More than half a million Americans develop congestive heart failure every year. It is the number one reason patients over sixty-five years of age are hospitalized. The problem is growing: the number of hospital admissions for heart failure has more than doubled in the past two decades to more than one million. Not long ago these patients might have died of their disease, but now, as medicine has advanced, they are able to live with it. (Ironically, as medicine becomes more successful at treating sickness, the set of people who are ill is growing.) The total cost of treating the disease is more than $40 billion per year, and the majority of patients still die within five years of diagnosis.
To improve inpatient heart failure management, I wrote up a standardized physicians’ order set for use in the emergency room. I put together a “care map,” a formalized treatment algorithm, for nurses. I met frequently with clinical staff, trying to discover ways to improve treatment. A big problem was a lack of health literacy—patients not knowing that they needed to eliminate salt from their diets or take their medications regularly, for example—which was due in no small part to inadequate teaching on the part of their care providers. A typical complaint from patients was that their doctors had told them they had weak hearts but never told them why. “I spent two weeks in the hospital, but no one ever talked to me about it,” one patient told me. “They never said, ‘This is what is happening. This is what you can expect.’ In fact, no one ever talked to me about it until now.”
At a clinical team meeting one morning, a Haitian nurse asked me rhetorically: “So do the private doctors go into the room and explain to the patients what they have? Well, I’ll tell you, they don’t. It is my contention that they don’t get the proper education, and that’s why their care suffers.”
“It’s not all the doctors’ fault,” another nurse countered. “Sometimes I blame the patient. You go in there and they got a million questions, but when the doctor goes in there, they say everything’s fine. They don’t want to ask the doctor anything.”
“And why is that?” I asked.
“Because they have a relationship with me,” the nurse replied. “They don’t have a relationship with the doctor, especially if he’s just seeing them in the hospital. Doctors come and go. They don’t really talk.” The Haitian nurse nodded vigorously in agreement.
Those first few months at LIJ, a large number of my inpatient consults came from Rajiv because he would accept horribly sick patients from other hospitals (his motto was “Just say yes”), then dump them onto the heart failure service. Apart from taking the initial call and occasionally catheterizing the patients he accepted, he rarely took care of them, leaving that responsibility to clinical cardiologists like me. The fellows groused. They had to do most of the work managing these train wrecks.
Though I was an employee of the hospital, my salary, as with all physicians at LIJ, was linked to how much revenue I generated (though not nearly as directly as if I’d been working for myself in private practice). “On January first, everyone talks about research and teaching,” Rajiv warned me when I started. “But on December thirty-first, they only want to know how much money you’ve brought in.” The revenue was measured in terms of “relative value unit” collections. RVUs define the values insurers place on medical services. For the past twenty years a committee (called the Relative Value Scale Update Committee, or RUC) comprised of twenty-nine physician representatives from the major medical societies has proposed specific RVU amounts for seven thousand medical services. (Though the recommendations are only suggestions, history shows that they have almost always been accepted by Centers for Medicare & Medicaid Services [CMS], the agency that administers Medicare and Medicaid, and not long thereafter by private insurers.) The RVUs are multiplied by a conversion factor (currently about $35 per RVU) to come up with the dollar amount physicians receive as payment for their work (with some adjustments made for geographical cost differences). For example, a moderately complex outpatient visit (coded 99213) is valued at 2.0 RVUs by Medicare and reimbursed about $70. Therefore, a general internist who sees fifteen moderately complex patients six days a week for forty-eight weeks out of the year, after subtracting office overhead (rent, staff salaries, malpractice insurance, and other expenses) of 50 percent of total revenue (a reasonable average for most physicians), will earn about $150,000 a year before taxes. (The first ten patients each day just cover practice costs.) Primary care physicians have often complained that representation on the RUC is tilted toward specialists, who have weighted reimbursement rates away from evaluation and management services (basically office and hospital visits) and toward procedures. Others have criticized CMS for allowing its payment rates to be determined by the very group that receives those payments.
Whatever the economics, I quickly learned that it was important to see as many patients as possible. The talk around the hospital those first few months was “Rajiv’s brother has opened shop; let’s give him some business.” On the wards, doctors—even cardiothoracic surgeons who might have dismissed me a few months prior, when I was still a cardiology fellow—frequently stopped me to say hello. (“So you’re the famous Dr. Jauhar! I’ve been seeing your name on charts all over the hospital.” “No, that’s my brother, Rajiv.”) One afternoon I met a Korean internist with a stained shirt and bad breath who talked to me about the merits of being a hospital employee. “Basically, you’re trading income for security,” he explained. Hospital employment offered a guaranteed salary and a better work-life balance. Private practice—where doctors are independent contractors endeavoring for themselves—typically required longer hours but was rewarded with higher earnings.
“Do you ever think about private practice?” I asked.
He laughed. “Not anymore. My wife tells me all the time, ‘You don’t know how to be social, drum up business.’ It’s easier when you start off private, but once you start working for a hospital, it is hard to develop.”
“So you’re here for the long haul?”
“Yes, I am institutionalized,” he replied with a grin. “It’s like that movie The Shawshank Redemption. He was in prison for so long he didn’t know what to do when he got out.”
I mentioned what Rajiv had told me were the three attributes of a successful private practitioner: accessibility, availability, and affability.
“I heard there was another one,” he said coldly. “Average.”
The subject of private practice was a frequent topic of discussion in the doctors’ lounge, where private practitioners and hospital employees frequently sat to discuss cases or business over a cup of coffee. Dr. Mukherjee, a pulmonologist, had quit his hospital job for private practice about two years prior. “Initially you’re excited because it’s something new,” I heard him tell another doctor, a kidney specialist, “but time passes, and then slowly you start to think, What nonsense am I doing?”
The kidney doctor laughed. “I was told that a more profitable career than being a physician is pole dancing,” she said. “So I’ve been trying to get slim going up and down the stairs.”
In November, with Sonia (who had deferred taking a job so she could take care of our newborn) and Mohan back in our apartment and comfortably in their daily routine—bath, nap, park, nap, etc.—I started to spend more time at work. I was getting busier at the hospital. My department finally hired a nurse practitioner for me, John Meister, a congenial man who had worked as a CCU nurse for over twenty years. Nurse practitioners have advanced nursing degrees and licenses that allow them to work at least partly independently of physicians (they can write drug prescriptions, for example). John had earned his degree about two years before we met. He was a stocky fellow of German descent beloved by his colleagues, inspiring greetings in the corridors from everyone from hospital executives to senior physicians to the custodial staff. He had earned all manner of nursing awards, including twice being named nurse of the year at LIJ. He told me that at the cardiologist’s office where he’d previously worked part-time, patients with v
irtually any complaint would get a standard panel of expensive cardiac tests: echocardiogram, Holter monitor, nuclear stress test. “And that’s even if you’re young and have only, say, one risk factor for heart disease,” he said. Of course, the tests have utility in the proper clinical situation, but in young people they are often unnecessary. Disillusioned by the mercenary nature of private practice, he’d decided to quit and work as a salaried employee at the hospital full-time.
Together John and I saw inpatients every day and outpatients three times a week. John saw them first, getting their histories and examining them; then we saw them together. (The more redundancy in our interactions, I figured, the less chance that something would get missed.) Ours were complicated patients who required a lot of attention, and it came as no surprise that private physicians, pressed for time, were referring them to us.
Harold Peters was one such gentleman, an eighty-seven-year-old who came to my office every couple of months, faithfully accompanied by his daughter. He had severely elevated blood pressure in his lungs, a result of congestive heart failure, causing him to feel terribly fatigued and short of breath. When I told him I could put him on an expensive new drug to treat the disease, he immediately dismissed the idea. “What’s the point, Doc?” he said. “What’s the point of a drug that costs the government thirty-eight hundred dollars a month? Isn’t it selfish?”
“What about the patient?” his daughter demanded.
“Yeah, well, I guess some people want to stay alive as long as possible. Not me. What’s the point of living if I can’t walk? I walk just a few feet and … I’m gone.”
“Wait, are you saying that you’d rather be dead than weak?” his daughter said.
“That’s exactly what I’m saying.”
“Well, we are not having this conversation anymore,” she said, waving her hand. “I am not ready to be an orphan.”
“See, Doc, that’s what I mean. It’s selfish.”
He told me he was spending most of his days alone in the house he had lived in for forty-eight years.
“In all that time you didn’t make any friends?” I asked gently.
“Sure I did, but…” His voice trailed off.
His daughter quickly filled in: “They’re all dead.”
He nodded dolefully. “Yes, most of my friends are dead.”
“But not everyone, Daddy.”
“Who’s still alive?”
“Mr. Barney.”
“Oh, I guess that’s true. Barney’s still alive.”
“Can’t you spend time with him?” I asked.
“Invite him over to play cards,” John, the nurse practitioner, suggested.
He shook his head. “No, we are not going to play cards.”
“Why not?” I asked.
“Well, let’s just say that Daddy’s more mentally agile than Mr. Barney.”
“So let him win!” John cried.
Patients came to us with a range of complaints, and not always concerning their physical hearts. Ella Gerson, whose heart was functioning at less than 30 percent of normal, told me this about her husband: “He drinks, Doctor, every afternoon, and if he doesn’t have it, he gets nasty. Seven bottles at our neighborhood bar. He used to walk there, but since his stomach cancer was cut out—only a little is left—now he takes the bus. After the operation he stopped for about a month because he couldn’t taste the beer, but when he got his taste back, he started drinking again.” She sighed. “After so many years, I have nothing left. I asked Dr. Briggs, my primary, ‘Send me to rehab.’ He asked why. I said, ‘To get away from my husband.’” Then she gave a sad chuckle.
I had my share of frustrations in the office. A frequent one was appeals to insurance companies to authorize office procedures, like echocardiograms. Some insurers refused to pay for certain procedures unless you called them up front. It was part of the “utilization review” introduced by managed care in the 1980s. A typical phone exchange would go something like this:
“Hi, this is Dr. Jauhar calling again for preauthorization.”
“Yes, Dr. Jauhar, hold on.”
A couple of minutes would pass. “None of the medical directors are available, Dr. Jauhar. Let me try to get a nurse for you.”
“Well, is a nurse going to be able to approve this test?”
“I don’t know if she’s going to be able to approve it, Doctor. You’ll have to discuss it with her … [blah blah blah].”
“So what are you going to do now?”
“I’m going to get someone. Hold on, Doctor.”
And then, inevitably: “At the tone, please record your message. When you have finished recording, hang up or press pound for more options.” Beep.
I enjoyed working with John and the fellows who rotated onto my service each month. We took care of very sick patients that most doctors at the hospital felt uncomfortable treating. We used novel drugs that few cardiologists had experience with. We brought our patients to an advanced level of care that hadn’t existed before I arrived. And so we quickly succeeded in carving out a niche for ourselves.
Esther McAllister was typical of our inpatients. About sixty years old, she was admitted to the hospital with fluid overload from not taking her medications and eating too much salt. Her legs were purplish and her abdominal wall was leathery hard, both consequences of severe heart failure. She was morbidly obese, weighing 320 pounds. All the teeth of her lower jaw were missing save one, which jutted out like a fang.
“I don’t know why they don’t bring you the bedpan when you need it,” she groused one afternoon, chewing gum like cud. Her Coke bottle spectacles lent her a schoolmarmish air. “Seems they’d rather clean up after me than give me the pan.”
I dispatched a resident to fetch a nurse’s aide.
“Last time I went in the bed, the man came in and said, ‘Do you do that on yourself all the time?’” She shifted uncomfortably. “They’d better hurry or there’s going to be another accident.”
I sat down in the chair next to her bed and leafed through her chart. John and Simon, our fellow for the month, remained standing, waiting for me to initiate the conversation. She had been in the hospital for over a week. “Feels like three years,” she said. “During the day, it’s hot as Hades. At night you can chip off the icicles.” Relieved of excess water weight, she was forty pounds lighter than she’d been on admission, breathing much better but still feeling weak with even a tiny bit of exertion.
“Have you been getting out of bed at all?” I asked her, turning a page.
“Not recently.”
“Not even to the bathroom?”
She shook her head.
“Where do you go?”
“Unfortunately, in the diaper.”
At home she’d been able to do most activities of daily living—bathing, dressing, preparing meals—though she’d been housebound. “I didn’t want to go out,” she explained. “I was feeling very down.”
“Well, that will hopefully change now that it’s getting warmer,” I said. “It’s been a rough winter. I’ve been a little depressed myself,” I added frivolously.
She perked up. “Who hugs you, Doctor?”
I laughed. “No one.” The sheer arduousness of taking care of a newborn had sapped the romantic energy at home.
“Don’t look at me,” John quickly interjected.
“I’ll give you a hug,” she said.
Embarrassed, I shook my head. “No, that’s all right.”
“No, it’s not all right. Come here. Give me a hug.”
She struggled to sit up, swaying from side to side to pull up her three hundred or so pounds. Then she grabbed hold of me. “If you get fifteen hugs a day, all your problems will be solved.”
“I wish it were that easy,” I said as she squeezed the air out of me.
“No, I’m serious,” she said. “A hug does something to your inside.” (No question about that, I thought, feeling my spleen being crushed.)
After breaking from her clench
, I had her sit up so I could listen to her chest. Her thick gray chin hairs tickled the back of my hand. She smelled of cheap perfume, but the odor was inoffensive, even slightly pleasant. While I was examining her, she glanced at Simon, the cardiology fellow, standing quietly behind me.
“What do you want to be when you grow up?” she asked him.
“I’m training to be a heart doctor,” he replied stiffly. “I have a couple more years.”
“I wanted to be a photographer’s model,” she said. We all laughed, except Simon. “Do you like old movies?” she asked him.
“Sometimes,” he replied, rocking nervously on his feet.
“Well, I love those old Betty Grable movies. And Marilyn Monroe, too. Did you know me and Elizabeth are only three months apart?”
“Elizabeth?” Simon said.
“Yes, Elizabeth Taylor. But we’re different. I only had one husband.” Simon stared at her impassively. “He was a good man,” she went on. “He said, ‘I’m the husband. I don’t want you to work.’”
“What did you do?” I asked.
“I didn’t work! What was I going to do, argue? Someone tells you, ‘I’ll support you,’ what would you do?”
An orderly arrived with a bedpan. I told Ms. McAllister that we would come back to see her the next day.
“Okay,” she said, turning onto her side so the receptacle could be placed under her bottom. She looked straight at Simon. “Smile, sweetie. It only gets worse when you get older.”
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