Abstract
Why was it important for me to undergo this research? Medicine is an often times neglected field for critical contemplation—likely because it is so necessary for life that it is often taken for granted. A lot of time is spent talking about larger pictures: how does public policy effect American economics. But analyzing the relationship between one doctor and one patient can be insightful for understanding what changes should be made at smaller scales. Health, and things that can affect our health, remain incredibly important. It is life itself, which is threatened by poor health care quality. Dissatisfaction with the system is at an all time high, and both patients and physicians are frustrated. I look at the problem at a number of different levels, as an American, as a diabetic, as the daughter of two surgeons, and finally, as an aspiring doctor. At the first level, I broadly examine what issues have made health care so vexing in the past forty years and how this affects both patients and doctors. At the second, I examine how doctor patient interaction, especially poor doctor patient interactions, can affect the health of patients by reviewing literature and looking at my personal history. At the third level, I examine doctors and how they relate to the system, as well as note attitudinal shifts among doctors, which could prove disastrous for the American health care system. At the fourth level, I talk about my own persistent interest in becoming a doctor, despite everything I have learned that suggests that this is not the brightest aspiration for a young adult to have, and talk about my own optimism for the future of the field.
Introduction
The role of physician has changed within American society over the last forty years. Many factors may account for this, from the passage of the Health Maintenance Organization Act of 1973 to the changing demographic identity of the average doctor. Patients still view doctors as professionals, but the public’s admiration for the field has declined to an all time low. Furthermore, the usefulness of doctors is becoming questionable, widespread, for the first time. The modern doctor represents, for many, an interchangeable source of medical advice, competing with the Internet, advertisements, and the nightly news. As such, the archetypical physician has fallen from respected and trustworthy to contemptible and egocentric, more concerned with annual incomes than the Hippocratic oath. In ways, this view of doctors as economically greedy yet empathetically stingy is not wholly inaccurate. Doctors today must deal with greater legal commitments, constraints that minimize the amount of time they are able to spend treating patients. But this is not a change that doctors are pleased with: seventy-four percent of physicians are dissatisfied with the hours they spend on administrative activities compared with the time spent interacting with patients. Few Americans are happy about the American health system.
But while understanding the shortcomings of health care may seem like a noble goal for policy makers, economists, and politicians, they are of little concern for the people who often get lost in the heated debates which have gripped the public’s attention following the election of progressive president Barack Obama. Whether or not health care needs to be fixed is not the largest concern to a thirty-four year old hypertensive, his older sister who has just been diagnosed with breast cancer, and the family doctor they have been seeing since they were teenagers. While national debates have primarily focused on the benefits or downfalls of implementing universal health care, more serious problems will arise if the public continues to ignore severe observed changes in physician attitudes. In 2002, 50% of physicians would not recommend the medical profession to young adults. There is a shortage of doctors, and this dearth of medical professionals will only get worse as we progress through the twenty-first century. Predictions currently figure around 9100 physicians will be missing by 2020. While opponents of liberal policies seem to blame this on Medicare, and see the disparagingly labeled “Obamacare” as possessing the potential to exaggerate this, a more worthy area for blame is the general public’s attitude concerning physicians.
There is a large disconnect in the American health care system. I will address these problems, with an eye on the actual interpersonal relationships that form when a patient enters a doctor’s office. After extensive review of the literature concerning doctor-patient interactions, I believe that if a physician is capable of developing and sustaining good relationships with one’s patients, it is possible to not only positively influence the patient’s health but also to change the patient’s perception of the health care system on a whole. Every single person in America could benefit from improvements in the Doctor-Patient relationship, because health care can potentially devastate our country’s economy, but it can also revitalize the lives of all Americans.
As an American, as a diabetic, as the daughter of two surgeons, and as a future doctor, it is my firm belief that I am capable of analyzing the entire field from many different perspectives. It is integrative and interdisciplinary views like this that should monopolize public debate.
Part One; General Practitioner in Observations
The other night I walked into a bar, around nine or ten. I go to school in rural central New York, and the congestion of bars reflected the surrounding population density. Tonight it was lifeless. The jukebox occasionally produced a nineties pop hit, but the majority of my time spent occupying a wooden bar stool was accompanied by the noise from one of three large televisions stuck to the walls. I was integrated into a conversation between the bartender, a bald man in his forties, and a regular, a type of person sometimes referred to derogatorily as a townie, whose age fell somewhere between mine and the bartender’s.
I had recently achieved the bar’s top honor, an award called the Big Shots Club. Proud of my recent admission into medical school, I had decided to have my honorary plaque engraved with my full name, plus the addition of the still ill fitting “MD.” They had been talking to me about this, until they finally managed to ask me the question I was still formulating an answer to: “Why do you want to become a doctor?” I had learned to be a fast talker under the influence of a pint of wheat ale, so I jokingly said, “I’ve seen a lot of doctors in my life. A lot of them have sucked. I think I can do better.” The regular nodded as if he could relate—an important skill for inhabiting small town bars. But then he vocalized his opinion and I was silenced for a moment, forcing myself to smile awkwardly where, for any other statement, I would have laughed. “Yeah, there’s a lot of bad doctors out there.”
I don’t believe bad doctors don’t exist; probability alone dictates that some must. But are there really “a lot of bad doctors out there”? Where did this sentiment originate, and how did it come to dominate public opinion? Norman Rockwell, beloved source of Americana, captured iconic scenes symbolizing at once the importance, the caring, and the social standing of every American’s family physician in the middle of the 20th century. Paintings of a doctor tenderly applying the stethoscope to a little girl’s teddy bear come to mind. Porcelain figures of doctors, both male and female, tall, attractive, slender, with caring smiles—representative of the outstanding citizen doctors used to be, still decorate my family’s art collection. These are images of a different time and from a different culture. In the 1950s, respect for doctors matched that of Supreme Court justices (Jauhar 2011). Today, it is not shocking to hear someone complain about the low quality of service they’ve gotten from the system. What happened?
It should be qualified here, however, that although there is a lot of anger with the system, if you ask Americans to talk about their personal physicians, they still recognize that doctors are professionals and deserve that level of respect at least. But that does not change the truth that the field of medicine has changed drastically, and one could argue, for the worse.
A lot of problems arose from probably well-intentioned changes in public policy. Health maintenance Organizations (HMOs) introduced managed care, which in theory, and theory alone, seemed a noble attempt to improve health benefits and reduce medical costs, when it was first legislated in the mid-seventies. But HMOs went about achieving this goal in a very perverted fashion. Ask any doctor to talk to you about managed care, and perverted will be one of the more pleasant adjectives you hear. The two largest complaints from physicians are the amount of paperwork they have to deal with to get compensated and the time this process takes away from time that could be spent with patients (Kaiser Family Foundation (KFF) 2002). The end result of managed care was to cut costs. That has not happened. There are still millions uninsured. Two trillion dollars were spent by the United States on health care in 2005. That was 16 percent of our countries GDP, averaging $6,697 per every single citizen. The Health Maintenance Organization Act of 1973 was passed because it seemed to be full of financial potential—yet since the 70s, health care costs have grown 2.5% faster then the nations GDP every single year. When we examine where this money is used, we find that only 21.2% of it ends up with physicians, the people who really are doing the brunt of the work. Where does that other 79.8% go? Seventy-nine percent of taxpayer dollars, seventy-nine percent of $2 trillion a year, gets lost in the system. To clarify, not entirely lost. 10% is spent on prescription drugs. Other large amounts of spent on hospitals (KFF 2007). But a mysteriously large amount of money ends up going to health maintenance organizations, which essentially organize the way health care functions, causing doctors to spend more time with paperwork instead of providing health care.
It’s not that doctors did not want the outcomes proponents of managed care said it would provide. 74% of physicians are dissatisfied with their work spent on administrative activities, activities that have drastically increased under the advent of managed care (KFF 2002). For patients, however, these are not the way physicians are usually viewed. Doctors are rich. Doctors are elitists. They lack interpersonal skills. They want to make more money, and therefore, they will deprioritize the time they spend with me.
Susan Kim is one of my closest friends. She has spent most of her life without health insurance. Even today, enrolled at a private University, in Chicago, the city that serves as the backdrop for the American Medical Association (AMA), she doesn’t know if she’s covered or not, or to what extent she is covered if she is. Susan doesn’t carry an insurance card around with her—she doesn’t believe she ever received one—so ultimately, if she ended up in an emergency room, it is unknown what expenses she would incur, though it is a safe assumption she’d be paying out of pocket. While one of the greatest fear associated with medical visits among the insured is the doctor’s diagnosis, Susan’s greatest fear, as an effectively uninsured person, Susan’s “greatest fear, is the bill.” Susan’s mother emigrated to the United States from South Korea about thirty years ago, raised Susan by herself after her husband inexplicably left, and continues to run a dry cleaners in one of the wealthier regions of the Chicagoland area, the North Shore. Yet Susan’s mom cannot afford health insurance. Susan’s mom works sixty-five hours a week, every week. Susan expressed frustration with the system, because her mom is getting older and more prone to diseases. Indeed, the amount of money spent per person for health care is highest for those above the age of 64, averaging $8,647 annually for senior citizens in 2004 (KFF 2007). This cost is momentous to low-income families, and even debilitating to the growth of promising young Americans. Susan is twenty-two and already in a state of persistent panic concerning her debt. She no longer believes she has a right to ask her mom for financial help in paying for things such as her education or her medical services. “My mom is 55,” she told me, after I had asked her how much she thought her mom worked in a week, “It’s not fair. She shouldn’t have to be working so hard at her age.”
This inequality, to my surprise, as an average American who feels like most doctors are living the high life comparatively, is not just felt by patients. Physicians feel it as well. I called my father to ask him how he felt about managed care, because as someone who has parents with medical degrees, I’ve never been too worried about my relationship to health care. To demonstrate how ridiculous the health care system had become after the introduction of managed care and HMOs, he told me about a time within the last decade when he had found out the annual salary of the CEO of United Health Care, an HMO. His response, ever logical, was to calculate how much he himself would have to work, as a surgeon, to validate making the kind of salary a CEO of an HMO makes. He discovered that he would get close, but not quite there, if he spent twenty-four hours a day, seven days a week, in the operating room excising gallbladders from sick patients. At two hours a case, he could theoretically become a wealthy man if he was able to perform over four thousand surgeries in a year. Though after the cost of malpractice insurance and his incurred increase for health care from working non-stop for an entire year, he’d probably end up where he started—worse off than an administrator. “It makes no sense,” my dad kept saying.
Patients are angry. Doctors are angry. And both have good reason to. Health is a touchy subject. But patient opinions are shaped by whom they’ve seen in the health care system. And their opinions influence the opinions of others. Some people like doctors and will always display respect towards physicians. When you’ve got a gaping wound on your leg from a game of baseball, and your neighbor, a plastic surgeon, stitches it up for you at no cost because all the nearby hospitals in the area are closed, you remember that kindness. Or when you’ve got a serious bacterial infection on your arm that isn’t clearing up with traditional antibiotics, and your pediatrician admits that the situation requires more expertise than he can offer, you remember that humility and that trust that ultimately saved you from losing an arm.
Other people think they are being taken advantage of, either by doctors themselves or by the insurance or the pharmaceutical companies. I have heard the anger from my parents. I have felt personal anger emanate as I leave the office of a doctor who has proven less than caring. I have heard conspiracy theories from disgruntled diabetics about how easy it would be to cure diabetes, but how it isn’t a high priority for drug companies because “There’s just too much money in the strips and the testers.”
Yet Americans continue to believe that their health care is superior to that provided in other countries. The cure for diabetes may not arrive for another fifteen years, or another fifty years, but it’ll be discovered in the United States when it is. But that still does not change the statistics that there are many more dissatisfied patients today than forty years ago. At its most severe, this is a matter of life and death; at its most mundane, the issue of health care possesses power to drastically change one’s satisfaction with life. And for many and myself, this is terrifying.
Part Two; Case Study of Me
I am not a hypochondriac. I have, however, required a diverse series of health services. Obstetricians, Pediatricians, Gynecologists, ophthalmologists, orthodontists, outpatient clinics, dermatologists, dentists, school nurses, nutritionists, school nurses, endocrinologists, physical therapists, and emergency rooms. I have required all of them to shape the person I am today: function, healthy, independent, and competent. Only once have I left a doctor’s office thinking, that person sucked.
I was in my late teens. For the last six years, I had met with a pediatric endocrinologist every three months for my quarterly check-ups. I was doing well with my diabetes. I knew this because after the nurse had taken blood from my pointer finger to run a hemoglobin A1c test—a diagnostic proxy that determines the range of one’s blood sugar levels over the last ninety day period—my numbers were always the lowest in comparison with all the others written down in a large white binder. My visits were almost always very pleasant. The nurses would ask me if I drank, smoked, or had sex, and I never had done any of those things. They’d praise me for being a dedicated varsity swimmer. One of the nurses had even been a swimmer, so we compared personal times and I listened to her fondest swimming memories. They asked me about my plans for higher education after high school and seemed impressed by the prestige emanating from my top choices.
But I was getting old. They recommended that I start seeing an adult endocrinologist. The office for adult endocrinology was in the same building, but I still felt like I was no longer wanted. This was a time when I only saw two physicians a year and I had developed a level of friendliness with the supporting nurses in that office that I couldn’t imagine seeing myself with any other physician. My mom made that first appointment. She is a female surgeon. As a result, most of the physicians I had seen in my life had been female. My mother had entered medical school when it was still a male dominated endeavor—the late seventies. Becoming a female surgeon was even more ludicrous. My mother is not a feminist, but she sees equality less as an option and more of a mandated command. So until there were just as many female doctors as male ones, we were only going to see lady doctors.
My mom and I say in comfortable enough chairs in the waiting room, watching the two receptionists deal with the inundations of calls, and reading the few magazines that had nothing to do with diabetes. When I was escorted by a nurse into my doctors examining room, I noticed diplomas from Northwestern. My doctor was smart. I swung my legs back and forth as I waited patiently to meet my new doctor. The nurse had already taken my height, weight, blood pressure and pulse. She had made small talk, but now I was alone waiting in a room with the blinds closed against the bright sun of summer of the Chicagoland area.
The door knocked twice and was opened by a tall Caucasian woman with unkempt brown hair and even messier eyebrows—owl like almost. She was wearing a long blue lab coat, a poorly cut pink cardigan, and a stethoscope. She removed her right hand from one of its pockets to greet me. She proceeded to sit down behind a computer connected to the clinic’s server and ask me a lot of general health questions. The electronic health data that had been collected from me over the last six years I had been coming to this health center should have been available to her. Maybe this redundancy was her way of getting to know me. I answered her questions the best I could. Because Dr. Cahn was effectively a stranger, I wasn’t as open to disclosing personal information.
One of the better arguments against health policy implementations that could cause patients to have to switch doctors, is that we are less trusting of physicians we have just met, we are less likely to divulge all of our fears and concerns, and our doctors are less likely to help us to their fullest qualified abilities. However, while it is comforting to see the same physician over long time periods, and while it was thought that longer maintained relationships could lower health costs significantly, studies have found no correlation between longer maintained physician-patient relationships and the use of preventative services, adherence to healthier behaviors, or decreases in ER visits by patients (Weiss & Blustein 1996). There is, however, something to be said for longer doctor-patient relationships and their effect on trust. Patients trust their physicians when they believe their doctor is honest, competent, and working in their best interest. Once trust is established patient satisfaction and adherence to medical advice increase (Fiscella et al. 2001). Patient health increases. Mutual trust is also important for allowing patients to express themselves and make educated health decisions for themselves (Hughes & Larson 1991).
After the round of general questions, she started asking me questions about my blood sugars. I was supposed to keep a journal, but with my hectic schedule this was something I rarely did. I swam four hours a day and was still applying to colleges. She began to get frustrated by my inability to provide concrete and satisfactory information concerning my blood sugar trends. I was guesstimating, and for someone more concerned with illness than a person, this was would be very frustrating. Fifteen percent of patient encounters are reported as frustrating by physicians (Krebs et al. 2006). But physician identity can significantly predict how often a doctor gets upset with his or her patients. Unfortunately for my self esteem, as I sat on my hands, my new physician was poised to be angry. Krebs et al. found that physicians who were regularly highly frustrated were more likely to be under forty than over forty years of age, to be female rather than male, and to be subspecialists instead of generalists. It also did not help to be in poor to fair health. My tall, female endocrinologist who had graduated from Northwestern’s medical school within the last five years, and whose BMI I guesstimated was somewhere in the low thirties, fit all of these descriptors.
I was shamed that I had not brought in more helpful information about the disease I had suffered under for the last six years, but that self-loathing transformed into sad incredulity when my doctor said what I’m sure few patients would choose to hear. “Well,” she said exasperated, “If you don’t bring in the sheets, I really can’t help you.” Hostility. There are four main communication types regularly employed in physician-patient encounters. Of the four, hostility is the least preferred, behind the top rated reassurance, followed by neutrality and humor. Both patients and physicians rate these communication styles in the same way (Linn and DiMatteo 1983). I had never been talked to this way before, and I prayed that this was anomalous, and not something I would have to look forward to as I entered the realm of health care catered for adults.
Dr. Cahn’s constant use of a computer in the examination room was also distressing. The majority of my health records have been digitalized, and for the most part, I am happy about this. When I went to see an allergist after an unusual anaphylaxis, she knew all the medications I was on and it saved both of us from talking and hearing about unnecessary life details. I wasn’t scared about my allergies, and I didn’t want or need extraneous coddling. But this wasn’t about allergies—this was about diabetes. I was an adult, yes. I didn’t need a sticker or a lollipop. But I was scared. My endocrinologist addressed me as if I wasn’t even human; we were not equals. She didn’t look at me as she made her remark of annoyed helplessness, so she couldn’t see my face fall, my eyes wander towards my shoes, still kicking in the air, but more restrained now. It turns out that not looking at your patient increases their dissatisfaction. Roter et al. reviewed studies1 of nonverbal behavior, and found that patients enjoyed doctor visits when less time was spent reading charts, more time was spent being looked at, when the attending physician nodded more, and when the interpersonal distance maintained was minimized (2005). My endocrinologist did none of these things.
The worst part of my visit, the worst part of our interaction, was her tone. She had sounded annoyed. Tone is considered a paralinguistic speech feature, somewhere between verbal and non-verbal communication. When surgeons use more dominating tones, they get more malpractice lawsuit claims brought against them (Ambady et al. 2002). When my endocrinologist used dominating tones, I was able to assess where I fit into the doctor-patient relationship. This attempt to understand where you fit within a hierarchy is a common cognitive process undertaken by all humans while socializing and is called ‘standing.’ Specifically for doctor visits, standing, trust, and neutrality are all important for a patient to be able to make good decisions. The ability for patients to make their own, well informed decisions, is a part of procedural justice, and if a physician fails to convince a patient that they are trustworthy and unbiased sources of information, and if the patient believes the physician holds them in contempt, the autonomous patient will make poor decisions (Hughes and Larson 1991). I could tell from Dr. Cahn’s tone that she did not care about me, and as a result, I was not at all inclined to listen to the advice or instructions she gave me when I left that day. Tone influences if patients accept or reject their physician’s suggestions (Milmoe et al. 1994). Of the many times I have gone back for a check-up, I have only created a blood sugar journal once. And even then it had been an anemic effort—I had made up a couple of values. I was human. I had feelings that could not be conveyed in milligrams sucrose per deciliter.
And I am not alone in this view. Diabetics are very non-adherent. Adherence to medical advice is recognized as an important criterion for improving medical care for several reasons. With improvements in health care and technology, a number of diseases now require patients to take care of themselves. You can live with diabetes now, but you have to monitor and regulate yourself, by yourself. Similarly, hypertension is now recognized as bad for your health—hypertensives must change their diets or regularly take medication. Failing to implement medical advice can result in unnecessary morbidities and mortalities (DiMatteo 2004).
Non-adherence also represents a huge economic loss to health care. In the year 2000, the non-adherence rate was 24.8%. In that same year, 759 million doctor’s appointments were carried out—that means that some 188 million visits resulted in patients not listening to health advice. With 53 million of these visits using public health resources, the economic waste of non-adherence could be as high as $300 billion every year (DiMatteo 2004).
The non-adherence rate for diabetics is much higher, at 32.5%, than almost any other disease—save sleeping disorders (DiMatteo 2004). We also suck at interacting with our doctors. The majority of diabetics prefer passive roles when it comes to medical decision making (Arora and McHorney 2000). This may be due to the inherent high anxiety of chronic disease, which makes patients more readily defer to dominating physicians.
That clearly happened that day I discovered that doctors could suck. But it was not just her fault for being frustrated or my fault for being terrified. It was both our faults because we weren’t interacting in a vacuum. We were interacting with each other. There are no easy fixes for how patients and doctors should interact, just as there are no easy fixes for diabetes. But there are always suggestions: Dr. Cahn should try to understand the psychosocial drain of endocrine disorders. I should take my health seriously instead of having “stress black-outs”; I let an abstract fear of the future dictate less than health behavior in the present.
The problem I faced that day is actually a huge problem facing the current medical model. Only 28% of physicians give their patients the prompting or the time to express themselves (Van Dulmen and Bensing 2002). For physicians, this can be done fairly easily: show a little empathy and ask why your patient came in today. What are their symptoms? Thoughts? Feelings? When patients disclose stress, they grow confident that their physician cares for them, and this release has actually been shown to have positive physiological effects for the patient. Disclosure can improve immune function, lower hemoglobin A1c, and lower blood pressure (Van Dulmen and Bensing 2002).2
In contrast, I have been shadowing a doctor, an osteopath, Dr. Williams, for an entire semester. A general practicioner with an office set up in a small town of eight-hundred, he worked with a diverse group of patients: farmers, teachers, drug addicts, business people who lived in Syracuse suburbs, the unemployed, the chronically unemployed, blue collar workers, and children. Despite the diversity of the patients he saw and the problems he was presented with he excelled at connecting and comforting patients. Both his ability to relate to patients and to communicate nonverbally made him a superior physician. The biggest test to Dr. Williams patient-centered approach came in the form of a suspected narcotics addict.
“I hope Tom comes in today. He’s a trip,” Dr. Williams said to me. I looked up from my reading. He had rotated around in his office chair to face me and his hands were on his knees. He looked very excited, but in a slight sarcastic way. “I’m pretty sure he’s addicted to narcotics. And he’ll try anything he can to get me to prescribe him some more.” I said some conversational fodder, like “whoa,” even though I was inwardly trying to determine how worried I should be. The way society paints addicts, well… Norman Rockwell wouldn’t take a brush to the subject. American culture is deathly afraid of addictions to prescription narcotics, to the point where most Americans have been found to reject what they consider effective medicinal pain relief treatments because they fear addiction. Physicians also tend to see patients asking for drugs as a sign of blatant drug-seeking behavior. Under-medication is quite common in patients facing chronic pain (Post et al. 1996).
As I silently read papers and listened to Dr. Williams record notes on various patients he had seen in the morning, breaking up sentences and thoughts with truncated utterances of “period,” and “paragraph,” respectively, I heard the door open and a new conversation starting up. Shortly thereafter, the secretary walked in and handed Dr. Williams a note. “Tom says he’s going to die from pain.”
“Did he now?” Dr. Williams chuckled. They conversed briefly. I closed up my notebook. “He’s here.”
Dr. Williams had told me a few things about Tom before we were ‘introduced.’ First, Tom had recently failed a urine test for THC, the active component in marijuana. Second, Tom had left Dr. Williams a speaker system as a gift during their last appointment. The failed urine test concerned Dr. Williams because Tom had told him he had stopped smoking, yet here was a lab result declaring otherwise. The gift also concerned Dr. Williams, because gift giving, especially something as potentially expensive as speakers, was an inappropriate gesture for a doctor-patient relationship, and even more inappropriate if the patient was potentially trying to finagle morphine. Third, Tom showed signs of classic manic depression. This was fairly evident as I stood in the corner and watched the two of them interact for forty-five minutes, the longest visit I had ever seen Dr. Williams make. Tom was animated, swearing often, not following any sort of syntax as he constructed sentences with content that contradicted prior statements. Fourth, Dr. Williams had said that Tom would probably be really nice to him until Tom realized that he would not be getting the full prescription like he wanted, “Then I’ll be the most evil person in the world,” Dr. Williams said. He seemed humored. I pretended that I wasn’t scared.
Sure enough, when Dr. Williams said that he would be writing a prescription that tapered Tom off of morphine, the patient became very confrontational. Dr. Williams response was to become more paternalistic, which was the first time I had seen him attempt to maintain a level of authority above a patient for an extended period of time. Physician paternalism is a way that doctors can relate to patients. It is often associated with the way doctors used to talk to patients in the fifties, when doctors possessed a wealth of health knowledge that would be practically unknowable for the average patient, thus making it okay for doctors to tell patients what to do without listening to the patient’s concerns. This is directly opposed to a type of relationship, which is increasingly being advocated, patient autonomy, wherein the patient can listen to what the doctor says, but ultimately has more than enough right to make their own decisions, independent of what a doctor may want. Patient autonomy, and its importance, is taught in many medical ethics courses, and is the reason why there has been so much research on patient-centered care and its benefits over traditional doctor-patient interactions. Patient centered care improves patient adherence, helps improve the control of chronic diseases, increases patient satisfaction, and increases a patient’s understanding of symptoms (Jenkins and Fallowfield 2002). This type of care is most employed by female physicians, who are statistically more capable of talking about psychosocial problems with patients and are statistically recognized by patients as being more empathetic, and general practitioners.
The benefits of this approach become less clear when dealing with addicts. First, trust becomes an unknowable variable when the person talking to you is addicted to drugs. I have had a family doctor tell me straight out that you should never trust anything an addict tells you. And he meant anything. Something as mundane as “Is the patient taking his COPD medication regularly?” was a question that the patient was not qualified to answer. After Tom had left, I had told Dr. Williams about this philosophy, adopted by another general practitioner, and he shrugged, “I mean, there are some things I know I can trust. But things that are dependent on him taking his narcotics, I’m less sure of those things.” It sounded very pragmatic. But trust is something that should have to work both ways. If I have to trust my doctor that she is doing everything in her ability to offer me her best advice, opinions, and support, she should also have to trust me that I am answering her diagnostic questions truthfully, expounding on my symptoms, and willing to follow her advice to improve my own health.
Second, and this is rather abstract, are people still people when they are addicted to drugs? Are people still autonomous, is what I should say. Chronic pain is oftentimes described as dehumanizing. Post et al. illustrated this idea with the following quote:
Pain is humiliating: it destroys all sense of self-esteem accompanied by feelings of helplessness in the grip of pain, dependency on drugs, and being a burden to others. In its extreme, pain destroys the soul itself and all will to live (350).
Was Tom really feeling pain? Or was he feeling the pain of addiction? In either case, did he lose his claims to his own autonomy? If we consider Tom to be in an emergency state, which, as a dysfunctional member of society—chronically unemployed and quite possibly addicted to narcotics—he could easily be, then could not Dr. Williams waive all of “Tom’s” rights in order to save Tom from himself? Dr. Williams assumed a very dominating persona when interacting with Tom, and I believe it resulted from these reasons. Most notably was Dr. Williams’s change in posture. Generally the doctor keeps his hands in his pockets or at his sides. When interacting with Tom, he crossed his arms. What amounted to a very slight gesture, ended up being a large tell for the doctor, who never crossed his arms when meeting with patients. Patients are dissatisfied with this posturing (Roter et al.) because it makes their physicians seem more dominating. Just like with tone, dominating behavior is not what patients want in their doctors because it makes them feel like their physician doesn’t care about them or their opinions.
Was Tom different, though? Dr. Williams persistently disagreed with Tom about a number of smaller issues. Each time, however, it appeared that Dr. Williams was in the right. For example, when they disagreed on how long after smoking did THC remain in the body, capable of detection by urine analysis, I was almost positive that the doctor’s answer of three days was much more likely than Tom’s guess of three months.
After Tom had left, disgruntled with a prescription for morphine that he would probably burn through in two weeks instead of its prescribed month, Dr. Williams expressed dissatisfaction in the way that he had interacted with Tom. I told the doctor that I thought he had done a great job—in comparison with the other family practitioner who would not believe anything uttered from the mouth of a chronic marijuana toking twenty-something, Dr. Williams had tried to relate and reason with Tom despite Tom’s level of aggression. I thought that that was very commendable. Dr. Williams was still a little uncertain. But this is also a less well known trait of doctors: they always think they could have done better; they are always striving for perfection (Beck et al. 2001).3
Part Three; The Doctors’ Daughter
I always would have been connected to the concerns of the American health care system even if I had never come down with diabetes. Both of my parents are surgeons. They met during a thirteen-hour surgery, standing over an alcoholic with advanced pancreatic cancer. Now, even though they have identical degrees, their careers are significantly different. My mother is a professor at a medical school outside the city, while my dad works at many different hospitals in the heart of Chicago, not in the loop, but further West, in less iconic places.
Sometime within the last year, my father was raving during dinner. He usually doesn’t expound about his job much during family dinners, but tonight he was ranting as he sawed through his chicken. He had been called a few minutes before sitting down at the table, a head nurse asking him to come in on his only day off to work on a patient no one had informed him about prior. He had excused himself from the kitchen where he had been watching the Golf channel and where my mother and older sister were still re-heating white meat and steaming frozen vegetables.
My dad rarely sounds happy when he talks on the phone, a combination of his inability to speak softly and his Nigerian accent. He was getting old—past the federally mandated age for retirement. Yet he still remained on call. Occasionally he’d get calls of emergencies, and he’d have to drive through the city at 2 AM. Tonight, however, the situation did not seem pressing. A lot of work he gets called in to do is not really necessary. This phenomenon, that occurs because hospitals and doctors would like to avoid the severity of malpractice lawsuits, is derisively called CYA, or “cover your ass”, by physicians. My father settled the dispute with the head nurse. “Is doctor Bekele on call? Have Bekele cover it.” But his frustration persisted through dinner.
Most of the patients my dad sees are on government health programs. This does not upset him too much, in fact, he says, he would love to be able to make enough money from seeing some patients so that he could devote one day a week to doing surgeries at low or no cost. But he recognizes this as an ideal situation, which is unlikely to happen, if only, he mentions cynically, because too many well-off, or well-enough-off people would take advantage of such a set-up.
Though my dad works in Chicago and Dr. Williams works in central New York, their lives seem to have similar frustrations. Many of the patients Dr. Williams saw were on Medicare or Medicaid. He had begun the process of sending all three of his children to college and would be paying tuition for the next six or seven years. He expressed quiet shame at not being able to see everyone who wanted his help, and that he had had to turn prior patients away due to insufficient funds.
The first time I met with Dr. Williams he began briefing me on what to expect from his practice. Lots of paperwork, he told me, would mean I would be spending a lot of time sitting in his office, watching him do it. “Bring homework,” was his advice. There were no windows in his office, just a lot of medical flyers tacked to the walls giving advice on how to treat some of the more common diseases—diabetes, arthritis, asthma.
Dr. Williams attended a Medical school in New York state and earned his D.O., or doctorate of osteopathy. A doctorate in osteopathic medicine is viewed as an equivalent to a doctorate in medicine, but osteopaths approach care in a more holistic fashion. He defends his choice to practice family medicine because he likes working with people, not just diseases. He told me that if I was more interested in disease, I should not be in family practice.
It has become more noticeable that while overall doctor shortages are putting a stress on the health care system, the area that will suffer most from a reduction in numbers is primary care (Baron 2010).4 In 2002, the Kaiser Family Foundation surveyed 2,608 physicians who worked in direct patient care. Family doctors. These are not specialists. These are people who refer the masses to the appropriate specialists. These are people that the entire health care system would collapse without. The attitudes of these physicians were bleak. Fifty percent of them would not recommend the profession to young adults. Fifty percent. Half of America’s general practitioners have been so brow beaten that they would strongly discourage young adults to become doctors. I have witnessed this first hand with general surgeons. When my dad brought me to the operating wing of one of Chicago’s biggest hospitals, in small talk many of his fellow surgeons asked me what I wanted to do. “I’m pre-med,” I’d say, simple, short. They’d shake their heads. “Don’t become a surgeon.” Sometimes I’d get prolonged anecdotes about how little sleep they’d gotten in the last week or how much better it would be for me if I became a dentist or a radiologist. Those are important people, too. They just get to make their own hours. They get to sleep.
My mother had a similar attitude. When I first told her as a nineteen-year-old that I didn’t really want to go to medical school, her response was sullen but accepting. “You should become a PA. It’s only two years of school, you can do almost everything a doctor can, and you end up making about the same amount of money.”
Doctors don’t even want to be doctors anymore.
Why? This self-loathing originates with public opinion. Doctors really do feel that respect for the medical field has declined significantly in the last decade, and will continue to decrease. But this is only half of the problem. Public opinion is tied up with public policy concerning health maintenance, and they both feed on each other in a negative way. Last year, in 2010, an article was published in the Journal of the American Medical Association (JAMA) that talked about how the way doctors are viewed ultimately influences the way doctors are legislated for or against. Before managed care and HMOs, doctors worked in a simple fee-for-service set-up. Doctors set their own prices and they made their own rules. In the early eighties, for example, my father was still operating under this system. A man came in with an abdominal aortic aneurism. That’s bad. The man easily could have died, but my father was a well-trained surgeon and it was his job and he had sworn an oath. That surgery made my father about $21,000. Very pricey, but he had saved a life. Today my dad still does this surgery; people will never stop getting abdominal aortic aneurisms. However, today my father only makes $2,000 for the same surgery. Where has that $19,000 gone? Malpractice insurance, surely, ending up with lawyers. Managed care, of course, because the surpluses the program makes inevitably wind up with upper management. More necessary, some of this money ends up going towards better tests and better labs—better technology which lessens the mortality rate for these types of things. But the remainder of this $19,000 deficit is a result of the lack of trust people have for doctors.
Jain and Cassel write in JAMA that physicians can be seen by the public as one of three types of people. The knight, the knave, or the pawn. Until somewhere in the 1970s, doctors were seen as knights. Courageous people who put patients in front of themselves, who were well educated and put that medical knowledge to good use, and who would always strive for self-improvement because it meant they would be better at helping people. In the seventies, however, the introduction of HMOs briefly increased the wealth of doctors because in its golden hour, managed care was able to allow more people to see doctors, increasing the amount of work doctors were doing and increasing their annual profits. At this time, the average doctor’s income was nine times more than the average American (Jauhar 2011).
With this wealth, Americans began viewing doctors as knaves, or people who cared more about their personal gain than helping others. This is where the system stands today. As a result, it has become a popular for managed care to embed incentives into policy, to reward doctors for doing the right things when dealing with patients, instead of being able to safely assume that all physicians are working towards helping patients without ulterior motives like accruing large amounts of wealth.
The third category is pawn, which represents the most likely future of the American physician if these social issues are not addressed. The pawn is neither good nor malicious. The pawn will follow rules, not because they are right and not because they will gain anything for themselves by following them, but because they are rules. The pawn has no motivation for self-betterment. The pawn does not move the medical field forward. But if doctors don’t want to be doctors anymore, we may end up with only pawns examining patients.
Part Four; Is There a Doctor in Me?
This will become your conclusion. Try to maintain optimism, and talk about the value of becoming a primary care physician. Also discuss how excellent health care in America is, despite the fact that it lacks financial stability. Discuss the optimal health care relationship; discuss its feasibility and its promise for change.
Why do I want to be a doctor? I didn’t always want to be a doctor; most likely because of what my parents said every night they came home from work. Or maybe it’s because of what they never told me because they were always busy. The first rough draft of my personal essay for my Medical School application had declared this sentiment in the very first line. But when I determined that my GPA was not as sufficient as I had planned it to be, I decided to change my essay, omitting the fact that I hadn’t really wanted to be a doctor until the start of my junior year. It’s not like I could not see myself as a physician—I looked trustworthy and wise in a white jacket. The problem was entirely a lack of motivation. Consider what doctors have to do to become doctors. How much money do they have to borrow, how many hours they continue to study after college. How many moments they miss out on from popular culture because they are too busy studying (I have asked my parents if they remember seeing Star Wars, any of them, but they never made it to the theaters, not once, because of Medical School and residency). Then consider the hours they put in dealing with regulations and re-certification once they’ve become doctors. Think about the additional hours they spend dealing with inept hospitals or filling out mandated paperwork.
My parents did not filter what they told me. And it all sounded horrible.
But I am a human being, and it occurred to me when I was around twenty years old that I cared about other human beings, too. My dad told me once, “To those whom much is given, much is expected.” It’s a quote from John F. Kennedy, a paraphrase of a line from the Book of Luke. I think the context was probably something about how America had obligations to do good for other countries because America at that time was enjoying lots of wealth and was capable of doing such. I got lucky that my parents had provided entirely for my education. A lot of people can’t afford it. A lot of people look at the cost of medical school and panic.
I also am lucky that I am insured and that my insurance is of good quality. I’ve looked at how much money my insurance saves me in a month, and the costs of being a type I diabetic in America is simply unsustainable. Keeping in mind that diabetes is a growing affliction, this can only suggest that something must change.
In a perfect world, doctors would still be perceived as knights. So in the ideal world, we wouldn’t have legislation like “no caps for medical malpractice claims,” which is devastating in states like Illinois. This means that not only would the burden of paying back medical school loans look less and less momentous over time, but certain specialties would not have to worry about having nobody to fill their positions. Family practice is not a high paying job for someone who has a spent $200,000 or more on a medical degree. Likewise, obstetricians are heavily discouraged from practicing if only because malpractice insurance is illogically high for something so vital for life.
In this ideal world, patients would practice autonomy but also have respect for doctors. This respect would increase the amount of trust between parties, and would help the doctor be a better doctor (Empathy as Emotional Burden citation) and the patient better at following medical advice. Patients would be healthier. Patients would require fewer visits to the ER. Patients would get healthier quicker and would suffer from fewer complications. Less money, or the trillions of dollars spent annually, would have to go towards unnecessary procedures to protect doctors from being sued for “not checking every single possibility.”
This is an ideal world, but it’s enough for me to hope that one day, not only will Americans have the best medical technology in the world, but it will also have doctors with the best technical competence and the best ability to craft the “art of care.”
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