Doctored: The Disillusionment Of An American PhysicianJune 2015
By Astrid Derfler Kessler
An Interview With Sandeep Jauhar
A book by acclaimed author and physician Dr. Sandeep Jauhar reveals the realities of the modern health care system in Doctored: The Disillusionment of an American Physician. This memoir, a follow-up to his previous publication titled Intern, reveals the troubling truths about the state of today’s medicine that Dr. Jauhar encountered after accepting a position at a large teaching hospital in New York. Some of the realities he was forced to face included pressure to meet bottom lines at the expense of patient care, ordering expensive tests and exams for profit purposes only, the obvious cronyism that came into play when referring patients to specialists, and how overwhelming paperwork led to too little time to spend with patients.
Filled with anecdotes about his patients and their experiences, as well as personal stories regarding his own family, career, and choices, Doctored tells the story of an American physician who is not afraid to challenge the status quo in his search for a better system for everyone.
LE: In the opening chapter of your book, you write that you are struggling with your chosen profession.
SJ: I have become the kind of doctor I never thought I’d be—impatient, occasionally indifferent, and at times dismissive or paternalistic.
Most of us went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income. There is a palpable sense of grieving. The job for many has become just that—a job. Something fundamental is lost when physicians start thinking of medicine as a business.
LE: Please provide an example of how generating income superseded patient care.
SJ: Because insurers had been slashing reimbursement rates, my colleagues and I were told we had to increase our relative value unit collections—or the currency of medical payment. Some physicians responded by upcoding—claiming greater complexity in patient encounters than was in fact the case—and fraud investigations at some centers were under way.
Since I wasn’t going to upcode, what the department’s directive meant for me on a practical level was that I had to see more patients. I reduced time in my schedule earmarked for new patients from 60 minutes to 40 and for established patients from 30 to 20. With administrative tasks, conferences, teaching, chart reviews, and letters and phone calls … gobbling up my day, I began to rush through visits, hurrying patients along in subtle and not so subtle ways. I stopped small talk. I interrupted histories after a few seconds to get patients to the point. I even urged patients to breathe faster when I was listening to their lungs.
LE: Do you feel you compromised your patients and yourself?
SJ: You can often do a passable job, but it’s impossible to appreciate the subtleties of patient care when you are rushing. Racing through patient encounters, you practice with an ever-present fear that you will miss something, hurt someone, and open yourself up to legal, not to mention moral, liability.
LE: What was your solution to coping with this kind of rushing and quick turnaround?
SJ: To cope with the anxiety, you start to call in “experts” for problems that perhaps you could have handled yourself if you had more time to think through the case. Apart from the perverse incentives of our fee-for-service system, a major driver of overconsultation is the uncertainty engendered by the hurried pace of contemporary medicine. Some doctors call consults just to cover their [behind].
LE: Health care costs are at an all-time high. Doesn’t this kind of care you’re describing actually end up costing more in the long run?
SJ: The Institute of Medicine estimated that wasteful health care spending—spending that doesn’t improve health outcomes—costs $750 billion in the US every year. Excessive paperwork and administrative costs account for some of this waste, but unnecessary or inefficiently delivered services, especially in hospitals, account for the lion’s share.
LE: You have numerous examples of this waste and how it backfires and typically costs more.
SJ: The more pressure put on doctors to cut costs by working harder and faster, with shorter hospital stays and quicker patient turnover, the more uncertainty doctors feel and therefore the more likely they are to utilize CT scans, MRIs, expert consultations, and so on. There is no more wasteful entity in medicine than a rushed or incompetent doctor.
LE: How does it affect a patient?
SJ: The consequences for patients are troubling. Too many consultations leads to sloppiness and disorganization. With bulky care teams, there’s diffusion of responsibility. Who’s in charge? Who is spearheading treatment? Nowhere is this more evident than in the hospital discharge process.
LE: And as you point out in the book, this leads to patients being pushed out of the hospital too quickly, only to return shortly.
SJ: Hasty readmission is an indicator of an inefficient, if not dysfunctional, health care system.
A study in the New England Journal of Medicine (2009) found that one in five Medicare patients discharged from the hospital was readmitted within a month. One in three was readmitted in three months. Readmissions are costly. In 2004, the expense to Medicare for unplanned readmission was $17.4 billion—17% of its total hospital budget.
LE: What can be done to reduce hospital readmission rates?
SJ: There are many things doctors can do… They could ensure discharged patients get timely follow-up appointments. [Half of all discharged patients readmitted in 30 days had not seen a doctor after discharge, according to a New England Journal of Medicine study.] They could do a better job of ensuring that patients obtained their medications and understood how to take them.
Doctors can also do a better job of educating patients about which symptoms and signs presage worsening of their disease—shortness of breath and leg swelling in congestive heart failure, for example—so they could quickly see their primary physician rather than go to the ER. We know patients with a clear understanding of discharge instructions are 30% less likely to return to the hospital. But research shows inconsistency at best in achieving these goals.
LE: The government wants to get more involved in curbing health care costs and has come up with incentives and fines. How do you respond to this initiative?
SJ: Congress and the Obama administration are doling out penalties on hospitals with high readmission rates [which] could forfeit up to 3% of Medicare payments in 2015. But these incentives are misdirected. Hospitals don’t hospitalize patients; doctors do. And doctors currently stand to gain little from lowering readmission. In fact, they will lose revenue.
As is so often the case in our health care system, doctors’ incentives don’t serve a broader social goal. This virtually guarantees that proposed reforms like cutting readmissions, reducing unnecessary testing, and adopting computerized medical records will fail.
LE: What about rewarding hospitals that reduce patient turnaround?
SJ: The agency that runs Medicare is considering giving bonuses to hospitals that lower readmissions below average. Though I think it’s a good idea, I believe some of this money should be shared with doctors. Current law prohibits hospitals from paying doctors for reducing hospital services even if the goal is to provide more efficient care.
In an interview with U.S. News and World Report, Dr. Jauhar summed up his feelings on his chosen career choice. “I’m not disillusioned with being a doctor,” he said. “I’m disillusioned with our medical system and the way it’s structured and how dysfunctional it is and how difficult it makes it for doctors to provide good care and do what they were trained to do.
“I would tell perspective medical students: It’s a great profession still because it’s a profession where you undeniably do good things for people and in most cases, you earn a healthy income, and you get to think about really cool things about science and about humanity, so it’s a great profession, but it’s a profession that has been adulterated by a very dysfunctional system, so go into it with your eyes open. Focus on the good things [like] conversations with patients, which really mean a lot. They don’t pay the bills, necessarily—but they’re very rewarding.”
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Dr. Sandeep Jauhar is a cardiologist and the director of the Heart Failure Program at Long Island Jewish Medical Center. Jauhar was a PhD student in physics at Berkeley when a girlfriend’s incurable illness made him yearn for a profession where he could affect people’s lives directly. But he soon came to realize that his new chosen profession often had little regard for patients’ concerns. Dr. Jauhar’s first book, titled Intern: A Doctor’s Initiation, detailed his 80-hour workweek and the exhaustion, mental pressure, and moral conundrums he faced in his first year of medical residency. Dr. Jauhar also writes regularly for The New York Times.
To order a copy of Doctored: The Disillusionment of an American Physician by Dr. Sandeep Jauhar, call 1-800-544-4440.