Thinking Like a Doctor: Why They Charge So Much
Lee, Thomas H.
Thinking Like a Doctor: Why They Charge So Much by Thomas H. Lee Ask medical students-mature adults in their 20s and 30s-why they chose medicine, and they'll give you the same answers they used...
...Medicine demands a lot of rote memorization and rigid adherence to not-so-glamorous routinea good doctor doesn’t skip rectal exams...
...Nurses cannot...
...As a result, most hospitals and the health care system are in serious financial trouble...
...For example, 40 or 50 patients will be given appointments for the hour at which a clinic opens, rather than spacing them out over the afternoon...
...Drug reactions kill about 160,000 a year...
...One resident I know recently had to fill out a questionnaire and became depressed when he got to the part about “Outside Interests” and realized that he no longer had any, except sleeping...
...This system means that most of the patients will wait 1 or 2 hours, but it eliminates the possibility that a doctor will sit idle if one patient is late...
...Medicine has created disappointment through its own success...
...The demands of medical school and residency are beyond the imagination of most Americans-they were certainly beyond mine when I applied...
...And they continue to draw the best people...
...We in medicine live in an enclosed little world, one that has absorbed nearly all our time and energy and shaped our attitudes...
...and they tend to like that...
...Get an M.D., one learns, and you can touch or ask anything, dominate people while helping themand get a lot of praise (and money) for it...
...Even the most cynical doctor still sees a little bit of Albert Schweitzer in the mirror...
...This much is clear-doctors were once medical students, who were once pre-meds, who were once in high school...
...It’s taking a good medical history, murmuring appropriately “I see” or “That must have been very painful” or “We see this often in cases like yours...
...Hospitals reinforce the loss of control, stripping patients and dressing them in gowns that do not quite close in the back, performing tests without warning or explanation, sticking tubes in every orifice...
...When pressed, most will concede that they're dimly aware of other attractions-the independence, the secure and ample income-but these are described as incidental fringe benefits...
...But even when they can’t, huge decisions are left to them by default...
...license plates to- gifts from drug co @ini&.-‘l<$ut the most serious effect of hedicine’s star system comes when \doctors believe their own hype-when th&,@ar patipts say, “You gave me life,”‘and _think to themselves, “He’s right...
...The doctor is a star and virtually every aspect of patient care revolves around him...
...Do the sacrifices of youth justify huge fees in middle age...
...While reciting the stories, you realize that your vocabulary and viewpoint have changed...
...These will be welcome changes, and they ought to be made...
...Doctors in turn increasingly view patients as potential legal foes and devote nearly as much energy to avoiding law suits as to curing disease...
...But fatigue has its romantic advantages, temporary though they may be...
...It’s as if the people and their doctors were enemies forever...
...Not for everyone, but the intense competition for admission has forced many undergraduates to concentrate on science at the expense of history and humanities courses that might provide insight into the world in which medicine is practiced...
...What am I going to do-go out skydiving...
...When medical students are worked at a sane rate, they’ll feel less self-pity and won’t think later on that they have a right to be millionaires...
...Their patients had only one complaint-they wanted their physicians to “dress like doctors...
...There is no time for sports, reading, or relationships...
...Doctors like to tell the joke about a man who dies and finds himself standing in a long line outside the Pearly Gates...
...Some of it is the morning-after disillusionment that followed the euphoria ushered in during the 1930s with the development of “golden bullets” that could wipe out or limit the greatest killers of that time...
...In some ways, a romantic self-image makes a good physician...
...In a 1977 Harris survey, only 43 per cent of Americans expressed confidence in physicians, versus 76 per cent in 1966...
...And they develop a fondness for perks, rangingfrom M.D...
...There’s pressure to talk about cadaver dissection, psychiatry, and pelvic exams...
...This task and many others could be performed by nurses or paramedical workers, but the team approach is still alien to most hospitals...
...But what do their patients think...
...I suspect that such fantasies of martyrdom go on in America today and are in fact an essential part of modern medicine...
...Malpractice suits are only one part of the evidence...
...they’re normal people in a profession that has allowed their fantasies to become reality...
...One Friday evening recently, over beers at a bar, I asked a surgery resident who was winding up his fifth year of 36 hours on, 12 off, just what kept him going...
...Once residency is over, there are no teachers to impress, no peers to dazzle, and a new form of positive reinforcement must be found by medicine’s compulsive over-achievers...
...Money becomes a factor for doctors when they are too old and jaded to play the game, when they try to cash in their chips in private practice...
...Some patients do need full explanations, while for others a few milligrams of Valium will do...
...These broad attitudinal changes have worked their way down to the wards and waiting rooms, where an adversary system has crept into the doctor-patient relationship...
...An estimated 2.4 million unnecessary operations were performed in 1974, leading to 11,900 fatalities at a cost of $3.9 billion...
...By telling a mildly selfdeprecating story, they show an (even milder) degree of humility...
...Thinking Like a Doctor: Why They Charge So Much by Thomas H. Lee Ask medical students-mature adults in their 20s and 30s-why they chose medicine, and they'll give you the same answers they used at 12: "I want to help people...
...A tall figure in a white coat came, took away their pain, and drove off in an Oldsmobile...
...I don’t see any point in being told I have six months to live...
...And the cockiness that steadies a surgeon’s hand can make him an impossibly obnoxious political foe...
...He said he didn’t know, and I believe him...
...Doctors tend to draw a distinction that the public cannot-between their system and themselves...
...In some countries, care is delivered by coordinated health teams, but U.S...
...I usually have more important things to do, like pushing didge...
...At those times, I’m aware that if there were any other pedestrians on the street at that hour-and there usually aren’t-they might look upon my spent figure with a mixture of awe and admiration...
...These hospitals’ most treasured commodity is physician time, and they are designed to make the doctor’s day as painless as possible...
...But it’s also the fault of doctors’ failings...
...Illness is itself a reminder of the vulnerability and helplessness that many patients felt as children...
...Typically, early in childhood, they broke an arm...
...After a time, you find that you’re most comfortable with other people in medicine, grousing about malpractice premiums and the hours you work...
...And it’s not stuttering when you ask a priest if he has ever had VD or a woman whether she’s reached menopause...
...But most doctors don’t like to give decisions away, or even discuss them...
...In short, doctors are not just like other people-they're even worse...
...Paternalism Paternalism in general went out of style in the 60s, I thought, but in medicine it remains as fashionable and functional as black bags...
...In fact, the defense doctors most commonly offer for their high fees is a blunt, “We work harder than anyone else...
...In that case, I’d want my doctor to use his good judgment and not tell me...
...Both agreed that on the nights when they had to operate at 3 a.m., neither thought of money...
...Once you’ve developed your professional cool, it’s easier to make decisions on how much to explain, how much to withhold, and what simply to command...
...A system US...
...For example, a college graduate who wants to become a heart surgeon faces a minimum of 11 years of training, maybe more...
...Remember your last visit to a clinic...
...Doctors shouldn’t exclude themselves from political discussions by their obstructionism, and politicians shouldn’t count them out as some sort of fringe group...
...One resident I know scheduled a talk for his students for 2 a.m...
...h e doctor is a star...
...Moving up this Great Chain of Being requires good grades at each step in disciplines that reward hard work more than raw I.Q...
...The more important forces were motivations for which money is often only a substitutepraise from superiors, the admiration of peers, the gratitude of patients...
...Only a joke, and not a very good one at that, but doctors love it for two reasons...
...and for many, the making of a doctor-and the process of acculturationactually begins long before college, or even high school...
...Who wants to be treated by an equal when Blue Cross will pay for a father figure...
...So people in medicine tend to savor their weariness-blood-shot eyes are their red badge of courage...
...Although they vaguely know of the country’s health care crises, they are content to be perfectly functioning cogs in a machine gone awry...
...Before I came to medical school in 1975, I would have agreed with that notion...
...Luckily for them, medicine not only forgives these notions, it cultivates and redeems them...
...Some physicians realize that solving medicine’s problems will demand working with the rest of the community, but this message hasn’t seeped down through the ranks to pre-meds, and no wonder...
...Your professional cool reminds you and your patient that you’ve been through this before, so you might as well handle everything...
...Only 60 per cent of U.S...
...In fact, he knew just what kind of doctor he was looking for...
...That judgment seemed a bit harsh on everyone concerned when Shaw's attack on medicine appeared in 1911...
...No wonder many patients complain that they “feel like a little kid...
...Because of the effectiveness of these drugs and vaccinations, infections like pneumonia and polio are less significant today than chronic diseases like heart disease and cancer, for which no wonder drug exists...
...The reasons are psychological and cultural...
...In fact, after a few years at med school, many students feel uncomfortable during their rare encounters with old friends “on the outside...
...While doctors are young, they do work harder than anyone else...
...Some of these problems are solvable and some aren’t...
...In fact, a fundamental part of medical school is developing your “professional cool”-all the little things you do to reassure the patient that everything’s in control now that you’re here, even if that’s not exactly true...
...They like control, and patients are generally content to let them have it...
...The pay is better than it used to be-interns at Manhattan’s New York Hospital make $16,000 a year...
...The trick is knowing which are which...
...Pre-payment would motivate doctors to keep people healthy and encourage patients to seek care early in the course of their disease, making health care more effective and efficient...
...Even the strongest individuals are less independent when sick, and many patients are at least partly looking for an authority or father figure who can take control and magically make their problems disappear...
...More than once, I’ve found myself walking, exhausted, along Manhattan’s York Avenue in the dark, white jacket slung over my shoulder, sleeves rolled up, tie loosened, top button unbuttoned, pants splattered with blood and iodine, in desperate need of a shave and shower...
...Doctors are not monsters who must be broken or conquered...
...There are now some valuable reforms of health under discussion, but I’m worried by the tone of the debate...
...Illness has always had a magical significance, and today, despite increased understanding of afflictions ranging from crabs to cancer, the sick remain creatures of superstition...
...They come to believe in their own omnipotence and try to extend their expertise beyond their field-to the lives of their patients and to hospital administration...
...These are justifiably distressing statistics, and they have helped bring about the fading of the Norman Rockwell image of doctor as friend, neighbor, and occasional savior...
...Like most people, I've often gone without doctors because of the expense, and when I did go to my local clinic, I usually sat an hour or more in the waiting room, enraged, reading stale copies of Time or Highlights for Children...
...Can you get excellence with arrogance, dedication without martyrdom, direction without domination...
...The climax of the healing ritual is the collapse of the stricken shaman, who then overpowers the disease at great personal expense...
...One answer is to play to their psychic needs: these are prima donnas, people who like recognition and control...
...Many people are torn between the security a dominating traditional physician can sometimes provide and their distaste for the paternalism that often comes with it...
...For example, one non-doctor friend recently told me that he despised doctors on principle, but accepted them as a necessary evil...
...Can you ask for the good without the bad...
...Health care programs cannot, after all, be forced on doctors and still work...
...Does aiming for med school necessarily mean excluding all other interests...
...The current generation of physicians has always thought of itself as technically superb, hard-working, and justifiably paternalistic, and there is no reason to believe that the doctors they are training now will be any less humble...
...The problem with doctors is that so many are sure they can tell...
...You have to work too hard and long, in the libraries and labs, alone...
...My father's a doctor...
...They consider themselves free agents, responsible only to themselves and their patients...
...Pain is commonly unconsciously interpreted as punishment, evoking questions like “Why me...
...It’s a delusion often shared by patients...
...From that moment, they knew what they must be, and set off on the long, lonely road to an M.D...
...Like lovers looking for the women of their dreams, these youths come to medicine full of fantasies about what wearing a white coat means...
...Getting into medical schools has never been more arduous...
...Even the most cynical doctor still sees a little bit of Albert Schweitzer in the mirror...
...These patients gravitate to doctors who complement them, who accede to their wishes, and who are often themselves pleased to avoid choices...
...Some psychiatrists would suggest looking as far back as toilet training, where the roots of obsessiveness and compulsiveness lie...
...Significantly, many of them even bear the same name-a “Doctors’ Hospital” can be found in cities throughout the country...
...Most hospitals are run not by businessmen but by doctors, as if the idea of a doctor working for an MBA was too offensive to consider...
...Medical students work similar hours, and pay for the privilege...
...Doctors raise their fees each year not to meet their rent, but to give themselves the little pats on the back that once carried them through their training...
...The need for large fees seems to arise later, once a doctor leaves the academic environment and heads for the suburbs and private practice...
...You don’t need a sense of community or political savvy to get into medical school, and besides, there’s no time to develop them...
...You have to carefully avoid technical terms and even more carefully screen out material that might be too shocking...
...Probably, but the consequences are subtle...
...But spread that over 100-hour work-weeks, and it amounts to $3.00 an hour, less than the hospital janitors make...
...Not surprisingly, the hospitals that doctors like most are the ones that treat them best...
...This means that individual patients will probably have the same complaints about doctors for some time to come...
...that does not account for their personalities and motivations is doomed...
...They don’t dress or make small talk as well as lawyers...
...Does it matter if doctors know little of music, art, or sports...
...And that’s where many of medicine’s problems begin...
...Medical school is perhaps the single most important influence on the behavior of doctors, and changes in medical education will take 20 or 30 years to show up as changes in the health care system...
...All the purposeful activity and the people clamoring for attention It also makes them feel important, makes doctors feel harried, overworked, and underpaid...
...There are many patients who demand full explanation of tests, description of all options, and final control over decisions...
...Where Doctors Come From A surprising number of physicians have always known that’s what they wanted to be, even at ages when their friends were still earnest about becoming cowboys or quarterbacks...
...A shaman in many African tribes exorcises disease by absorbing it into himself...
...But doctors are also romantic with all the word’s negative implicationsthey’re self-indulgent, they’re false martyrs, they’re naive...
...I blamed all this-my illness, the wait, even the old Time magazines-on doctors, who I imagined were spending my fee on Cadillacs or golf clubs...
...During the early years of their careers, when doctors are forming their professional self-image, they work from motivations other than money...
...I want a doctor who will tell me everything, explain every detail, hide nothing-unless the news is terminal,” he said...
...But in the meantime, what do we do with the doctors we’ve got...
...And good medical students begin developing methodical study habits early in their schooling...
...There’s something about going to work in the dark and coming home in the dark-realizing that you’ve missed another day’s light completely-that Nothing infuriates [doctors] pearly as much as the inference that they are overpaid...
...The AMA goes so far as to call the physician’s duties “a sacred trust...
...But until then, few are obsessed with making money-there isn’t even time to spend it...
...And he’s not alone...
...In fact, I believe that part of the problem with doctors is that so many of them are incurable romantics about their role as physicians-romantic not in the amorous sense, but in the imaginative and emotional aura with which they surround their work...
...In medicine, the better and more desirable an internship is, the poorer it pays-the prestigious hospitals offer more important attractions, such as excellent teaching and good laboratories...
...As everyone knows, doctors run their own lives...
...Pre-meds are urged to choose from a range of majors that, to paraphrase Dorothy Parker, runs the entire gamut from biochemistry to biology...
...He’s understandably furious until he finds out who the Gatecrasher is-God playing doctor, of course...
...medicine is large1 a one man show...
...And they have a tendency to blow fortunes in the stock market...
...He waits patiently until he sees someone in a white coat jump out of a Lincoln and rush past the line into heaven...
...Cleaning up my affairs would take a few days, and knowing would just ruin my last six months...
...Designing such a system here will require closer cooperation between health planners and doctors than we have seen...
...Of course, you understand,” he added, “I would never go to a doctor if I suspected that he might do such a thing...
...Very few feel guilty about the money they earn-they feel they deserve it...
...In medicine paternalism remains as fashionable and functional as black bags...
...In the end, their psychic needs usually win out...
...But it also fosters the very qualities that doctors’ critics find so irritating...
...The form may have changed, but the message remains the same: our suffering shall set ye free...
...Doctors are in general less slick than other professionals...
...I want a career in which I'll be respected and needed...
...So they are shocked and hurt that at a time when their technical capacity to treat disease has never been greater, discontent with doctors is at an all time high...
...The dedication that keeps a doctor in the lab can isolate him from the rest of the world...
...When pressed, most will concede that they're dimly aware of other attractions-the independence, the secure and ample income-but these are described as incidental fringe benefits...
...The profession has to change, but its members also have to be understood...
...There’s a tacit faith that somehow all this suffering will one day make us better physicians...
...When they go to bars they order beer, because they don’t know the intricacies of hard liquor...
...I was told that otherwise I would hurt my chances,” one of my classmates recalls...
...It sustains you through years of endless work, through grim nights when patients finally die...
...Disgruntled patients are ignoring medical advice and criticizing doctors not just for medicine’s political and economic woes, but also for their paternalism, their huge incomes, and their whining insistence that they work harder than anyone else...
...doctors belong to the AMA, and most join for the insurance plans and access to scientific literature...
...f But these days, Shaw seems to have been too generous in his characterizationif the view of doctors that's riow popular is true, he should have stressed the extraordinary greed, insensitivity, and narcissism many perceive in them...
...and the joke underscores a basic fact of medical life: doctors come firstbefore nurses, before administrators, even before patients...
...Maybe, but it won’t be easy...
...But what do their patients think...
...Majoring outside the sciences is often interpreted by admissions officers as a lack of commitment to medicine...
...And as individuals, most are indeed decent and competent...
...Medical schools know patients often like paternalism and quietly teach the art...
...During most of that time, his life will run in 48-hour cycles-36 hours “on,” 12 “off...
...Eventually I’d be seen for a few minutes and pay a ridiculous price...
...And an Opinion Research poll last year showed that 69 per cent of Americans consider doctors’ fees a major source of medical inflation...
...medicine is largely a one-man show...
...Thus doctors have a high rate of private airplane crashes-they can’t believe they, of all people, would really crash...
...The most successful doctors are the ones who understand these feelings, who know that sometimes scientific explanations provide neither comfort nor enlightenment...
...Naturally, he’s never met a doctor he trusted and probably never will...
...He takes the history, examines the patient, writes every order and prescription...
...but to understand why they exist and how to meet them it’s necessary to understand how doctors think...
...I can’t remember the last time I touched a bed pan, and I plan to avoid doing so as long as possible...
...For example, fee-for-service billing provides no incentive for preventive medicine and is a major cause of medical inflation...
...There is,'^ after all, something glamorous about carrying a beeper that may go off any , minute, calling you to an emergency- 1 ’ it means you’re needed...
...These seem worthwhile goals, and the current medical school admissions crunch indicates that they’re widely perceived as such...
...Because applause and respect are more important to doctors than money, it’s possible to design a workable health care system that lets them keep their star status while reducing their income, as has been done in England...
...The real question is not “How much are they making?’ at this point in one’s career so much as “Why do they do it at all...
...After all, they’re the ones with the M.D...
...And then there’s the case of the three young doctors who started a prepaid group practice in New England and provided quality care at low prices in an informal atmosphere typified by their flannel shirts...
...My father's a doctor...
...Most doctors are at least consciously dedicated to selfless purposes-the prolonging of life, the relief of painand I’ve never heard one refer to medicine as his “job...
...The American Medical Association has fought pre-payment and health care reform, and doctors are of course guilty of supporting its policies, passively or otherwise...
...Money is the substitute...
...Only doctors or medical students can “push didge”-inject digitalis through an intravenous line...
...Another funny thing about doctors: Nothing infuriates them nearly as much as the inference that they are overpaid...
...They insist on having things their own way, whether they’re in an operating room or PTA meeting...
...Somehow, a gaunt, exhausted doctor seems to be sacrificing his own health for his patients’, and thus must be more dedicated than the deeply tanned playboy just back from the Carribean...
...They’ve been called butchers, egomaniacs, and right-wing fanatics, and handled the criticism by ignoring it...
...After three years of working with doctors and patients, I’ve learned that while physicians individually are guilty of many offenses, physicians collectivelythat is, the system they’ve set up-are at fault for far more...
...just like other Englishmen: most have no honor and no conscience...
...The price for doctors’ convenience is often paid in time, money, and even the dignity of everyone else involved...
...I recently heard of one young woman who, although always critical of empty ritual in other aspects of life, was nevertheless upset during a hospitalization that her intern wore sneakers...
...Doctors usually get used to working alone instead of in teams...
...Medicine and medical schools ’ I collaborate in reinforcing the star , system, where every doctor is overburdened with work but pampered while doing it...
...George Bernard Shaw, who hated doctors and lived to 95, wrote in The Doctor's Dilemma that "Doctors are Thomas H. Lee is a third-vear student at Cornell Medical School...
...George Bernard Shaw, who hated doctors and lived to 95, wrote in The Doctor's Dilemma that "Doctors are Thomas H. Lee is a third-vear student at Cornell Medical School...
...adults in their 20s and 30s-why they chose medicine, and they'll give you the same answers they used at 12: "I want to help people...
...so they would “get used to staying up...
...I think doctors are basically decent folks, who have lost touch with their patients, who are caught up in their own fantasies about their job...
...But mention their $63,000 median income for 1976, or its 9.3percent annual growth rate, and watch their blood pressures soar...
...In this not-very-efficient system, doctors do a lot of running around, while everyone else-patients and staff-spends a lot of time waiting for them...
...Interns and residents have done precious little agitating for higher pay, and until recently they were barely paid at all...
...Probably not, but it’s easy to see how interns might while away the nights dreaming of how their superhuman efforts will one day reap superhuman rewards...
...They rage about malpractice premiums, med school debts, and above all the emotionally and physically draining hours they put in...
...But physicians Michael D. Sullivan in general do not consider themselves political creatures or fully understand their collective economic impact...
...Sometimes, doctors have appropriate drugs or operations, and can do just that...
...Another resident, a woman in her third year, said it was “inertia,” and I believe her, too...
...At its purest, this attitude becomes what I call Exhaustion Chic-the celebration of sleeplessness for its own sake...
...Many even ask to be called by their first name, while continuing to address their physician as “Doctor...
...The results can be therapeutic...
...When they have a broader understanding of the rest of society, they won’t be so cavalier with their patients...
...And I think there are also subtler reasons, deeply ingrained in medicine...
...Some anthropologists believe that healing in all cultures involves common rituals, among them human sacrifice-of the healer himself...
...I want a career in which I'll be respected and needed...
...encourages self-pity...
Vol. 10 • May 1978 • No. 3
