PARTS AND MONEY
As you become a physician, you feel as if you are learning to see people as a compendium of parts and a source of income: parts and money.
No one pulls you aside during training and tells you this plainly.
Just the same, you learn, as I did in the first month of medical school when my very first patient died before I could ask her her name.
Before meeting her, I had not had personal contact with any real patients, just abstractions of patients. The first weeks of medical school were filled with a series of PowerPoint presentations. We watched as animated arrows flashed and the Krebs cycle generated energy, or molecules bound to receptors and cell membranes opened, like the locks of a canal, so that potassium and sodium ions could travel in and out of a cell. Professors discussed the body as a series of simple machines. As they spoke, we dozed in the darkened lecture hall. When the fluorescent lights flickered on, we rubbed our eyes, collected our backpacks, and stumbled upstairs to the anatomy lab, where we dissected the upper back of a corpse while avoiding its dead eyes.
After a few weeks of this, the medical school sent us away for week-long apprenticeships in the practices of rural primary care physicians. We were going to see real patients! On the first Monday, I woke up early and put on my least-wrinkled shirt and an almost-matching tie. I covered these up with a short white poly-cotton-blend lab coat. In the mirror, I looked more like a busboy than a physician. To shore up my authority and clarify my role, I filled my pockets with medical tools—a penlight, reflex hammer, stethoscope, and tuning fork—that I did not know how to wield.
I arrived before the first patient, and the physician greeted me in his consultation room. He was young, but his office was old-fashioned, the walls dotted with diplomas and framed Norman Rockwell lithographs. His oversized wooden desk faced two leather chairs. As I sat before him, he said he liked having students. “It gives the patient someone to talk to while I am seeing the previous patient. You can sit and listen, while I keep moving. I have to move, move, move if I want the lights to stay on.” So we began, and I followed his rhythm. I would go in first, fumbling through the patient’s history and exam for a few minutes. Then the physician would enter while knocking, striding from the door to the patient’s back and placing his stethoscope under the shirt without invitation. “Take a deep breath. Good. And again.” While he lifted his stethoscope off the chest, he would advise more meds, or a new med, as he marked a billing code on the patient’s chart. With these codes he monetized every minute of his day. He later told me that if he spent ten minutes with a return patient, he generated a profit. If he spent twelve minutes, he broke even. If he spent fourteen minutes, he lost money. His profits depended on efficiently moving patients through the clinic.
That afternoon, in the midst of this bustle, the office phone rang. The adjacent hospital was calling. “A patient of your practice is coming to the hospital by ambulance. Can the physician come?” The physician had a double-booked morning, so he sent me instead. “It will be good for you to see how the Emergency Room works,” he said, and patted me out the door.
I was eager to see an acutely ill patient instead of the people with chronic diseases who filled his exam rooms. I ran across the parking lot, my tools dully rattling in my pockets. When I arrived, the Emergency Department was tensely quiet as the nurses prepared for the arrival of the patient. Then the paramedics arrived, pushing an aluminum gurney with an unconscious woman cradled between its rails. The lead paramedic announced his cargo: “Fifty-six-year-old woman. History of hypertension and diabetes. Collapsed at work twelve minutes ago. BP 50 over nothing. Pulse 52. ST elevations in V1–6.” As they spoke, they wheeled the unconscious woman toward ED-1, the largest bay in the Emergency Department, the bay where the tools to revive the most critically ill patients were arrayed. The woman’s dress was cleaved open by sterilized scissors to bare her chest. A pair of physicians and a trio of nurses descended on her. Together they moved about her, announcing their actions to one another: “Cardiac monitor in place. IV access obtained. Labs drawn. Administer streptokinase.” Using their skills in concert, they localized the failing part: her heart.
The diagnosis was apparent to everyone in the room but the patient and me. She was unconscious, and I was ignorant. I stood still, afraid that my movements would be disruptive, while the paramedics, nurses, and physicians worked. They spoke to one another in code: “STEMI. Unresponsive. Won’t make it for transfer to perc.” They worked together through a familiar algorithm, following a lifesaving script. Despite their coordination, the patient’s heart never regained its rhythm.
As the exhausted physicians and nurses left the room, they finally departed from the script. “Tombstoned. You ever seen that before?” one of them asked. “Broken pump. Too bad,” the other commented. The woman’s parts had failed her.
Nursing assistants moved in. They cleaned the woman’s body, removing the medical waste that littered her exposed thorax. I stood at the foot of the bed, uncertain what to do. I averted my eyes and noticed a stain on my new white coat.
As I looked for something with which to clean it, a nurse approached me and said, “Her son is in the waiting room, but the physicians are busy with another patient who just came in. Can you talk with the son and tell him what happened?”
Too afraid to say no, I mumbled, “Sure,” and then made a quick call to the physician’s office, seeking guidance about how to tell a son his mother was dead. The physician’s receptionist put me through to the clinic nurse. “The physician is busy seeing patients, so you will have to do it yourself,” she instructed. “It’s what physicians do.”
I wanted to do what physicians do. I entered the Family Waiting Room and asked for the “son of our emergency patient.” A young African American man about my age was standing in the middle of the room, rocking from side to side. He had been called from his work as a cook and was still wearing his own white coat. Through tears, he asked, “Where is my mother? What happened to her? Where is the doctor?” I stammered, realizing I did not even know his mother’s name. All I could do was repeat what I had heard. “Her heart failed her,” I said. “Her heart failed her. She died.” He let out a cry, and only then did I learn my patient’s name.
“She’s not a ‘her’! She’s my mama. Her name is Gloria. Gloria! What will I do without her?”
. . .
That morning I had watched paramedics, nurses, and physicians working efficiently, if unsuccessfully, to save Gloria’s life.
I had also seen how they looked at Gloria. In the Emergency Room, they saw a massive heart attack and worked efficiently to treat the broken part. As they did so, her primary care physician was in his office, where patients were viewed as billing codes. He knew that if he left his outpatient practice to see Gloria, he would lose the revenue from his scheduled appointments. If he visited her in the hospital, he could not bill for providing services to Gloria or her family because, by the rules of Gloria’s insurance, only the hospital could bill for a physician’s services. So the physician stayed in the clinic to keep the lights on. As he labored, Gloria’s son lost his mother.
Parts and money—too often that is what we physicians see when we look at patients. What is broken? Can it be patched or does it need to be replaced? How much can I bill for the procedure? How much of that fee will I take home?
The questions Gloria’s son asked that morning were very different. He wanted to know where his mother was, what had happened to her, where the physician was, and what he would do without her. He also wanted to know why I did not know her name. I tried to respond as best I could, but my words did not satisfy him or me. Instead, our meeting was another alienating encounter in a society divided by class and race. I was so confused by it that I began asking myself what we hope for when we call in the doctor.
Everyone has a story about medicine’s failures. When you need medical assistance, it is difficult to find any physician, let alone the right physician. The queues are long, the costs high, the outcomes inconsistent, and the experiences alienating. Everyone also seems to have a solution—prioritize primary care, promote evidence-based medicine, provide universal insurance, pay for performance, push down costs.
As I continued my training, I sought out the most promising initiatives to “fix” medicine, its finest traditions, and tried most of them out. Along the way, I learned that few of them address the questions of Gloria’s son, for almost all fail to take into account the lessons of history, of how medicine moved toward the system we have today. The advances in knowledge in twentieth-century medicine began with a change in physicians’ self-perception in the nineteenth century; modern medicine was born when physicians learned to see like scientists. And I suspect that medicine will advance once more only when physicians change their self-perception again.1 In contemporary medicine, the underlying problem is that we see the wrong things or, rather, not all of the right things when we look at patients. My encounters with Gloria and her son led me to seek better ways of seeing patients and of being seen by patients. I am trying to find a renewed vision for medicine.
Medical training is a series of vision lessons. In each encounter with a patient, you learn something about being with the ill. On my first day in that rural clinic, I learned that a physician does not need to know the name of his patient and that an unskilled student might have to tell a son that his mother was dead. In the medical community, knowing names and communicating with families were less important than generating money by trying to fix faltering parts.
I also learned that even when physicians and nurses and paramedics work together as a team, even when they follow an evidence-based script in pursuit of consistent outcomes, the care they offer is often dehumanizing.
Fifteen years later, I still remember the name of the rural physician, even though we spent only a few weeks together, but I cannot remember Gloria’s real name; I remember only that her son knew it and I did not. I can remember the name of a physician but not of the first person I watched die. I worry about what that says about me. Am I broken, or is medicine?
I suspect that the answers are yes and yes.
. . .
To write this book, I had to give Gloria a name and re-create dialogue from memory, which means that the story of Gloria is a representation of an event rather than a transcription. However, the details of her death came from records I made at the time. During my training, I wrote letters, sporadically kept a journal, and composed case presentations. I drew upon those occasional writings for this book. As with Gloria and her son, I do not remember the names of all the people I write about. Even when I do remember the names of the people I write about, I changed their names and identifying details to preserve their privacy. I hesitated to alter the names and details, but I did so for two reasons. First, these stories belong not to me but to the people I have been privileged to meet. Ideally, I might contact each person and seek his or her permission, but these episodes occurred over two decades, and it would be impossible for me to find all the patients. Many are deceased. Second, these stories concern only a portion of each person’s story, his or her time as a patient with me, so I tell them as I experienced them while remembering that they are vignettes, not the entire story of any particular person. I tell these stories from my perspective, flawed as that may be. Any resulting errors or mistakes belong on my ledger, not on those of the people I describe.
The dialogue reflects my memory of the feeling and meaning of conversations as I experienced them, aided in some instances by personal reflections, letters, or journals I kept at the time.
The physicians and teachers I do name have consented to my doing so; I thank them for their generosity.
Many of these stories date from when I was in medical school and residency, but some happened when I began practicing as a psychiatrist. As I tell my friends in other specialties, most of medicine is beginning to resemble psychiatry because it is less concerned with trying to save people like Gloria from dying of a heart attack in the Emergency Department and more with attending to her chronic heart disease back in the office. There are no cures for chronic diseases like diabetes and hypertension, so the measures of a physician’s success are changing. At our best, psychiatrists are ahead of that change. The majority of our patients have chronic diseases whose cures are in the future; our present success is best measured by our ability to persuade people to seek health rather than by telling them the right thing to do or by performing a procedure upon them.
. . .
I interact with colleagues in other specialties every day because I spend my days entrenched in a contemporary hospital. On the floor below our ward, surgeons are bravely using the latest instruments in operating rooms. On the floor above our ward, internists are maintaining the faltering bodies of ill people through techniques only dreamed of a half-century ago. I travel often between our ward and these other particular, peculiar spaces of contemporary medicine as a physician consultant, teacher, and administrator.
As I move between these wards, I am struck by the confusion within medicine. The units shine, the surgical instruments are precise, the medical techniques are novel, and yet the physicians are discouraged. Physician burnout, early retirement, and suicide are increasing.2 Most physicians report that they would discourage a student from joining the profession. No one thinks the current state is acceptable, so reforms are forever being proposed, studied, implemented, and abandoned. Few of these reforms address the problem I consider fundamental: that we no longer see our patients as people. In fact, most reforms shift the frame ever farther away from the individual patient to the health of populations by attempting to standardize outcomes on a population basis. We are encouraged to count something, rather than to see someone.
Many reforms also shift the authority of healthcare decisions away from physicians. So why do I write about physicians? After all, more than ever before, healthcare requires the kind of coordinated teamwork I saw in the attempts to save Gloria. Nurses deliver most of the care in hospitals. If you want to select a good hospital, you should choose it based on the ability and stability of the nursing staff, rather than on the achievements of its physicians. Occupational and physical therapists rehabilitate most serious injuries. If you want a torn ligament repaired, make sure you have a good physical therapist as well as a good orthopedic surgeon. Social workers transform the trajectory of a child in foster care; if you want to improve the health of small children, social workers can matter more than pediatricians. Pharmacists prevent life-threatening medication errors: if you are going to take a dangerous medication like warfarin, find a skilled pharmacist as well as a highly trained internist.
As each of these professions develops its own specialized approaches and knowledge bases, practitioners are often required to obtain a doctorate in the field. We can no longer speak about “doctors” in healthcare and be sure of what we mean. In my job, I work with chaplains, nurses, nurse practitioners, pharmacists, physical therapists, psychologists, and others who hold doctorates. All of them can be rightly addressed as “Doctor.” Members of each of these professions can improve the health and well-being of an ill person, often more effectively than a physician.
I write about physicians in part because I am a physician and in part because, at least for now, physicians still make the important decisions about what goes on in medical care. Physicians admit patients to hospitals where nurses care for them, assign patients to the rehab where physical therapists help them regain mobility, refer children to social workers who intervene in their lives, and order the medications a pharmacist compounds and monitors. Among practitioners, physicians are disproportionately represented in the leadership of hospitals, universities, insurers, and regulators. In the coming years, physicians may play a smaller role in the healthcare system, but for now the habits of physicians remain a critical factor in healthcare reform. To transform healthcare, we must engage physicians.
Every physician is a particular, unique individual. There is, as the saying goes, no vision from nowhere. I was a reader before I was a physician, and so my own vision is shaped by a love of history, literature, philosophy, and theology. These books guided my vision and taught me the meaning of events like Gloria’s death. I share my search in the hope that if we physicians can learn how to attend to patients as fellow creatures, we can renew the practice of medicine.