spurned by other doctors, and, finally, all those patients with “good” insurance who can’t reach their doctors, or don’t want to wait for them, or know they can get more high-tech attention in an ER than in a doctor’s office (whether they really need such attention or not). In other words, excessive use of ERs in the U.S. is a multifactorial problem, the symptom of an uncoordinated, dysfunctional health care system where insurance coverage is spotty and inequitable, doctors often inaccessible, and many patients’ demands ill-informed and imprudent. Our ER problem won’t go away until the system that spawned it gets fixed.
TOHL: You write that 20% of the 12.5 million people aged 65 years or older who are hospitalized annually in the U.S. develop delirium. What exactly is this and is it preventable?
In many studies of hospitalized patients, the incidence of delirium – an acute change in mental status (characterized by confusion, disorientation, inattention and agitation) – is even higher than 20%. This fact is remarkable not only because delirium causes much suffering for patients (and their families)–and, sometimes, serious harm–but also because, in many cases, it is entirely preventable. The key to its successful management is twofold: 1) The doctor must know the patient (otherwise, how can a doctor recognize change in a patient’s mentation?); and, 2) The doctor must find and eliminate the precipitating cause of delirium, most commonly a drug (or combination of drugs) prescribed to treat the patient’s medical conditions. Unfortunately, worsening fragmentation in the U.S. health care system–where patients are handed off frequently from one doctor to another (any one of whom may have prescribed the offending drug)–has increased both the incidence and the danger of this very serious problem.
TOHL: From hypochondriacs to patients with panic attacks, you cover a lot of stories having to do with psychological issues. In fact, you had one patient who would inject herself with a bacteria filled syringe just to get attention. How common are cases like this and as a doctor are you trained to deal with them?
Patients with factitious illness–people who purposely hurt themselves or make themselves sick (sometimes, deathly sick)–are uncommon. But patients who suffer from physical symptoms caused entirely by psychosocial distress–anxiety, depression, stress, loneliness, frustration–are ubiquitous, frequent fliers in every doctor’s practice. In fact, some estimates suggest that one-quarter to one-half of all patient visits to primary care doctors in the U.S. are prompted by such “psychosomatic” symptoms. Most doctors in the U.S. today have been inadequately trained to recognize and help these patients, many of whom get worse while their doctors (clueless about the patient’s underlying psychosocial distress) pursue useless diagnostic tests and referrals to subspecialists.
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