Doctored

by Sandeep Jauhar

  SIXTEEN

  Follow the Money

  I am dying from the treatment of too many physicians.

  —Alexander the Great

  Pia was born on July 1, the date that medical school graduates start their internships. When people ask me if she is “Daddy’s girl,” I am reminded that human relationships are constrained by biology. Girls so often fancy their fathers. Even my sister, Suneeta: though she spent so little time with my busy father growing up, she still adored him. Dad always says how wonderful it is to have a daughter. Girls are more sincere, he says. And loyal.

  Our baby girl and her accoutrements quickly swallowed up the little remaining space in our apartment. We put her crib in Mohan’s room and had him sleep with us, throwing off his schedule, which started to conform more and more to ours. It was a subpar solution, but there was little else we could do. The hourglass had turned, and Sonia and I both knew our time in Manhattan was coming to an end.

  The prospect of suburban living created a peculiar polarity in my mind. I feared the loneliness and insularity of the suburbs—was there anything more depressing than the manicured patch of lawn in front of the local bank?—and yet my remembrances of my suburban upbringing were mostly fond ones. (Or had I just filtered away the terribleness?) I’d grown up in Southern California, at the edge of the desert—a wasteland, and not just because of the cacti—and though I now fancied myself an urban guy, I had vaguely happy memories of my childhood: dirt biking on the dunes behind the train tracks, catching crickets in the backyard at dusk, playing touch football on the street at night, scuffing my knees on the gray asphalt.

  Of course, it was a very different time from today. There was little parental supervision; mothers and fathers didn’t feel compelled to be their kids’ best friends or social secretaries. Nowadays there is such little tolerance for ignorance about our children’s whereabouts, but back then, at least in our middle-class neighborhood, it was the norm. Most of the moms had full-time jobs. My friend Billy’s dad worked nights at the printing press, so though he stayed at home during the day to supervise, he slept most of the time—he was morbidly obese and had sleep apnea to boot—and we were left largely to our own imaginations. We’d thumb through Stevie’s dad’s collection of Playboys and Penthouses. We’d ogle our friend Sammy’s older sister, Jessica, sunbathing topless (or so we wanted to believe), through a hole in the fence. We scaled a hundred feet up the exterior of the clock tower at the local university. Once, we even considered jumping off Billy’s roof into his swimming pool, desisting only after Carl, a kid from up the street, deemed it a bad idea. But moving out of the city wasn’t about nostalgia or reliving a lost time or providing a more natural place for my children to grow up. It was essentially about a lack of space, and the lack of money to buy more.

  * * *

  Because insurers had been slashing reimbursement rates, that summer my LIJ colleagues and I were told we had to increase our “relative value unit” collections, or RVUs (the currency of medical payment). With all the cuts in reimbursements over the prior few years, academic medical departments across the country had suffered sharp downturns in revenue. Some physicians had responded by upcoding—claiming greater complexity in patient encounters than was in fact the case—and fraud investigations at some centers were under way. Obviously I wasn’t going to upcode, so what the department’s directive meant for me on a practical level was that I had to see more patients. I reduced the time in my schedule earmarked for new patients from sixty minutes to forty and for established patients from thirty minutes to twenty. With administrative tasks, conferences, teaching, chart reviews, and letters and phone calls to physicians, hospitals, and pharmacies increasingly gobbling up my day, I began to rush through visits, hurrying patients along in subtle and not so subtle ways. I stopped making small talk. I interrupted histories after a few seconds to get patients on point. I even urged my patients to breathe a little faster when I was listening to their lungs. “Doctor, I just want to know…” “One second, ma’am, please, one second…”

  With the added density in my schedule, I started to cut corners. I discovered that one of my patients had herpes zoster—shingles—which would have fully explained her chest pains. The ER didn’t pick up on it, and neither did I or two cardiology fellows who examined her. She noticed the telltale rash only while she was bathing, after undergoing a costly and unnecessary cardiac workup. “It’s pathetic,” I wrote in my journal. “We don’t open our eyes, and what did I do with the next patient? I still didn’t disrobe him to examine him properly. I can’t believe I’ve become like this. I hate myself for not trying harder.”

  You can often do a passable job, but it is impossible to appreciate the subtleties of patient care when you are rushing. Kenneth Ludmerer, a physician and medical historian at Washington University in St. Louis, has said that “the single greatest problem in medicine today is the disrespect of time. One cannot do anything in medicine well on the fly.” So, 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. To cope with the anxiety, you start to call in “experts” for problems that perhaps you could have handled yourself if you had 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 ass.” Sometimes the “easy” consults are the hardest ones, not because you don’t know what to do but because you have to figure out why you were called in the first place. Wanton consultation is a consequence of the zip drive of modern medicine, in which patients are compressed into a smaller and smaller space-time.

  One of my patients, Nora Mitchell, went to the ER after swallowing a tiny fishbone. She told me about the experience when she came to see me. “They kept me down in that ER for two days, Dr. Jauhar! They did X-rays, EKGs, CT scans, God knows what. They had an ENT doctor come by. They called a pulmonologist. They told me to follow up with my cardiologist. I told them it had nothing to do with it. It was the fish!”

  The Institute of Medicine, a respected think tank, recently estimated that wasteful health care spending—spending that does not improve health outcomes—costs $750 billion in the United States every year. Excessive paperwork and administrative costs explain some of this waste, but unnecessary or inefficiently delivered services, especially in hospitals, account for the lion’s share.

  This is the sad irony of the cost containment paradigm. The more pressure on doctors to cut costs by working harder and faster, with shorter hospital stays and quicker patient turnover, the more uncertainty doctors often 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.

  The consequences for patients are troubling. Having too many consultants leads to sloppiness and disorganization. Mr. Wolski complained about this when I went to his hospital room one morning. “Man, there are really some incompetents in this place. Around midnight, I’m eating something and a nurse comes by and says, ‘Nothing by mouth after midnight.’ After midnight, some character comes upstairs and says, ‘I think you’re going for dialysis.’ I asked him, ‘How do you know? Am I or not?’ but he didn’t have a clue. He said he’d check, but he never came back. This morning, in comes Dr. Richards. He was amazed that no one had dropped a central catheter in me, so they did that.” He shook his head in disgust. “Then it turns out no one did blood tests and they needed to find out what my Coumadin level was, so they ran around doing that. Then they came in at eleven-thirty this morning and cheerfully said, ‘You’re going to dialysis.’ They took me downstairs. I started feeling sick. I asked them to let me dangle my legs over the side of the stretcher, but they wouldn’t let me. I couldn’t get it through to them. Nobody listened!”

  With bul
ky care teams, there is diffusion of responsibility. Who’s in charge? Who is spearheading treatment? Nowhere is this confusion more evident than in the hospital discharge process.

  In 2009 a study in The New England Journal of Medicine found that one in five Medicare patients discharged from the hospital was readmitted within a month. One in three was readmitted within three months. Readmissions, so plentiful, are costly. In 2004 the expense to Medicare for unplanned readmissions was $17.4 billion—17 percent of its total hospital budget.

  Hasty readmission is an indicator of an inefficient, if not dysfunctional, health care system. Many factors contribute to the problem: poor communication, inadequate discharge instructions, spotty information transfer, and delayed outpatient follow-up. And all these things derive in part from the lack of time health care providers have for patients.

  Doctors working in hospitals are increasingly rushed. The arsenal of tests, therapies, and technologies is more complex. Resident work schedules have less total and consecutive hours, so there are more handoffs and less continuity of care and attending physicians have had to take on more responsibilities than in the past. As Dr. Donald Berwick and Dr. Allan Detsky recently wrote in The Journal of the American Medical Association, inpatient care at teaching hospitals has become a relay race for physicians and consultants, and patients are the batons. In a recent study of nearly three thousand adults, 75 percent of inpatients were unable to name a single doctor assigned to their care. Of the remaining quarter who offered a name, 60 percent were wrong.

  There are many things doctors could do to reduce hospital readmission rates. They could ensure that discharged patients get timely follow-up appointments. (In the New England Journal study, half of all medical patients readmitted within thirty days had not visited a doctor after discharge.) They could do a better job of ensuring that patients obtained their medications and understood how to take them. When I was a fellow, one of my elderly patients bounced back to the hospital simply because she’d missed her morning dose of diuretic on the day after discharge. Though I’d given her prescriptions and gone over the dosing schedule, I hadn’t checked whether there was someone available to drive to the pharmacy to get her medications, an oversight that resulted in a $10,000 rehospitalization. Doctors could 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 physicians rather than go to the emergency room. We know that patients with a clear understanding of discharge instructions are 30 percent less likely to return to the hospital. But research shows inconsistency at best in achieving these goals.

  After so many years in medicine, I am convinced of one thing: The vast majority of doctors aren’t bad. It is the system that makes us bad, makes us make mistakes. Most doctors—and this is certainly true of my colleagues at the hospital—are willing to stay late and work hard to provide good care. But they are struggling to do so in a system that is diseased. I often think of Dr. Nelson from my residency days at New York Presbyterian Hospital. A retired old-timer, he’d come to all our morning reports. He’d hold special teaching rounds with the residents. We’d groan when he came around because we didn’t have the time to spend an hour on one patient. But he showed us the ideal, how best to approach a difficult case, even if you could reach it only every once in a while. Still, people used to whisper about Nelson. He’d had a busy practice. He used to be a terror with residents, dismissive of his patients. So over time he obviously had to change, too.

  To curb health costs, Congress and the Obama administration are now doling out penalties (as of October 1, 2012) on hospitals with high readmission rates. Hospitals, many with very narrow margins, could forfeit up to 1 percent of Medicare payments in 2013, 2 percent in 2014, and 3 percent in 2015 and after. But these incentives are misdirected. Hospitals do not hospitalize patients; doctors do. And doctors currently stand to gain little from lowering readmissions. In fact, they will lose revenue. As is so often the case in our health care system, doctors’ incentives do not serve broader social goals. This virtually guarantees that proposed reforms like cutting readmissions, reducing unnecessary testing, and adopting computerized medical records will fail.

  The agency that runs Medicare is considering giving bonuses to hospitals that lower readmissions below the 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. But such “gainsharing” will align physicians’ incentives with cost-cutting goals. Our system, structured to encourage overutilization, needs to provide some inducements to reduce the amount of health care, too.

  You have to motivate doctors to do the right thing. You can appeal to professionalism or altruism, to doing well for patients or serving a greater social purpose, but as I have come to learn, nothing today influences physicians’ behavior (even if unconsciously) like hard cash. If you want to understand why doctors behave the way they do, look at the schedule of Medicare payments. As in politics, just follow the money.

  SEVENTEEN

  Speed Dating

  We trust our health to the physician … Their reward must be such, therefore, as may give them that rank in the society which so important a trust requires.

  —Adam Smith, The Wealth of Nations, 1776

  Despite the increased workload at the hospital, I needed to find another moonlighting opportunity to make up for the shortfall in income. Though I knew I’d have to purchase my own malpractice policy, I figured it would be worthwhile if I earned at least $35,000 per year moonlighting, roughly double the insurance premium. But notwithstanding searching for several months, I was unable to find a regular gig like the one I’d had with Chaudhry. An imaging company was looking for a cardiologist to supervise its New York City operations. “You can expect a contract to arrive in your hands in the first part of September,” a sales rep promised me in an e-mail, adding that I could make roughly $700 per week, but I never heard from him again. A private cardiologist told me that an outfit in Queens called Daval Diagnostics was looking for someone to read its nuclear stress tests, but when she called on my behalf, the manager wanted to know if I’d be referring my own patients for testing. “They want to know what you can bring to the table,” she explained. So that fell through, too.

  Since I was taking doc-of-the-day calls every week, I reached out to private internists who had clinical privileges at the hospital, offering them “general medical consults” on my ER patients, wishfully thinking that if I built up my referral network, Chaudhry might take me back. It was a different sort of challenge: beating a flawed system, finding a way to extract what I needed. Though mercenary, it still held a peculiar kind of attraction.

  However, my efforts fizzled badly. Most internists I contacted weren’t interested in coming to the hospital. One of them straight-out told me not to call him; he was trying to eliminate his inpatient work. (Later I discovered he was doing the same consults for another cardiologist.) It was embarrassing, really, trying to practice quid pro quo medicine—and failing. Perhaps the internists found me ingratiating or my designs too obvious. Perhaps referral patterns were already set. Perhaps my efforts weren’t backed up by jocularity or friendship. Or maybe I just wasn’t the kind of person who could pull it off.

  At Rajiv’s urging, I invited his friend Sameer Chawla, the private internist Chaudhry and I had once courted, out to dinner. The three of us met one muggy summer evening at an Indian restaurant near the hospital. Sameer was a short man, faintly canine, with a knotted beard and a small bhag turban. The evening started off well. Rajiv ordered Black Label Scotch and a platter of lamb chops, Punjabi style, the Rajiv Jauhar appetizer special (“I come here so much, they named a dish after me!”). We gossiped about medicine on Long Island: private practices being bought up by hospitals, Medicare fraud audits,
and so on. Sameer told us about nursing home doctors who hospitalized patients with false diagnoses like “altered mental status,” admitting these patients through a network of colluding physicians so monitors wouldn’t detect the deceit. He mentioned pharmacists in Queens who were offering physicians bribes for fake prescriptions that the pharmacists would then submit to insurers for reimbursement. “Imagine getting one hundred percent profit from Medicaid!” he exclaimed. I listened in disbelief.

  Midway through bowls of spicy chicken makhani and saag paneer, I gently brought up the subject of referrals. Rajiv had advised me to tell Sameer that I was still partnered with Chaudhry and that we were trying to generate more business. So I suggested the following arrangement: Chaudhry and I would rent space in Sameer’s office, Sameer would provide us patients, and all resulting cardiac procedures would be done back at Chaudhry’s workplace. But Sameer immediately dismissed the idea, saying he didn’t want anyone coming to his office. When he left to go to the bathroom, Rajiv shrugged and said, “He does things by the book,” of course making me feel even worse. It was bad enough trying to make a backroom deal, but I couldn’t even get that done. When Sameer returned, he asked me about Sonia. I told him that she had just passed her internal medicine board exams but was at home for the time being, taking care of our newborn. He encouraged me to move to Long Island. “Put your wife to work,” he said. “We will keep her busy.” I told him I’d mention it to Sonia.