Appointment
“Would you like to come on through. The doctor’s ready to see you now.” An invitation often associated with a slight twinge of anxiety. Perhaps you’re not feeling well, or you’re about to learn the results of a test. However, rather than dwelling on patients’ expectations and experiences, this is the time to look at the other side, at the physicians and how they are faring.
There is a lot of attention being paid to the medical profession at present, and for the past few months I have been reading about the challenges faced by practitioners. The books I’ve studied are largely based on experiences in the US, but some also cover the UK and Australia. The accounts from all three countries appear very similar: most doctors have less time to spend with patients, as their work is taken up with more diagnostic systems and specialists, IT systems to record patient interactions and billing requirements, and income pressures squeezing the space in the timetable available for each appointment. In this environment many doctors find they are unable to attend to the patient as a person, as a fellow human being, to the degree they might want to do so. As I read, I could see they find this situation more than trivially unsatisfactory.
To start, what have I learnt through my own experiences? Most have been very good. I can remember the first doctor I saw as a young child, our family doctor in London. He was West Indian, a large man (or at least I thought so at the time), and what remains from those early years is the image of a kind person, thoughtful and careful, talking to me like an adult. Whatever else happened, he established an expectation that all doctors would be like him. We moved to another part of London in my teenage years, and I have no recollection of my next GP. I suppose that has to be good: either I didn’t need visits to the doctor, or those I had were fine.
Married, and living in Cambridge, the next GP in my life was immensely important, as he saw us through three pregnancies, various illnesses, and the stresses and strains of a new environment and a new life. In my memory I see a tall, older man (he was probably 40 years old, or less!), immensely patient, who was able to devote time not just to immediate medical issues but also to longer term psychological concerns. I suppose he was like an uncle for both of us, thoughtfully listening, advising, sometimes prescribing a necessary medicine. Then we moved to Edinburgh, and I can’t recall our doctor there. I do remember the specialists my wife saw, as she had a tough time, including going to hospital with gall stones and other debilitating complaints.
However, this was also the beginning of my lifelong work involvement with hospitals. I was involved in a project aimed at introducing a better understanding of behavioural sciences into the curriculum for medical students, work that was to take me to hospitals and medical schools in the US and all over Europe. I also started working with medical administrators: my first study was on how to select those students on entry who would turn out to be successful practitioners. This exercise resulted in the suggestion “use a pin to pick randomly among the applicants who were above a certain (high) level of achievement at school: there’s no better way.” It wasn’t adopted!
Some years later, we arrived in Australia. I was sick when we moved into our medical centre apartment in Adelaide. Summoned by my wife, the doctor living next door came to see me: he stood on the other side of the room to assess my problems, as my wife had told him we had been in various dubious countries (Iraq, Bahrain, India, Malaysia, Indonesia) prior to our arrival. Eventually, he concluded I had chickenpox, not surprising since we had stopped over with relatives in Perth, where the daughter had chickenpox! Relieved, he decided he could look after me, and became, by default, our new GP (he was actually a heart specialist!).
Every move is a search for a new doctor. Going to Melbourne, we started again, and once more, I can’t remember anything about our first family doctor there. Thirteen years, and no recall at all. However, following a divorce and second marriage, our next family physician was another practitioner from the same ‘school’ as the West Indian GP of my childhood, caring, thoughtful, always with time to talk beyond the immediate presenting needs. When my new wife found she was pregnant, looking very serious our doctor asked what we wanted to do about the pregnancy, clearly concerned, since we were both older, that the answer would be termination. Once we got past that, she leapt up, hugged my wife, and was as delighted as we were.
Some years later my wife became very ill. Her oncologist was as caring as our GP. To my surprise, the surgeon was also seemed attentive and thoughtful (atypically I thought!?). The hospital experience was unexpectedly demanding: the surgery ran for nearly four hours, and the surgeon came straight out to see me, tears in his eyes, to explain how much had been excised. Three months of care ended in the ICU, with her oncologist coming in every other day. He was distraught that we couldn’t find a way to stop her decline. Both warm and considerate people.
Today, married again, we have another caring and sympathetic family practitioner. Have I been lucky? My experiences suggest doctors are as good now as they were sixty years ago: not just (better) technically qualified, but good in being attentive to the patient as a person. But to say that is to ignore that I am a ‘privileged white male’. It also leaves to one side other doctors who were less ideal, whose names are lost, the experiences gently fading into a forgotten past. Based on what I have been reading, I have been very lucky, getting a better deal than many others.
As I said at the outset, this is a good time to examine the other side of the relationship, not just through my experiences, but other views of a doctor today. Those books I mentioned provide abundant evidence. Many have written about the lack of time to engage with the patient, with the computer and its data entry requirements conspiring to make visits transactional rather than personal.[i] I have read articles about the dilemmas doctors face as they try to keep a focus on the person in front of them, rather than just on the symptoms they are expected to address.[ii] Right now, I am reading a book about doctors as people rather than as practitioners, about the fears, frustrations and failures that characterise their lives, especially as they qualify to practice.[iii]
Aware of my interest, recently a friend sent me a link to a video explaining that the current concern by administrators over medical practitioner burnout is willfully mistaken, as it implies the practitioners are at fault: the problem is better described as ‘moral injury’, where the values they hold come up against life on the front-line of medical care. Compelling: please watch it. [iv]
There are so many pressing issues. A major area is finance. With medical training typically extended over a decade or more, the costs to qualify for practice leave the physician with a huge debt to recoup, creating an inescapable and major concern for the next ten years or more. When it comes to paying for treatment, the US is currently wracked with arguments over high charges for medical care, in a country where many lack adequate medical coverage or insurance, health outcomes are relatively poor, and the overall system is clearly inefficient, with evidence of money being wasted (often, it seems, it is gobbled up by drug companies and the like). At the same time, the UK and Australia are trying to cope with rising health care costs and related issues in maintaining a financially viable universal health care system. It’s a mess.
Yes, it’s a mess, and yet there are many individual doctors who survive, sustain their ideals, and offer outstanding care. Lucky (okay, privileged) people like me find them. What about the others, those that made it through the costly training system but to the detriment of the ideals with which they began, let alone those who didn’t even get that far? Yes, I have met some. The family practitioner before the one I have now was a young woman who appeared paralysed by her fear of facing a malpractice suit: too cautious to offer any definitive diagnosis of symptoms, however trivial, she was always quickly referring everything on to a specialist.
Many writers have described how the medical system came to its present sorry state, and I don’t want to cover that ground.[v] However, looking forward it is reassuring to see the possibility of major reform is a hot issue on the political agenda right now, with good reason. There has to be better approach better than the one in place today.
At one extreme is Senator Bernie Sanders, who back in September 2017 proposed a ‘Medicare for All’ Bill, a single-payer health care system where the government covered the costs. Now running again for President, he is pushing his single payer health care system as a key part of his platform. It’s radical! It would be a national health insurance program for everyone who lives in the US, encompassing all medically necessary services, from routine doctor visits to surgery to mental health to prescription drugs, (elements to do with dental and optical services are included, as well as some parts of long-term care). The original bill included a four-year phase-in, during which time 55-year-olds could choose to join in the first year, 45-year-olds in the second, and so on. It is not clear to me if you could opt-out and have private insurance instead, or in parallel as in Australia, but something of that kind appears to be the case.
How would Medicare for All work? Similar to systems in other countries, the government would set reimbursement rates for services, drugs and medical equipment. For users, there would be no costs: in US terminology, no deductibles, no copays, no coinsurance. This is big money! The proposal covers nearly a fifth of the economy, and has resulted in a huge debate (no, a huge amount of disagreement) as to how the taxes to support costs would be balanced against the savings on the present system. Big money? Estimates range from $25tn to $32tn over ten years (the current US Federal budget for 2019 is $4.4tn, representing 21% of GDP)!!
Bernie Sanders might be at the extreme, but there are other presidential candidates leaping into the debate about medical care. Senator Kamala Harris first appeared to support the elimination of private health insurance.[vi] But later her remarks were less extreme: she “would also be open to the more moderate health reform plans, which would preserve the industry, being floated by other congressional Democrats. … a compromise position that risked angering Medicare-for-all proponents, who view eliminating private health insurance as key to comprehensive reform.” However, “ her willingness to consider alternate routes to a single payer system should not cast doubt on her commitment to the policy.” [vii] Confused? In politics, it’s often confusing!
Senator Elizabeth Warren has also been pushed on the future of health care. In an interview, she said that the key issue on health care was “how do we get universal coverage. Medicare for all. Lots of paths for how to do that. But we know where we are aiming. And that is, every American has health care at a price they can afford. And that the overall costs in the system are held as low as possible … So right now, there are multiple bills on the floor in the United States Senate. I’ve signed onto Medicare for All. I’ve signed on to another one that gives an option for buying in to Medicaid. There are different ways we can get there. But the key has to be always keep the center of the bullseye in mind. And that is affordable health care for every American.” [viii]
While candidates for the presidency and other political leaders are stating their positions, the shifting views make for interesting commentary. But will the current momentum for change evaporate once other issues are found to be more ‘attractive’ across the electorate as a whole? Is universal health care likely to remain the one major policy issue to determine the next President?
In the middle of all this, a key question has to be what doctors think about all this. I can only assume many must be torn between two quite contradictory perspectives.
On the one hand, I am certain they are anxious to see a better system emerge, one where their lives are not driven by insurers’ codes and anxious managers, able to grasp back the seemingly elusive possibility of a return to effective patient-focussed care and evidence-based treatment.
On the other hand, any changes are likely to threaten incomes and the hierarchy of relationships they have had to battle to become established and rewarded. Like most people, they can see the benefits of changing the system, and yet are likely to resist any changes which might impact on their earning capacity and where they sit in the medical structure. I wouldn’t like to be a medical practitioner today, reading about the issues, the proposals for change, and the glaring threats and uncertainties as to what the range of possible changes might mean.
“Would you like to come on through. The doctor’s ready to see you now.” As a part of a creaky, expensive and inefficient system with radical changes still under consideration, as has been the case for years, I wonder how ‘ready’ the doctor feels? Ready to drop out of the system? Ready to switch off the computer, and be the doctor they want to be? Ready to forget about the next appointment, and look for another life with more personal satisfaction, an alternative way to fulfill a desire to help other people? Or ready to turn to the computer system and start inputting codes, with little time left for what they were trained to do? Ready for what?
[i] As described in Atul Gawande’s recent article ‘Why Doctors Hate Their Computers’, https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers
[ii] Atul Gawande, who writes compelling books and articles on medicine today, is particularly insightful for me: a recent article was about patients as people, ‘Curiosity and What Equality Really Means’, https://www.newyorker.com/news/news-desk/curiosity-and-the-prisoner
[iii] Caroline Elton, Also Human, Basic Books, 2018
[iv] https://www.youtube.com/watch?v=L_1PNZdHq6Q
[v] For a brief overview of the recent history, see Jonathan Engel’s ‘Unaffordable’, Univ. of Wisconsin Press, 2018
[vi] https://www.youtube.com/watch?v=DJhuPtIsUI0&feature=youtu.be
[vii] https://www.cnn.com/2019/01/29/politics/kamala-harris-medicare-for-all-eliminate-private-insurers-backlash/index.html
[viii] https://slate.com/business/2019/01/elizabeth-warren-dodges-kamala-harris-medicare-for-all-question.html
