The thoughts I express here come from my experience working with scores of physicians as director of a physician wellness program, as well as 30 years experience in teaching and practice—both public and private--in both medicine and psychiatry. Like most of us, I’ve had my share of challenges trying to get patients the care they need in the chaos of the current system. I’d like to start by sharing one of these experiences with you (all details changed for confidentiality):

My heart went out to this patient when she first came to my office, with a severe depression caused by the unexpected death of her father. This sweet and bright young woman was so distraught, she spent her sessions sobbing in the corner of my office couch, and so suicidal she required 24-hour observation to keep her from jumping in front of a car or subway. Realizing she needed urgent admission, I made several calls to her insurance company to let them know I was admitting her, and to make sure the hospital was in their network. Fortunately it was, and this young woman had a hospitalization that not only saved her life, but turned it around—she is now thriving. Unfortunately, her family is now facing what might be called "iatrogenic bankruptcy" as their insurance company—who never informed us of this requirement-- denied reimbursement for her expensive hospitalization on the grounds that it had not been properly preauthorized!

Sir William Osler said that being a physician is a "noble calling" that "provides the greatest opportunity to exercise the mind and heart," and I agree: even in these difficult times for our profession, it is still an incredible privilege to be someone’s doctor. However, given the challenges we are currently facing, it seems that fewer and fewer of us are actually able to experience these noble rewards. There is good evidence that physicians across the country are experiencing a pervasive malaise. For example, a 2002 study of physicians’ satisfaction found that 87% of the doctors surveyed felt morale had declined significantly in the last 5 years; 58% said that their own enthusiasm for practicing medicine had lessened; and almost half said they would not recommend medicine as a profession.

We all know the problems: Mountains of paperwork, more and more patients in less and less time, and more time arguing with insurance representatives than working with our patients! Often it is difficult to find time to do an adequate diagnostic interview, much less to build the relationships that are so important for maintaining trust and optimizing adherence. Physician autonomy is compromised when every decision is second-guessed by 3rd party payers, and the much-trumpeted "patient choice" is meaningless when patients cannot choose their own doctor if he or she is not "in network," and when longstanding doctor-patient relationships are ended abruptly because of the loss or change of insurance policies or jobs.

The average physician’s office deals with over a dozen different insurance companies, and spends a great deal of time and money doing so. A recent study found that the average physician spends 3 weeks per year dealing with health insurance related administration, and primary care physicians spend 1/3 of their total practice time doing so!

We all know and complain about these problems, but do we consider how many of them may be caused by our present healthcare system? I believe this system has a very detrimental impact—not only on our patients’ health, but on all aspects of our practice. It goes to the heart of how we feel about our work and ourselves and affects much of our day-to-day practice experience.



Here I’d like to share another recent incident from my practice:

A middle-aged woman I cared for over 10 years needed an urgent detox admission, when her chronically excessive drinking got out of control after a devastating job loss. At the time of admission she was not only on the brink of a prescription drug overdose, but was dangerously hypertensive and tachycardic from alcohol withdrawal. The insurance company refused to cover her hospitalization on the grounds that it was not "medically necessary." She was discharged after 1 1/2 days, still emotionally and physically tremulous, to finish the detox alone in her apartment, with only a distant brother and myself to watch out for her.

Those of you who have seen patients through such situations—and much worse—will understand the anxiety and concern I felt for these patients and their families, as well as my intense frustration. Certainly this is not how—or why—I learned to practice medicine: to stand helplessly by as unconcerned, self-interested insurers deny and limit care for needy patients, and undermine the relationships I have worked so hard to create! And how do such experiences affect us? How do they affect our spiritual and emotional well-being? Our ethics? What can it mean for us doctors, who went into medicine to help people, to find ourselves participating—willingly or not—in a system that turns patients away because they can’t pay our fees; or to watch our patients suffer and even die because they can’t afford insurance and/or needed healthcare; as do approximately 45,000 Americans/year?



Many commentators point to the presumed greed of health care providers in contributing to the costs and problems of our current system. Perhaps, given the recent hijacking of our healing mission, it is not surprising that some of us turn to monetary rewards to replace the deeper rewards of our work that have gone missing. In the June 9th issue of the New Yorker article, Dr. Atul Gawande explored how the medical culture of profit and self-interest in one Texas county has caused extreme overutilization of medical treatments and procedures, leading to the highest per capita medical costs in the nation and creating a culture of providers who seem to have lost sight of our healing mission. Such trends, in contrast with the dedicated attempts of many providers to improve and reform healthcare, do represent, in Dr. Gawande’s words, "a battle for the soul of medicine," and a battle also for its future.



Dr. Gawande believes that this battle will be won by changing the culture of medicine itself. While such cultural changes are clearly essential, in order to restore meaning and effectiveness to our work, it is also essential that we change the system by which health care is organized and paid for. Some of our colleagues may be engaged in healthcare profiteering, but they contribute little to the overall costs of healthcare, and are vastly outnumbered by those of us who desperately want a system that allows us to provide good care for our patients and to believe in our work again.



What, then, would it be like to be part of a healthcare system that really worked, for our patients and ourselves? A system in which no patient is turned away because of inability to pay, or suffers pain or disability because they have inadequate to no health insurance? A system in which we have time to ask patients about what’s going on in their lives, and how it’s affecting their health. How much more could we do with time and reimbursement for patient-centered services like a careful history to diagnose Mr. Jones’s stomach distress, or counseling Ms. Smith about caring for her son’s asthma? Imagine being able to do the operation your patient needs, not the one the insurance company will pay for. Imagine never having to spend another minute on the phone fighting with an insurance company, or losing another patient because they no longer have a job or an insurance policy. And finally, imagine coming back to our noble calling, and being the kind of doctor you really want to be.



A utopian vision? Perhaps. But we physicians can bring it closer to reality by speaking out for our unique viewpoint. A recent survey found that more than a third of physicians supported the "public option," but how many of us have actually expressed our opinions publicly? Now is the time for us to speak out loudly and strongly for the healthcare system we and our patients desperately want and need.