Sick and Tired

By NANCY GIBBS

"I do not know a single thoughtful and well-informed person," George Bernard Shaw once said, "who does not feel that the tragedy of illness at present is that it delivers you helplessly into the hands of a profession which you deeply mistrust."

That sentiment is mild compared with some of today's reviews. Doctor bashing has become a blood sport. To judge by the popular press, which generally lacks Shaw's subtlety, too many physicians who are not magicians are charlatans. The ^ air of the operating room, where once the doctor was sovereign, is now so dense with the second guesses of insurers, regulators, lawyers, consultants and risk managers that the physician has little room to breathe, much less heal. Small wonder that the doctor-patient relationship, once something of a sacred covenant, has been infected by the climate in which it grows.

All this means that it is simply harder to be a doctor now than it was a generation ago: harder to master the art and the craft, harder to practice, harder to savor the natural pleasures of healing. Patients loudly long for the days of chummy family doctors and personalized care, when Marcus Welby would make everyone well. But it turns out that the distress is mutual, the frustration shared. Many patients may be surprised to learn that the doctors are suffering too. Listen to them tell it:

-- "Once most people treated me as a friend and a confidant," recalls Boyd McCracken Sr., 65, a family practitioner from Greenville, Ill. (pop. 5,000), who remembers making late-night house calls. "These days the malpractice threat has created a definite wedge between a physician and some of his patients."

-- "I think patients have become consumers," says Robert Rogers, an ophthalmologist in Pompano Beach, Fla. "They are no longer interested in their doctor, who has perhaps been their doctor for five, six, ten years. They are really interested in what it's going to cost them. It's just like they're going shopping at the local supermarket."

-- "I get no sense they trust me," says Jonathan Licht, a San Diego neurologist. "You tell them, 'You're O.K.' They say, 'No, I'm not O.K. I think I have a brain tumor.' Then they keep asking, 'How do you really know?' "

All across the U.S., among family doctors and brain surgeons, in large cities and small towns, the tensions are growing. Perhaps many doctors just miss their pedestals and the days when their patients were more respectful and their diagnoses unchallenged. But the soreness may also reflect the stresses and strains of a profession in transition. Nothing in medicine is stationary: the blinding speed of technological advances, the splintering effects of specialization, the onset of medical consumerism, the threat of malpractice suits have all bruised the doctor-patient relationship in recent years.

There are rich ironies here. Never have doctors been able to do so much for their patients, and rarely have patients seemed so ungrateful. Eighty years ago, a sick man who consulted his physician had roughly a fifty-fifty chance of benefiting from the encounter. The doctor's cheery manner and solicitous style were compensation for the uncertainty of a cure. "Medicine originally was mainly talk," says Sidney Wolfe, a physician who directs the Public Citizen Health Research Group in Washington, "and very little effective diagnosis and treatment."

Compare that with the prospects of today's patient: what was once miraculous is now mundane. The flutist has her severed hand sewn back on. The man with the transplanted heart goes skiing. As a society, Americans are living longer and well and with less to fear from diseases that ravaged whole generations. Life expectancy has jumped during this century from 47 to 75 years. And yet the physicians, victims of their own success, are finding that however swift the advance of medical knowledge, it is still outpaced by public expectations. "The public thinks that all diseases should be treatable, all disabilities reparable," observes John Stoeckle, chief of the medical clinics at Massachusetts General Hospital. "And there should be no pain and suffering."

So naturally, the public is far from content. In part the problem lies with the failure of the profession and the government to police medicine adequately, since the stakes could not be higher. If a stockbroker is incompetent, his client may lose his savings; if a doctor is negligent, his patient may lose his vision, his memory, his mobility or his life. Though the public, the government and the physicians themselves have become more vigilant, the persistent stories of medical mishaps continue to take their toll on patient confidence.

The anger and suspicion toward doctors are easy to measure, even without reading the tabloids or watching Geraldo for the latest tally of medical misdeeds. When the American Medical Association conducts surveys of public attitudes toward physicians, it finds a troubling loss of faith. Even people who esteem their own physicians often deride the profession as a whole. In 1987, 37% of those polled did not believe doctors take a genuine interest in their patients. Only 45% believed doctors "usually explain things well to their patients."

A doctor's words may speak louder than actions, but every patient hears them differently, and doctors end up feeling they cannot win. When Cincinnati receptionist Doris Roetting had a mastectomy in the fall of 1987, her surgeon assured her that she was recuperating nicely. Her oncologist, however, was a bit more explicit, to Roetting's dismay. He quietly explained that she had a 90% chance of being alive in five years and an 80% chance of surviving ten years. Some patients might have been grateful for such candor; Roetting went home in tears. "I think everybody who has cancer knows there is a chance they can have it again," she says. "These doctors should show a little more finesse."

Tact and tenderness may be a lot to expect from someone who must spend roughly twelve years learning the trade, work impossible hours, be available to patients day and night, keep abreast of changing technology and live a peaceable life while constantly dealing with death. "The patient wants the best of both worlds," charges Lester King, a Chicago physician and medical historian. "He wants the knowledge and precision of the most advanced science, and the care and concern of the old-fashioned practitioner."

For more and more doctors, that is just too much to ask. They feel the wrath of their patients and realize the job is not going to get any easier. A March 1986 survey of physicians in the Minneapolis-St. Paul area found that nearly two-thirds of them were "pessimistic about their professional futures," and a like number said they would not want their children to go into medicine. Applications to medical schools for the 1988-89 school year declined 15% from 1986-87, reflecting a contagious concern about the profession's future.

As ambivalence and hostility divide doctors and patients, medical experts are struggling to explain the troubled relationship and find ways to revive it. Some of the conflict arises from human nature. How can doctors feel comfortable when patients come into the office prepared to sue them for everything they own? How can patients trust a doctor who has a clear financial interest in prescribing expensive, intrusive and perhaps unnecessary therapies? When doctors disagree, how can a patient know whom to believe? Both sides recognize that the demands of treatment have changed in ways guaranteed to alienate doctor and patient.

The most obvious source of friction is the new technologies that enter into every stage of treatment. Since the end of World War II, as the science of medicine rapidly evolved, the craft overtook the art. Many physicians regret that they now spend far more time testing than talking, which may make for more accurate treatment but less personal care. The race to stay abreast of each new development can consume a doctor's every waking moment. "Technologies have put a kind of emotional moat between doctor and patient," laments David Rogers, professor of medicine at Cornell University Medical College. Some tests, particularly the CAT scan and colonoscopy, not only frighten but dehumanize patients by reducing the body to an intricate piece of machinery.

Doctors often find they can do more but explain less, leaving their patients with the impression that treatment is not to be understood, rather to be suffered. The doctor, for his part, may want to reassure the patient, but balks at taking the time to deliver a discourse on molecular biology. "You have to be tolerant," says Lake Forest, Ill., cardiologist Jay Alexander. "You have to be able to answer questions, and it's got to be an answer that the patient is able to understand. Twenty years ago, I imagine, less explanation would have been necessary." The suspense and confusion weigh heavily on patients and their families. Author Norman Cousins and his followers believe lack of concern for the patient's state of mind can actually cause physical harm. "At its worst," argues Cousins, "it's a form of malpractice."

Yet keeping patients informed becomes ever harder when each test is performed by a different technician in a different building, with no one wanting ultimate responsibility. For Josefina Ponce, a day-care worker in Los Angeles, it took four visits and twelve doctors to have one gallbladder operation. "I saw one doctor in the emergency room, then a second doctor," she recalls. "On my second visit, I saw three different doctors who knew nothing about my case. I was told what my surgery date would be, and I said I wanted to meet my doctor. But I was told there would be five doctors, and it could be any one of them."

Those who, like Ponce, lament the anonymous quality of their treatment reflect a second revolution in patient care: the rise of the medical- industrial complex. Every bit as important as the advances in technology are the means of delivering them and deciding who should pay. Instead of an individual doctor seeing his regular patients in the privacy of his office, the typical encounter now occurs in the thick of a vast corporate hierarchy that monitors every decision and may weigh in against it. Marketing medicine has become very big business.

As costs have risen, the past decade has seen an explosion in prepaid, "managed" care. More than half of all physicians work in some kind of group practice, most commonly a health-maintenance organization. Patients pay a flat annual fee in exchange for care that is provided by HMO member doctors. As private corporations, many HMOs can be quite profitable -- so long as their patients do not get too sick. The number of patients enrolled in HMOs has doubled in the past five years, to 32 million, often at the urging of cost- conscious employers. The goals: efficiency through greater competition, lower costs, accountability and better preventive care.

But the results may be mixed. Patients relinquish much of their freedom to choose who will treat them, and can be lost in a shuffle between rotating doctors. The physicians, meanwhile, are transformed from professionals into employees, with a duty to serve not only the interests of their patients but the demands of the corporation as well. "They're asking physicians to pay for their decisions," says internist Madeleine Neems in Lake Bluff, Ill. "That's a terrible concept. When you analyze whether or not a patient needs an expensive test, a lot of times it's not a clear-cut yes or no. I don't want my finances tied into those decisions."

Doctors resent spending extra time with patients who demand exhaustive explanations or who merely exercise their hypochondria. "If you have to spend twice as much time because a patient's assertive and he wants to ask questions, it's certainly difficult to bill for that period of time," says cardiologist Alexander. "Lawyers and accountants don't have third parties or government agencies looking over their shoulders to determine whether their billings are fair." Patients understandably take a spare-no-expense attitude toward their health, but that is not a philosophy likely to keep a medical company in the black.

Physicians and patients who are not part of an HMO have found their lives affected too. The government (as the largest health insurer) and the private insurance companies have tried to cap medical costs by deciding in advance how much a particular treatment should cost and balking at anything above that amount. Many doctors can no longer decide how often they see a patient, when one can be hospitalized, or even what drugs may be prescribed. Those decisions are now in the hands of third parties, hands that have never touched the patient directly.

Medicare and insurance-company guidelines, for example, forbid cardiologists to hospitalize patients for a coronary angiogram unless the patient is desperately ill. Otherwise, it must be done on an outpatient basis. As a result, Los Angeles cardiology consultant Stephen Berens sometimes has his frail or elderly patients take a room in a nearby hotel the night before the procedure. If he decides the patient needs a temporary pacemaker during the angiogram, he often implants the device but does not charge for it, because the Medicare system denies payment except in cases of very obvious need. "To make them approve it, I'd have to exaggerate the risk of going without it," he says. Berens would once have charged $200 for the pacemaker; now he absorbs the cost.

More than a doctor's pride and cash flow may be at stake. Some physicians warn that the need to make rapid decisions, see more patients and control costs could result in faulty diagnoses. Promising but expensive treatments cannot be provided to everyone who needs them, so what is to prevent reserving such care for the rich? The new pressures on hospital care have also affected the way young doctors are trained. Doctors lose the sense of satisfaction that comes from having a personal relationship with patients and helping them through crises, since hospital stays are shorter, patients are sicker, and treatment time is more rushed.

Not only have the scientific and organizational landscapes of medicine changed; so too has the social and economic climate in which physicians practice. In order to sustain public support and federal funds, the medical community trumpets triumphs with abandon. Hospitals spent more than $1.3 billion last year on marketing and advertising. Small wonder that even the desperately sick are surprised when they are not cured. "The whole idea is false," argues author Richard Selzer, a retired surgeon in New Haven, Conn. "No one has ever got off the planet alive. The natural course is to be born, to flourish, to dwindle and to die. Yet the medical profession has encouraged people to think of the natural course as an adversary, to be fought off until the bitter end. Of course, doctors cannot live up to the expectations they have aroused."

Physicians certainly cannot hope to satisfy patients who, instructed by the consumer movement, have come to view medicine as a commodity like any other, despite the fact that it is unlike any other. Once people would no more price- shop for a doctor than they would for a church. But today some patients switch doctors for as little as a $5 saving on the price of a visit. "You can be a mediocre doctor and discount your fees enough to have all the business you want," observes James T. Galyon, an orthopedic surgeon in Memphis, "rather than trying to be a very fine doctor and achieving a professional reputation that will cause other doctors to refer patients to you. The loser in the long run is the patient."

Other patients are shopping not for savings but for status. This inspires physicians to spend valuable time on self-promotion and merchandising, not skills that contribute materially to patient care. "My feeling was that if you're a decent physician giving decent service, that's really all you should have to do," says Florida ophthalmologist Robert Rogers, who has hired a business consultant to help manage his practice. "But patients don't seem to want that. They like the flashy stuff. They like to see your name in print. They like to see you lecturing."

In an effort to be educated consumers, today's patients read books with titles like What Your Doctor Didn't Learn in Medical School and Take This Book to the Hospital with You. The message is that a smart patient is an informed patient, who challenges a doctor's authority rather than submits uncritically to the physician's will and whims. Yet that approach rubs raw against a basic instinct. Patients want to trust their doctors, to view them as benign and authoritative. Even those who privately question a doctor's decisions may be loath to express dissent. Doctors admit that an aggressive or challenging patient can be very irritating. "When you can, under certain circumstances, play God, you sometimes tend to behave like you are God," says Cornell's David Rogers. "The enormous satisfaction of being able to help a lot of people makes you impatient with those who question your judgment."

The ultimate price of inflated expectations and consumerist attitudes is the treacherous legal reality that confronts doctors today. Anything short of perfection becomes grounds for penalty. And once again, while it is the doctor who must pay the high insurance premiums and fend off the suits in court, the patient eventually pays a price. The annual number of malpractice suits filed has doubled in the past decade and ushered in the era of defensive medicine and risk managers. No single factor has done more to distance physicians from | patients than the possibility that a patient may one day put a doctor on the witness stand.

Manhattan cardiologist Arthur Weisenseel remembers the elderly woman who arrived in Mount Sinai Hospital's emergency room having suffered a heart attack and battling pneumonia. A man and a woman hovered by her bedside, and the emergency staff assumed they were worried relatives. Then the man pulled out a yellow pad, asked for the correct spelling of Weisenseel's last name and identified himself as the family lawyer. "I kind of lost it that day, and I told him to get out," Weisenseel recalls. "That may have been the most distressing situation I've had in 22 years of practice."

The impact of possible litigation is felt long before a patient sets foot in the doctor's office. Some physicians, like Linda Bolton, a pediatrician in Birmingham, Mich., try to screen out potential problems. "It really dictates what happens at the office. If I feel I have people who are litigious, I prefer not to take them as patients." In the past, she has fixed her rates only after she has been notified how much she will have to pay for malpractice insurance.

The costs of practice have driven out hordes of doctors altogether. According to a 1987 survey by the American College of Obstetrics and Gynecology, 1 out of 8 U.S. obstetricians has left the field because of the malpractice threat. Those who manage to stay in business may feel forced to practice a kind of medicine that assumes every patient is a prospective litigant. Such defensive tactics are antithetical to compassionate care: the doctor ends up being afraid of someone he or she wants to help, cautious about trying attractive new treatments and emotionally aloof from someone in need of emotional support.

Doctors recognize a vicious circle here, but there are indications of a possible break. Last year, for the first time in more than a decade, medical malpractice suits abated. Claims settlements were down $100 million from the 1987 high of $4.2 billion. In response, several major insurers have reduced their premiums. On the basis of studies showing that physicians who know their patients well over a long period are less likely to be sued, more doctors are looking for ways to avoid the fearful, adversarial climate that prompts them to retreat emotionally -- which ends up making a suit more likely. "Many malpractice suits come because people are angry at their doctors for not communicating," says Cornell's Rogers. Consumer advocate Michael Rooney of the People's Medical Society agrees: "It's when they feel they've been hurt or betrayed that they sue."

The relationship is actually poisoned on both sides. Patients may insist on the most conscientious care and yet balk at the battery of tests that doctors order to cover themselves. "You come in for an ingrown toenail, and they turn you inside out giving you all kinds of tests that you don't need," says columnist Ann Landers, who receives complaints from all concerned. "The bill is horrendous. The doctors want to be able to prove that they didn't miss anything. It makes people mad, and I don't blame them."

Even as natural a procedure as giving birth has been greatly distorted by the epidemic of lawsuits. "Mothers believe that all babies should be born perfect," observes Massachusetts General's Stoeckle, and here the bond of doctor and patient may be most fragile. Doctors order expensive tests and uncomfortable procedures as protection against future suits. The costs to expectant parents are exorbitant, and discomfort during delivery is heightened: nearly one-quarter of all U.S. births are currently by caesarean section, which can be less risky to the baby than vaginal delivery and makes the doctor less vulnerable in court.

Finally, there are those who argue that litigation actually slows the progress of medicine. "Innovative techniques don't get used very often for this reason," says George Miller, an orthopedic surgeon in Washington, N.C., who last year won a malpractice suit that had dragged on for "eight long years." Doctors find themselves taking a more rote approach, what some call "cookbook medicine." By following standard procedures as much as possible, the physician may hope to avoid any controversy that might arise in court -- and thus steers clear of promising, if less proven technologies and treatments.

The combination of these factors -- the welter of technology, the intrusions of corporate medicine, the high expectations of patients and the threat of malpractice -- has cast a pall on the practice of many older physicians. "I detect a certain despondency among doctors my age, in their later 50s," says Memphis surgeon Galyon. "They will frequently say something to the effect, 'I'm glad I'm this far in my profession and not starting out.' "

Oddly enough, many young physicians do not feel the same way and still see in medicine a career of compassion and challenge, despite its loss of luster in recent years. Their attitudes may reflect new priorities in many medical schools. Traditionally, med school, internship and residency were a notorious, competitive ordeal that all but guaranteed less humane doctors. "It makes book learning and grade getting their yardstick, not kindness, gentleness and taking care of people," says Dr. E. Grey Dimond, founder of the School of Medicine at the University of Missouri at Kansas City and a leader in humanistic medicine.

That may be changing, thanks to some innovative programs that are challenging the conventional curriculum. The most visible experiment, following an example pioneered at Missouri, was launched at Harvard Medical School in 1985. The goal of Harvard's New Pathway Program was to focus from the very first day on the doctor-patient relationship, rather than rely solely on textbook learning. "Even in an era that is overlaid by science and technology," says Harvard Professor Ronald Arky, "doctoring still involves an intimate, close contact with the patient, and somehow that was being pushed out." Small groups of students work closely with a physician and meet with patients on hospital wards almost immediately, in an effort to mix basic science with clinical decision making. Course work draws not only on science but also on literature, history, anthropology and sociology.

As more hospitals and universities increase the emphasis on the doctor- patient relationship, there are signs that attitudes are changing. When humanistic courses were introduced in the 1970s, high-powered students resisted what they viewed as soft science. "Now the students see that the shine on their shingle is affected by what people think of them as human beings," says author Cousins. The profession is attracting a different kind of student: many are less concerned with accumulating wealth for its own sake and more comfortable with patients who ask questions and challenge authority. "It's a much more difficult field now," says Dr. Matthew Conolly at UCLA. "I think we'll see a different set of motivations."

Doctors and patients alike may look forward to the day when better relations mean better care. A strong bond makes it easier for doctors to craft their therapy to the patients' needs. More cynically, some experts predict that competition among doctors will force a more humane approach as a selling point. Finally, the problem of reimbursement could be relieved if insurers came to value a good doctor-patient relationship and were willing to allow doctors more discretion. Says consumer advocate Rooney: "It's a recognition that, in the long run, it may be more important to talk to someone at age 28 than it is to clean out their arteries at 78."

In the end, however, the struggle between caring and curing is not likely to be resolved by invention or innovation. The next generation of doctors may appreciate that medicine is a fine art of human care; their patients may accept the constraints on physicians and resist the temptation to blame them for an absence of miracles. But even if relations ease, the challenges to patients and doctors will still grow. The practice of medicine, though it may become ever more precise, will never again be simple, never cheap and never magic.

CHART: NOT AVAILABLE

CREDIT: From a poll of 1,012 adult Americans taken for TIME/CNN on April 4-5 by Yankelovich Clancy Shulman. Sampling is plus 3%.

CAPTION: SATISFACTION AND DISSATISFACTION

CHART: NOT AVAILABLE

CREDIT: From a poll of 1,012 adult Americans taken for TIME/CNN on April 4-5 by Yankelovich Clancy Shulman. Sampling is plus 3%.

CAPTION: MALPRACTICE

CHART: NOT AVAILABLE

CREDIT: From a poll of 1,012 adult Americans taken for TIME/CNN on April 4-5 by Yankelovich Clancy Shulman. Sampling is plus 3%.

CAPTION: PRESTIGE

With reporting by Barbara Dolan/Chicago, S.C. Gwynne/Los Angeles and Janice C. Simpson/New York