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1:01 pm
Tue August 19, 2014

Cardiologist Speaks From The Heart About America's Medical System

Originally published on Tue August 19, 2014 5:47 pm

As a young doctor working at a teaching hospital, Sandeep Jauhar was having trouble making ends meet. So, like other academic physicians, he took a job moonlighting at a private practice, the offices of a cardiologist. He noticed that the offices were quick to order expensive tests for their patients — even when they seemed unnecessary.

It was "made very clear from the beginning" that seeing patients alone was not financially rewarding for the business, he says.

"Spending 20-30 minutes with a patient might be reimbursed $80, $90, but sending the patient for a nuclear stress test was much more profitable," Jauhar tells Fresh Air's Terry Gross. "A nuclear stress test, at the time when I started working, was reimbursed roughly $800 to $900."

Jauhar was supervising the tests that had been ordered by a physician — and some physician assistants.

"So even though I wasn't ordering the tests, I was in the office while these tests were being performed — and I felt really dirty about it," Jauhar says.

Jauhar's new memoir, Doctored: The Disillusionment of an American Physician, is about how doctors are growing increasingly discontent with their profession. And they're facing more pressures: As the number of patients they're expected to see increases, so does the amount of paperwork. While some doctors who perform a lot of procedures may be paid too much, he writes, many doctors, such as primary care physicians, aren't paid enough.

And, he adds, "the growing discontent has serious consequences for patients."

Jauhar, creator and director of the Heart Failure Program at Long Island Jewish Medical Center, talks about not only unnecessary testing but also uncoordinated care by multiple specialists.

"American medicine is the best in the world when it comes to providing high-tech care," he says. "If you have an esoteric disease, you want to be in the United States. God forbid you have Ebola, our academic medical centers are second to none. But if you have run-of-the-mill chronic diseases like congestive heart failure or diabetes, the system is not designed to find you the best possible care. And that's what has to change."


Interview Highlights

On common complaints doctors have

One of the issues with medicine today is that it's just become so complicated. More and more people are surviving with chronic illnesses, so you have folks in every patient panel who have multiple chronic diseases. And they come to the doctor and they have a whole host of issues that have to be dealt with. And [that doesn't even] mention preventative care, which has become a huge time problem for a lot of primary care physicians.

There's no denying that reimbursement[s] for office visits and for procedures have been drastically cut in the last two or three decades. And that was really an attempt to control health costs. And it seemed to make sense, but it resulted in doctors basically running on a treadmill seeing patients every eight to 10 minutes. So the lack of time to spend with any one patient is a big factor.

On "defensive medicine"

There's no question that there's a lot of unnecessary testing in American medicine today and the reasons for it are manyfold. Part of it is ... a lack of time. You have a patient come into your office and you have eight minutes with them and they have lower back pain and you don't want to miss something because one of the major causes of dissatisfaction among doctors today is malpractice liability; there's that fear.

A lot of doctors are practicing defensive medicine. There have been various estimates that defensive medicine costs up to $100 billion a year out of the roughly $3 trillion we spend on health care, so it's a huge, huge waste. ... It takes time to evaluate the patient, get a good history, examine the patient, and it's just so much easier to order a test-- especially when the financial incentives of the system are to reward for more and more testing.

On uncoordinated care by multiple specialists

Today if you go to a hospital, it's rare that you won't have multiple specialists on your case. And I'm a specialist [in cardiology], and when I'm called to see someone with a nonspecific symptom like shortness of breath, which could be a whole host of diagnoses, I'm apt to view the problem through my own expertise. And that's true of rheumatologists and hematologists and so on.

One patient who came in with shortness of breath — his primary care physician called 15 specialists onto the case. ... He underwent 12 procedures in the hospital, and when he was sent home he had follow-up visits with seven different specialists. ... We actually never figured it out. This is so common. ...

When you have a symptom like shortness of breath that has multiple inputs from different organ systems, probably the best doctor to diagnose that and treat that is a good general family physician. But when you call in these various specialists, they are apt to view the problem through their own organ expertise. And they make recommendations based on their own expertise and these recommendations are frequently not coordinated and so you get a whole host of recommendations and suggestions for care. But no one is really talking and trying to coordinate this care, so it makes it very difficult for the physician who is trying to manage the whole patient and treat the whole patient and getting these multiple inputs to know what to do.

On treating patients near the end of life

I've seen patients have their last days prolonged in misery because of the actions of their well-meaning family members who don't want to let go, and sometimes even by physicians and — unfortunately, at least in one case — by me.

I had a very dear patient of mine who had severe congestive heart failure and had a very leaky heart valve and she became one of my favorite patients. ... She was in her late 80s and one day I was told she was in the intensive care unit and it turns out she had gone to the emergency room with shortness of breath. ... She had gone into kidney failure because of the poor blood flow to her kidneys.

And I took the attending physician aside and said, "So are we going to provide dialysis?" And he said, "No." And I said, "Why not?" And he said, "Because I don't think it's appropriate, it's futile. She's at the end of her life." I couldn't see that because she had been so vibrant despite all the medical problems.

In the end I argued for being aggressive and he wouldn't budge and so I actually went to the chairman of the department and I transferred the patient to my care in the cardiac unit. ... And there I went through a lot of ... very aggressive interventions to try to save her. It wasn't because of financial incentives — I'm on salary — it was because I just didn't want to lose her. ...

About eight or nine days later she died. There's no question that I deceived myself — that I thought somehow I could keep death at bay and that my judgment was clouded by my love for this patient and not wanting to let her go. ...

Now I'm much more circumspect about how I handle these cases. And in recent years, I've created much more of a relationship with the palliative care team and the hospice team in my hospital. And I think it's been much better for my terminally ill patients.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

Transcript

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. My guest is one of many doctors experiencing a growing discontent with his profession. In his new memoir, "Doctored: The Disillusionment Of An American Physician," Dr. Sandeep Jauhar writes about the pressures on doctors today as the number of patients they're expected to see increases and so does the amount of paperwork.

While some doctors who perform a lot of procedures may be paid too much, he writes, many doctors, such as primary care physicians, aren't paid enough. And he adds, the growing discontent has serious consequences for patients. Dr. Jauhar is the creator and director of the Heart Failure Program at Long Island Jewish Medical Center, a teaching hospital. He's the author of an earlier memoir called "Intern" and contributes to The New York Times. His maternal grandfather was a doctor in New Delhi, India. His family moved from New Delhi to the U.S. in 1977 when he was 8. Dr. Sandeep Jauhar, welcome to FRESH AIR.

SANDEEP JAUHAR: Thank you.

GROSS: Let me quote something you write at the beginning of the book. You write, in the last four decades, doctors have lost the special status they used to enjoy. They made more and earned more respect than just about any other type of professions. Today, medicine is just another profession, and doctors have become like everybody else - insecure, discontented and anxious about the future. What are some of the most complaints you hear from your fellow doctors?

JAUHAR: I hear a host of complaints. Some of it has to do with medicine and the way medicine has become. And some of it has to do with the medical payment model or health care delivery.

So one of the issues with medicine today is it's just become so complicated. More and more people are surviving with chronic illnesses, so you have folks in every patient panel who have multiple chronic diseases. And they come to the doctor, and they have a whole host of issues that have to be dealt with. And not to mention preventative care which has become a huge time problem for a lot of primary care physicians.

There was a study a number of years ago that suggested that a doctor with an average-size panel of patients would have to spend roughly four hours a day just doing screening and preventive care - just coordinating that aspect of care, not focusing on urgent or emergency problems. So that's one factor.

There's no question, there's a lot of dissatisfaction about salaries and reimbursement. And it's very complicated, but there's no denying that reimbursement for office visits and for procedures have been drastically cut in the last two or three decades. And that was really an attempt to control health costs, and it seemed to make sense. But it resulted in doctors basically running on a treadmill seeing patient every 8 to 10 minutes. So the lack of time to spend with any one patient is a big factor.

GROSS: So, you know, you write that a lot of doctors don't want to be a private practice anymore. What are some of the reasons why?

JAUHAR: I think many doctors do still prefer the private model. But the fact is that today that private model is becoming less and less viable. The payment system is changing so that reimbursement to private physicians for procedures done in the office or for visits in the office have been cut drastically. So that you could do the same procedure, like an echocardiogram, as a private practitioner and make 40 or 50 percent what you would for the same procedure if you are employed by a hospital.

GROSS: Why is that - because the hospital already owns the equipment and you, in private practice, have to buy it? So you have to pay it off? Is that...

JAUHAR: Well, no. The private doctors are actually making less, and I think that is...

GROSS: Oh, just the reimbursement system - the way it's worked?

JAUHAR: The way the reimbursement system is currently, it's trying to push doctors into integrated care networks, so that there's better coordination. And there's a question that the system today is so dysfunctional because you have multiple doctors on any given case, and they all have their varied inputs. And they're not coordinating their care.

So the payment model has been changed so that it's beneficial to be in a system, like, for example, I am employed by a large hospital system. And I work with thousands of other physicians, you know, under one umbrella. And we have a computer system where we share patient information. That's the model that the government is trying to encourage. And it's a good model. But the fact is that if you are a sole practitioner or in a small group, it's financially becoming more and more difficult to survive.

GROSS: So because early in your career as a cardiologist you were have trouble making ends meet, you basically tried moonlighting. And you worked for a private practice. And the financial and work arrangement that you had with the head of the practice opened up your eyes to what some of the problems are that doctors in private practice face. So tell us a little bit about the work and financial arrangement that you had there.

JAUHAR: Well, a lot of academic physicians actually do moonlight to supplement their salaries. And I was introduced to a cardiologist who was mainly working in Queens and started working for him both in the hospital by seeing some of his patients in the emergency room for which I was paid a fixed supplement to my salary. And I also worked in his private office as well as satellite offices.

And so I would go on the weekends, see patients, and if the patient's needed cardiac testing, those patients would be referred back to his main office to get stress tests or echocardiograms. And what was made very clear from the beginning is that seeing patients was not financially that rewarding for the practice because seeing a patient, spending 20, 30 minutes with a patient might be reimbursed $80, $90. But sending a patient for a nuclear stress test was much more profitable. A nuclear stress test at the time when I started working was reimbursed roughly $800 to $900 and an electrocardiogram was reimbursed $350 to $400. So the whole point of the practice was to see patients - as many as possible - and order as many tests.

Now I wasn't ordering any of those tests, but I was - I mean, unless the patient really needed it. But I was supervising the stress tests that had been ordered by this physician who I was working with as well as some of his physician assistants. So even though I wasn't ordering the tests, I was in the office while these tests were being performed. And I felt very dirty about it.

GROSS: You felt that a lot of these tests were really unnecessary?

JAUHAR: Well, they were unnecessary. There's no question about that.

GROSS: See, that's everybody's fear, you know, that you're going to get a test because it's lucrative for the doctor as opposed to because you actually need it.

JAUHAR: Yeah. Well, there's no question that there's a lot of unnecessary testing in American medicine today. And the reasons for it are manyfold. Part of it is what I alluded to earlier. There's a lack of time. You have a patient come in to your office, and you have 8 minutes with them. And they have lower back pain. And you don't want to miss something because one of the major causes of dissatisfaction among doctors today is malpractice liability. And there's that fear.

So a lot of doctors are practicing defensive medicine. And there have been various estimates that defensive medicine costs up to $100 billion a year out of the roughly $3 trillion that we spend on health care. So it's a huge, huge waste.

GROSS: So I come in with lower back pain, you want to prevent me from suing you. What tests are you going to order on me?

JAUHAR: Well, it's not just preventing you from suing me, but there's also that fear factor that am I going to miss something? Am I going to hurt this patient? Does this patient potentially have an abscess or a tumor or is it just run-of-the-mill back pain? So that takes time. It takes time to evaluate the patient, get a good history, examine the patient. And it's just so much easier to order a test, especially when the financial incentives of the system are to reward for more and more testing. Let me just give you one example.

My father had numbness in his arm, and he went to the emergency room. A neurologist saw him, ordered a CAT scan because, you know, at his age with his risk factors, it was pretty clear he was having a stroke. And so he had a CAT scan, then he ended up going for an MRI. When the CAT scan was negative, the MRI didn't show anything, then he went for a transesophageal echocardiogram, a regular echocardiogram. He went for transcranial dopplers - just a whole host of tests. And nothing came up.

So he was sent home on multiple blood thinners for the stroke that the doctors assume that he had had. He went home, and then three days later, he had this numbness again. He came back to the emergency room, and they started ordering the same tests. And a nurse took me aside when I was down in the emergency room with my father. And the nurse took me aside and said Dr. Jauhar, I don't know if I should mention this, but your father really only has this numbness when he moves his neck this way. And I asked him to do that, and sure enough, that was the reason why he was having numbness. It just turned out he had a benign slipped disc in his neck. But no one, including two neurologists, examined him properly. It was just so much easier to order a test.

So when you have primary care physicians seeing 30 or 40 patients a day, every eight minutes, and they come in - the patients come in with a sort of nonspecific or an unclear diagnosis, it's just so easy to order a test and send a patient out and bring in the next patient.

GROSS: Is it also that - because there was an assumption he was having some kind of, you know, stroke or heart related issue - that he saw a cardiologist in the emergency room who was thinking in cardiology terms as opposed to, like, a general practitioner or, you know, a chiropractor, a rheumatologist who might've thought more about spinal issues?

JAUHAR: That's right. I mean, today, if you go to a hospital, it's rare that you won't have multiple specialists on your case. And I'm a specialist. And when I'm called to see someone with a nonspecific symptom like shortness of breath, which could be a whole host of diagnoses, I'm apt to view the problem through my own expertise. And that's true for rheumatology and hematologists and so on. One patient who came in with shortness of breath, and his primary care physician called 15 specialists onto the case - a hematologist, two cardiologists, a gastroenterologist, a pulmonologist, a nephrologist, and so on - 15 specialists. When he - he underwent 12 procedures in the hospital. And when he was sent home, he had follow-up visits with seven different specialists.

GROSS: So now I want to know what happened to the patient. What was responsible for the shortness of breath?

JAUHAR: We actually never figured it out.

GROSS: Oh.

JAUHAR: And this is so common. You know, it was probably a multifactorial problem. He had some anemia. He had some heart disease. He had some lung problems. And when you have a symptom like shortness of breath that has multiple inputs from different organ systems, probably the best doctor to diagnose that and treat that is a good general family physician.

But when you call in these various specialists, they are apt to view the problem through their own organ expertise. And they make recommendations based on their own expertise. And these recommendations are frequently not coordinated. And so you get just a whole host of recommendations and suggestions for care, but no one is really talking and trying to coordinate this care. So it makes it very difficult for the physician who's trying to manage the whole patient, treat the whole patient and getting these multiple inputs to know what to do.

So one aspect of the Affordable Care Act which I'm very supportive of is the recent reform that was just in the news that Medicare will now start reimbursing primary care physicians for care coordination because that's one of the biggest problems in American medicine today. It's that patients are sicker. They have multiple doctors, and their doctors aren't talking. And you need one physician to take all the information and synthesize it for the patient.

GROSS: If you're just joining us, my guest is Doctor Sandeep Jauhar. And he's the author of the new book "Doctored: the Disillusionment of an American Physician." And he is the director of the heart failure program at Long Island Jewish Medical Center and author of the previous memoir "Intern." Let's take a short break here, and then we'll talk some more. This is FRESH AIR.

(MUSIC)

GROSS: If you're just joining us, we're talking about some of the problems that doctors face today. My guest, Dr. Sandeep Jauhar, is author of the new book "Doctored: the Disillusionment of an American Physician. He's the director of the heart failure program at Long Island Jewish medical Center. Are you often in the position where either the patient or the patient's family wants them to have a very complicated procedure, like heart bypass or heart transplant, when you know that the patient is very frail and might not be able to recover from that but will, most assuredly, be put through a lot of suffering if they have either of those procedures? And if you are often in that position, how do you talk to the family and the patient?

JAUHAR: That's a position that comes up frequently in cardiac medicine. And in American medicine, we don't believe in limiting care. We offer the most high tech and aggressive procedures to some of our most elderly and frail patients. And so there are times when a patient requests a procedure that may have limited benefit and can cause a lot of suffering. And I feel that it's my job, as a doctor, to talk to them about it - not to make the decision for them but to explain what they're going to face because I see, just as often, where a patient will go through something like coronary bypass surgery and at the end of the month-long of rehab and pain, will say to me, you know, if I had known prior to the surgery what I know now, I would have just elected to take medications and enjoy the limited time that I had without going through all this pain-and-suffering. So I think it's really important for physicians to talk to their patients and communicate with them about what they know.

GROSS: So let's continue with this hypothetical situation that you're actually dealing with all the time where you have a very elderly, frail patient who probably doesn't have that much longer to live. They have a heart problem and, maybe, the family is pressuring them to go through with a heart bypass operation and prolong their life some more. You think, maybe, that's unwise and it will lead to more suffering and just make the time they have left more painful. Are there financial incentives that also lead you in one direction or another in a situation like that?

JAUHAR: Well, of course - I mean, the predominant American payment model today is fee-for-service. And doctors are rewarded for doing as much as possible. So the incentives are very skewed towards providing that operation - providing more care. There is nothing in place right now that would pay a surgeon for spending a half hour or an hour with the patient and counseling against surgery. That's what we need to change. American medicine is the best in the world when it comes to providing high-tech care. If you have an esoteric disease, you want to be in the United States. God for bid you have Ebola, our academic medical centers are second to none. But if you have run-of-the-mill chronic diseases like congestive heart failure or diabetes, the system is not designed to find you the best possible care. And that's what has to change.

GROSS: So getting back to that hypothetical patient who's family wants them to have the bypass surgery, you think it's maybe not such a great idea - that it will lead to more suffering - not necessarily prolong life. Ore the financial incentives in the back of your mind at all? - like, well, on the other hand, if I perform this, it's more money for the hospital. I don't know if you get a piece of that, yourself. So, like, do the financial incentives affect your decision at all?

JAUHAR: I think that doctors are human, and there's no question that financial incentives affect doctors decision-making. That's been shown over and over again. In my particular case, I'm employed by a hospital. I'm on a salary, and there's no incentive for me or there's limited incentives to provide more and more care. And that's why I prefer being an employee of a large hospital system. But if I were in private practice and I was finding that reimbursements had been cut so much that I was having a hard time maintaining my office and paying my overhead - which, believe it or not, a lot of physicians are facing today - then I might think differently.

GROSS: Doctor Sandeep Jauhar will be back in the second half of the show. His new book is called "Doctored: the Disillusionment of an American Physician." I'm Terry Gross, and this is FRESH AIR.

(MUSIC)

GROSS: This is FRESH AIR. I'm Terry Gross.

Let's get back to my interview with cardiologist Sandeep Jauhar, author of the new book, "Doctored: The Disillusionment Of An American Physician." It's part memoir and part critique of the American health care system. He's the director of the Heart Failure Program at Long Island Jewish Medical Center, a teaching hospital.

Some of your patients actually ask you to help hasten their death. What's your reaction when that happens?

JAUHAR: It's relatively rare and it's frankly not something that I feel comfortable with. So in the few instances that it's happened, I have consulted my colleagues on the ethics service and there's one particular instance of a patient who had severe coronary disease who was becoming short of breath all the time and she was in and out of the hospital and eventually she said, you know, in and out, in and out - I can't stand this anymore so I want you to help me die.

And I didn't know how to respond. So I went to the ethics team and there was a member on the team who said, I really don't see the big ethical problem here; you put her on a morphine drip and when she gets short of breath, you turn up the drip to control her symptoms.

GROSS: So with the increased morphine as the breathing got more difficult, would that hasten death, in addition to relieving some of the symptoms?

JAUHAR: It would. In the end she was put on a morphine drip and she was enrolled in hospice. And she actually didn't make it out of the hospital. She never went home. But there's one thing that she did say to me that I always remember. She said, my husband always told me the hardest thing to do in life is to die. I always thought it would be easy.

GROSS: Do you usually think of death as hard, watching your patients?

JAUHAR: It's hard. It's horribly hard. And it's really hard to escape, in my field - congestive heart failure because it is ultimately, a terminal illness. But there was so much death those first few years. It was very hard to take.

GROSS: The first few years you were a doctor?

JAUHAR: The first few years of becoming an attending physician.

GROSS: Do you think that high-tech medicine, including the high-tech medicine that you practice as a cardiologist, often makes death harder?

JAUHAR: I think so. And I've seen patients have their last days prolonged in misery because of the actions of their well-meaning family members who don't want to let go, and sometimes even by physicians - and unfortunately, at least in one case, by me. I had a very dear patient of mine who had severe congestive heart failure and had a very leaky heart valve and she became one of my favorite patients. She would call me several times a week sometimes just to chat or to ask about her symptoms. And I always loved talking to her because she was just such an irreverent soul. She was in her late 80s. And one day I was told that she was in the intensive care unit and it turns out, she had gone to the emergency room with shortness of breath and had been admitted to the intensive care unit, and no one had informed me. So I went down to see her and she was on a ventilator and she had gone into kidney failure because of the poor blood flow to her kidneys. And I took the attending physician aside and I said, so are we going to provide dialysis? And he said, no. And I said, why not? And he said, because I don't think it's appropriate; it's futile. She's at the end of her life.

And I couldn't see that because she had been so vibrant, despite all the medical problems. And in the end I argued for being aggressive and he wouldn't budge. So I actually went to the chairman of the department and I transferred the patient to my care in the cardiac care unit, in a different intensive care unit and there I went through a lot of - you know, it's still painful to talk about - but a lot of very aggressive interventions to try to save her. And it wasn't because of financial incentives; I'm on salary. It was because I just didn't want to lose her.

And so we put in a catheter into her lung to monitor the pressure. We put her on continuous venovenous hemodialysis. We checked bloodwork twice a day. And about eight or nine days later, she died. And there's no question that I had deceived myself; that I thought that somehow I could keep death at bay and that my judgment was clouded by my love for this patient and not wanting to let her go.

GROSS: How did your experience with the patient affect how you dealt with other patients in similar situations?

JAUHAR: So now I'm much more circumspect about how I handle these cases. In recent years I've created much more of a relationship with the palliative care team and with the hospice team in my hospital. And I think it's been much better for my terminally ill patients.

GROSS: So one more question, one of reasons why your area of specialization is cardiology is that both of your grandfathers died of heart attacks, one of them about at the age of 40 before you were even able to know him. Does that make you paranoid about your own heart because you're seeing people on heart failure all time - that's what you do. Your grandparents died - your grandfathers died of heart attacks. So do you worry about your own heart?

JAUHAR: Absolutely. I do. You know, I'm of Indian origin and South Asians suffer disproportionately from heart disease. Some people say, actually, our coronary arteries are smaller than those of Caucasians. But whatever the reason, a lot of us have very premature heart disease. So I do think about it. I actually recently had - was having - some nonspecific symptoms, some shortness of breath. So I went and - through the advice of my physician - underwent a couple of tests and one of the tests I had was a cardiac CT scan, and it was probably unnecessary. I remember the physician who I consulted with said, you know, it's probably not absolutely necessary but - for your peace of mind.

And it just reminded me that sometimes we do do tests for peace of mind, without any strong, sort of physiological basis for it. And so I ended up having the test and so it was a reminder to me that, you know, even as a physician who knows about the heart - just as human as anyone else and feel just as vulnerable about my heart and my health. And it's a reminder and it helps me practice, it helps me empathize with my patients.

GROSS: Well, I really appreciate you talking with us. Thank you. Thank you very much.

JAUHAR: Thank you. Thank you very much. It was my pleasure.

GROSS: Dr. Sandeep Jauhar is the author of the new book, "Doctored: The Disillusionment Of An American Physician."

Coming up, our classical music critic Lloyd Schwartz reviews a new recording of Mozart's "The Marriage Of Figaro." This is FRESH AIR. Transcript provided by NPR, Copyright NPR.

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