Why Your Doctor Isn’t Feeling So Well
Red tape. Managed care. Malpractice litigation. Insurance interference. Is it any wonder that doctors are burning out? Last year, 60 percent of doctors surveyed by the American College of Physician Executives said they had considered leaving medicine. “Physicians got to their medical careers by being curious, creative, passionate, and thinking for themselves,” wrote one physician who completed the survey. “Today’s environment in the healthcare industry does not reward those key attributes of happiness.” Doctors’ concerns affect us all. Here’s a look at what’s on their minds, and why we’d better listen up.
By Nancy L. Claus and Emily Perlman Abedon
In nearly every field of medicine, there is unbridled excitement over recent breakthroughs in the diagnosis, treatment, and cure of illness and disability. Research in genetics, new technology, cutting-edge tools and integration of knowledge from different fields empowers doctors these days to better diagnose and treat their patients. “The ongoing revolution in biomedical science is of an unprecedented magnitude, is accelerating dramatically, and promises almost unlimited opportunity for the betterment of humankind,” raves the Journal of the American Medical Association, even while warning that the undergraduate and graduate education of physicians may be unable to keep pace. “Research advances now occur so rapidly that integrating them into the curriculum or into clinical training is nearly impossible.”
But, for many doctors, keeping up with the times may be the least of their problems. The flip side to exciting new research and advances in healthcare is frustration with the current system of medicine itself. The profession used to be the epitome of prestige—every Mom wanted her son or daughter to become a physician. Now fingers are crossed for a dot.com titan. Doctors are bailing ship because, well, for one thing, the money isn’t what it used to be. According to The Medical Group Management Association, median salaries for primary care physicians rose only 2 percent last year to $171,599, falling behind the 3.2 percent inflation increase in 2006. Specialists’ median compensation rose just 1.7 percent to $322,259. In addition, doctors feel a loss of independence and a distinct sense of drowning in a sea of paperwork. And they’re lonely. Increasingly, it seems, because of the impersonalization of healthcare, physicians feel isolated from their colleagues. “When doctors do get together, they unload gratefully,” says Michael Krasner, MD, a Rochester-based specialist in internal medicine and pediatrics, who teaches stress reduction to physicians.
In a survey taken by the journal, Hippocrates, 73 percent of doctors consider daily interaction with patients to be the most rewarding part of their jobs. Numerous studies correlate doctors’ satisfaction and psychological well-being with their perception of control over their practice. Yet with managed care dictating the amount of time physicians can spend during appointments and limiting what treatments they may offer, physicians speak of being in an HMO straightjacket that has sunk morale. “I wish I could spend more time with my patients, instead of dealing with the insurance red tape, which is unbearable, but the clock is always ticking,” says one doctor who asked for anonymity.
Says Dr. Marla Koroly, chief medical officer at Northern Westchester Hospital (NWH) in
According to the Associated Medical Schools of New York (AMSNY), our state is facing a physician shortage that, by the year 2020, when lots of baby boomers will have reached retirement age, will become a “national crisis.” Not only will there be a growing number of people over the age of 65, but about one-third of active physicians will also be retiring, and there don’t seem to be many young men and women signing up to replace them. Medical enrollment in the state’s 15 medical schools has been flat from 1980 to 2005.
Every medical specialty is predicted to be hard hit, the association says, with primary care deemed most endangered. The reason? Again, money. Insurance companies tend to value and thus pay more for complex procedures over routine examinations, making the comparatively low income of primary care less attractive to medical students who often face huge loans to pay back.
An internist on the East Coast can expect to earn about $170,000, while a heart surgeon’s paycheck is more than two-and-half times as much, around $450,000. Small wonder that between the years 1998 and 2006, the number of residents choosing family medicine was cut in half. Indeed, a recent American College of Physicians’ report warns that, without reform, “within a few years, there will not be enough primary-care physicians to take care of an aging population.” Surprisingly, despite our aging population, the field of geriatrics faces enormous shortages, too. The reason? Again, money. The Institute of Medicine and a recent MedPAC report say low Medicare reimbursement levels are a major cause for inadequate recruitment into geriatrics.
“The lonely, garrulous physician, the lack of trained geriatricians, inadequate reimbursement, and spiraling healthcare costs are components of the looming crisis,” says Dr. Thomas Kalchthaler, chief of geriatrics at St. Joseph’s Medical Center and president and CEO of Geriatrics Services PC, in Yonkers.
Our Aging Population
ONE THING IS FOR CERTAIN: our graying population will increase, and, as a result, so will chronic health problems. There’s no question that the medical needs of an aging nation will further strain physicians. Heart disease and cancer are killers Nos. 1 and 2. According to the Centers for Disease Control, seven of 10 Americans who die each year—or more than 1.7 million people—die from heart disease or cancer. Here in Westchester, in 2002, according to the most recent statistics available, 70 percent of all deaths were attributed to these two diseases.
That’s a gloomy enough picture. But thanks to three megatrends about to collide—aging, obesity, and arthritis—a perfect storm looms ahead for American healthcare. The numbers of chronically ill elders could give any type of doctor aches and pains.By 2030, when the first baby boomers reach 84, the number of Americans over 65 will have grown by 75 percent to 69 million. More elders means more incidents of Alzheimer’s disease, a neurodegenerative disease that usually affects people over 60 and is the most common type of dementia. The Centers for Disease Control report that between 2000 and 2004, while deaths from heart disease dropped 8 percent; deaths from Alzheimer’s skyrocketed 32.8 percent and that number may fail to reflect the disease’s real public-health impact. There seems to be a blurred distinction between death with dementia and death from dementia, and numerous studies have suggested that death certificates substantially underreport Alzheimer’s as a cause of death.
According to the Hudson Valley chapter of the Alzheimer’s Association, about 20,000 Westchester residents are living with the disease. The organization estimates that, by the year 2050, that number will balloon to 57,000. Today, nearly half of those over 85 have the disease. What causes it? No one really knows, though many believe that it may be caused by an abnormal buildup of naturally-forming protein deposits in brain cells.
Still, there is a glimmer of hope. According to research by scientists at New York University Medical Center, a vaccine designed to combat the protein has proven effective in mice. Another study links popular cholesterol-lowering drugs (statins) to helping prevent Alzheimer’s. In a study of 110 elderly volunteers, aged 65 to 70, who had donated their brains to research, the brains of those taking statin drugs were found to have less buildup of the protein. Some experts suspect that Alzheimer’s is not a disease of the brain but of the blood vessel system. It may well be that many of the risk factors for Alzheimer’s are the same as those for heart disease and that the buildup of protein deposits in the brain is not unlike the accumulation of plaque in heart vessels.
Our Fattening Population
OBESITY, TOO, CONTINUES to rise as we age. In case you missed the headlines, haven’t taken a look around your local mall, or have failed to step on a scale lately, we Americans are fat—really fat. And we seem to be getting fatter. According to the University of Massachusetts Community Medical Center, in 2003, 65 percent of Americans were overweight, defined as having a body mass index (BMI, a measure of body fat based on height and weight of adults) of 25 to 30. (To find your BMI, go to www.nhlbisupport.com/bmi/.) By 2008, experts predict that the number of overweight adults in the U.S., those with a BMI of 30 or more, could reach 78 percent.
Fat does more than affect how we look. “Overweight people are at high risk for diabetes, hypertension, hyperlipidemia, coronary artery disease, joint pains from excess pressure on all joints and muscles,” says Dr. Jennifer Bagg, an internist affiliated with Sound Shore Medical Center in New Rochelle who specializes in preventive medicine. “People have to realize that there is no magic treatment. They must make lifestyle changes.”
But sometimes lifestyle changes—a euphemism for eating less and exercising more—are not enough to help some morbidly obese adults and, sometimes, surgery is deemed to be the only solution.
No one knows that better than Tony Seideman, a freelance writer in Peekskill, who has struggled with his weight all his life. The 49-year-old, five-foot seven-inch man developed diabetes six years ago. To control his blood sugar levels, which peaked at 450 (normal levels are from 80 to 130), every day he injected insulin into his bloodstream. “Seven months ago, I was three-hundred fifty pounds, my adult-onset diabetes was getting increasingly out of control, and my joints were beginning to break down,” Seideman says. He decided to undergo a gastric bypass operation. “Today, six months after the operation, I’m two-hundred and twenty-five pounds, my blood sugar has been normal without medication, and I’m feeling more energetic than I have in years.”
A less invasive solution? Lap-Band surgery, in which an adjustable band is surgically placed around the upper part of the stomach to reduce its capacity. The surgery, which was approved for adults in 2001 by the FDA, has some advantages: the Lap-Band is adjustable; the surgery to implant it is laparoscopic and, therefore, low-risk (unlike gastric bypass surgery which is more invasive and carries a higher risk of complications and even death); the surgery doesn’t interfere with the absorption of nutrients; and, with careful and proper documentation, insurance pays for it. Little wonder, then, that some hospitals are starting to offer this procedure to adolescents.
Our Aching Bones
SOMETHING ELSE THAT doctors are worried about: arthritis. According to the Arthritis Foundation, the number of Americans afflicted with arthritis, a painful inflammation of the joints, jumped from 35 million in 1985 to 66 million in 2005. Nearly one in three adults today has arthritis. It is the leading cause of disability in people over the age of 55.
However, arthritis is not one condition; it is a group of conditions with various causes. Rheumatoid arthritis and psoriatic arthritis, for example, are autoimmune diseases that cause the body to attack itself; septic arthritis is caused by joint infection; gouty arthritis is an inflammation that results from having uric-acid crystal deposits in the joints. But the most common form of arthritis, of course, is osteoarthritis, also known as degenerative joint disease. It can occur after a trauma or infection to the joint, but more likely as a result of aging.
“This is a challenging time for rheumatologists,” says Dr. Julia Yegudin-Ash, a rheumatologist at Westchester Medical Center. “Aging baby boomers are stressing the healthcare system with high numbers developing degenerative arthritis.” She laments that there have not been any breakthroughs for treating the frequently painful condition.
It’s a different story, though, for rheumatoid arthritis. “The discovery of a new class of medications, known as TNF inhibitors, have been very effective for patients with rheumatic diseases,” Dr. Ash says. Perhaps the best news is that not only do these treatments reduce inflammation and pain, they also slow down the progression of rheumatoid arthritis, according to Dr. Mark Burns, a rheumatologist affiliated with Sound Shore Medical Center in New Rochelle. “They are also showing promises with treating systemic lupus and other forms of arthritis,” he adds.
THERE’S REASON FOR OPTIMISM, though, according to Dr. Robert Russell, director of the USDA Human Nutrition Research Center on Aging at Tufts University. He sees a trend toward senior patients taking a real interest in their own health—improving their diet, taking medicines correctly, exercising—and improving their wellness dramatically.
“Our life expectancy has increased,” Dr. Russell says. “But in order for our quality of life to keep up, we need to have more than just the best and most advanced medical system. Now we need to have patients taking responsibility for their own medical care.”
Fortunately, technology abounds to help us. Interactive medical kiosks, like the educational diabetes display at Westchester Medical Center, have become a standard tool for healthcare providers to give patients clear, pertinent information. Patients and doctors in every field are using the Internet to help diagnose and explore options for treatment. “The days of doctors living in a very narrow relationship with their patients are gone,” says Dr. Renee Garrick, a nephrologist and Chief Medical Officer at Westchester Medical Center. “Patients today come in with information, prepared, knowing the questions they have for their doctor.” The Pew Research Center reports 80 percent of American Internet users (113 million adults) have searched for information on at least one of 17 health topics. Though the current group of seniors tends to be off-line, for baby boomersâ€š computers are a part of their everyday lives, and they show no signs of abandoning WebMD, Healthline, or Everyday Health. The risk, of course, is that some of what you may find online is pure opinion, or downright wrong. Anyone can sound like an expert these days. Your mother, your hairdresser, your next-door neighbor—everyone seems to know what’s wrong with you. To Dr. Garrick, all the extra chatter outside of medical facilities makes communication between physicians and their patients all the more critical.
“Doctors need to learn how to adjust their conversations to the needs and levels of individual patients,” she says, noting that medical schools and teaching hospitals across the country are now instructing their students to do just that.
But in the final analysis, it’s the doctor/patient connection that makes all the difference. “Although technology has made it so much easier to detect diseases at an early stage, the most important aspect of patient care remains the history and physical exam,” says Dr. Bagg. “Listening to the patient will help a physician to make the diagnosis.” Now if only the HMOs would cut the red tape, time limits, and other distractions, our healthcare system would stand a better chance of getting something close to a clean bill of health.