Published on Tuesday, December 30, 2003 by the Boston Globe
Better Doctors, But Worse Care
by Steve Bergman

TWENTY-FIVE YEARS ago I published "The House of God," a novel of my medical internship. It described a brutal, authoritarian system of training that dehumanized doctors and patients alike. Since then I have spoken with medical students and doctors at almost every medical school in America and have observed the historical movement of the training process. The irony is that as medical training has gotten better, patient care has gotten worse. Medical students are now better prepared. Many schools require "externships" where the student functions as a first-year resident. Some schools, like North Dakota, require that much of the student's final year be spent in a clinical practice with a senior doctor. Students are now more worldly -- they might have worked in a Cambodian refugee camp, an AIDS clinic in South Africa, or done rural health in Haiti. Given the fall in doctors' incomes and status, they are not going into medicine for the money or the prestige.

The training system is becoming more human. Traditionally it was run with a "power over" system where your rank gives you power over the next doctor down. This led to cruelty and even abuse. The lower-downs got isolated from each other and from their experience of the system itself. Now the system is more "power with," emphasizing dialogue and mutual decision-making. The recent cap on on-call hours is a great improvement. In the past, your doctor was so sleep-deprived that he might be seeing double and mistaking a heart murmur for a bowel rumble. The recent limit of hours to 80 a week is progress.

Now 50 percent of residents are women, who, as carriers of relationship in our culture, try to bring these priorities into medicine. Residents now get instruction in ethics, especially around the terminally ill. Emphasis is shifting from knowledge to understanding. With Palm Pilots in our pockets, there is an opportunity to shift from the clutter of information to the crux of understanding. Residents now have more time to think -- or, better, connect with patients and with each other.

Why have these improvements in doctors' training not significantly upgraded the overall care of patients? Three recent examples:

A pregnant woman goes into premature labor and is bounced from one emergency room to another until she starts hemorrhaging and is admitted, comatose.

A young woman faints in the heat and is brought to a large city hospital where the resident does blood tests and gets a CAT scan -- all because of the hospital policy to practice "defensive medicine" and avoid lawsuit.

An alcoholic, at the end of his three days of insurance coverage in Boston, tells the claims person -- a teenager in Topeka -- that he's afraid to leave and asks: "What am I gonna do?"

"Go out and get drunk," she says, "and we'll readmit you for another three."

These examples reflect the larger picture. None is cost-efficient or an example of good care. Preventive care is not valued. Hospitals are less available -- in the past several years approximately 1,000 hospitals (of a total of 6,000) closed their doors. The ones still in business are overwhelmed, cutting costs. Because of cost cutting and insurance industry pressure, the time a resident can spend per visit with any one patient is severely limited. The hospital stay is dangerously foreshortened, so the resident never really gets to know the patient well, never gets to use these new humanistic skills. Paperwork and defensive tests consume the resident -- about 25 percent of the $1.66 trillion per year health budget goes to administrative costs -- $399.4 billion a year for pushing paper instead of patient care. Because of all this, mistakes are rising: Your chance of being a victim of a mistake during your hospital stay is over 50 percent.

The reason doctors can't provide good care is that the American health care system prevents it. Doctors can't give the care they aspire to; patients feel the limited care.

Health care in America is a national disgrace. Many doctors my age are leaving medicine; many patients are irate. A national disgrace demands a national solution. Change will not come from the private sector. Insurance executives, after all, are the oil men of medicine. Only when things got really bad in medical training did we doctors act. The cap on on-call hours came from the combined pressure brought by patients and doctors. We doctors need to organize and resist -- perhaps announce an intent to strike, a year from today, unless there is a plan for a national system in place -- to revolutionize health care as we have tried to humanize our profession. America can afford it. It's a matter of priorities, efficiency (nationalizing could reclaim $325 billion annually of the $399.4 billion spent on "paperwork"), and finding a leader who understands that "compassionate" health care is more than a sound bite. The administration's war on Medicare ("We had to destroy it to save it") is a cynical election year ploy, a slip down the slope to privatization and profiteering. Ironically, one of the few issues the Bush administration has not misled the American people about is an overall health care plan -- it has none.

Dr. Steve Bergman is author of "The House of God" and "Mount Misery," which were published under his pen name, Samuel Shem.

Copyright 2003 Globe Newspaper Company.