Work has been getting me down as of late. It was a few short years ago when I was interviewing for medical school. I sat before a committee explaining why I wanted to be a doctor. I wanted to help sick people get better. In whatever creative way you say it, in essence, this is why people should be doctors. Instead I find year after year the patient less of a priority in the modern medical culture. We talk about evidence medicine and studies. We take board exams meant to be some sort of bar that we need to pass to prove we know the right things to do. Yet day in and day out I see these rules ignored, replaced instead by defensive medicine, lazy medicine, or just plain greed. It seems these days I hear more about the “cost” of things as opposed to the “right” thing medically to do. Before a patient is even in the system there is talk about their discharge planning and length of stay. Even taking a basic medical history is eroding away. Why take a history when you ask a consultant to solve a problem for you. I look at new trainees and many seem to be glorified secretaries. The top priority often appears to be writing a note and discharging a patient.
I often wonder what a hospital would look like if you put perfect strangers in there instead of doctors. Say for instance you took a stranger and said you are responsible for these 10 patients. Go! What would happen? I imagine the stranger would talk to the patient, noting their complaints. This person has belly pain. I better call the stomach doctor. This person has chest pain. I better call the heart doctor. Is this too far from what many actual doctors do these days? Perhaps it is a culture of defensive medicine or maybe it is just plain laziness. There are countless times when doctors fail to take even a basic history. My favorite is a person referred to cardiology clinic for left wrist pain. He sprained his wrist but no one bothered to take an actual history. They heard left upper extremity pain and sent them to the cardiologist. Sometimes chest pain can radiate down the left arm. A cursory 30 second conversation with the patient revealed this was certainly not cardiac.
Perhaps most bothersome is the culture change from a patient-centric to a business centric/shift based one. I will never forget a meeting in which I was arguing how defibrillators should be mandated on every floor. Someone promptly told me, we can’t afford that. There was no talk about the actual medical necessity, no talk about how we were no better than your average train station if someones heart were to stop on such floors. It clearly showed me how pervasive this culture of business replacing medicine has become.
Also, like a business, medicine has turned into a shift-based model. The future seems to be more and more of you being a patient in a hospital system as opposed to being a patient of a particular doctor. Private practices are being bought up by large hospital systems. The reason is simple. By consolidating, these systems can pay doctors less and be in a better bargaining position to get better pay from insurance companies. It seems inevitable that with a more corporate culture the doctor patient relationship will suffer. I don’t know about others but that relationship is a big reason why I wanted to be a doctor. The role of the doctor gets reduced. A doctor spends a decade training, learning what medicine to give for a particular condition only to not be able to give that medication because a particular insurance company on a particular day does not find it profitable. The doctor then has to take time out of her busy day to call and justify this decision to a secretary on the other end. The ludicrousness of this become apparent if you think of other professions having to do the same thing. A lawyer is about to give cross examine and is stopped, “Sorry in order to ask that question you have to get it prior approved by calling this number.” The lawyer would then call that number and for the next 30 min be bounced around before having to fax a form and try to get permission to use that question. If this example seems ridiculous it is far more ridiculous when people’s live and well being depends on such asinine protocols.
I guess I find myself longing for things to change. I miss medicine.