Source: Washington Post
Date: August 3, 2008
Author: Benjamin H. Natelson
URL:
http://www.washingtonpost.com/wp-dyn/content/article/2008/08/01/AR2008080102953.html
Ref: http://www.painandfatigue.com
Lost in a system where doctors don't want to listen
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I'd like to tell you about one of my patients. She's the kind of patient that
I enjoy seeing but that many doctors go out of their way to avoid. This means
that she's also the kind of patient I worry about most - a patient who in
the near future may be stranded without proper care as fewer and fewer
doctors, constrained by time and the economics of our health care system, are
willing to perform the fundamental task of diagnosing difficult or unclear
medical problems.
My patient is a 37-year-old woman, a mother of two teenagers, with a busy
career. She was in perfect health until July 2007, when, overnight, she came
down with what her doctor said was a case of flu. This 'flu,' however,
wouldn't go away. Her doctor assured her that she'd get better, but three
months after her first visit to him, she was back in his office, still
feeling ill. The doctor did a thorough medical evaluation, told her that he
couldn't find anything wrong and again assured her that she'd eventually
recover. A few months later, she was back again. This time, as she described
it to me, the doctor sort of shrugged his shoulders and told her that maybe
her problem was all in her head.
As you might imagine, the patient was put off by her doctor's dismissal,
which set her off on a gyre of doctor-shopping. Over the next six months, she
saw eight physicians, as well as a chiropractor and a homeopath, without
getting a diagnosis or any real help. Finally, she did an Internet search
and found me, a specialist in medically unexplained illness. All her tests
were normal, but I listened to her and was ultimately able to make a
diagnosis of chronic fatigue syndrome. We then launched into the treatment of
her symptom-based illness, a slow process that unfortunately doesn't end in a
cure but often leads to improvement.
The fact that this woman couldn't find a doctor to help her until she found
me says a lot about where the U.S. health care system is heading. The
economics of modern medicine have converted the doctor from Ben Casey to a
factory worker on a conveyor belt, and those economic forces are driving more
and more physicians toward specialties where they can spend less time with
patients and earn more money.
Learning how to make a diagnosis is a critical part of medical education. It
requires the doctor to listen to the patient describe the illness and then
put it in a personal health framework by asking about other symptoms,
previous medical problems (extending to the patient's family) and elements of
the patient's life story. Doctors usually schedule an hour for these initial
consultations, then 30 minutes for follow-up appointments.
Half an hour of a doctor's time is normally plenty for a straightforward
health problem and more than enough for a cold with a runny nose or a cough
with no fever. But what happens when your symptoms don't add up to a
clear-cut diagnosis? Studies have shown that in more than 50 percent of
cases, patient complaints don't have any diagnosable medical cause that can
be determined by careful laboratory testing. Pain, fatigue, dizziness and
trouble sleeping are among the most common symptoms, and doctors have
problems with these because they don't point to any particular diagnosis.
When that happens, the diagnostic algorithm learned in medical school breaks
down. The doctor's not sure what's wrong with the patient, and if he has a
busy office, he won't have time to think through the patient's complaints to
arrive at a coherent diagnosis. Very often, when all the tests are normal and
time has run out, the doctor will conclude a visit, as my patient's initial
physician did, by saying: 'There's nothing really wrong with you. I'm sure
you'll feel better in a few days - or weeks.'
Even doctors with time often prefer dealing with straightforward medical
problems. I have a friend who's an allergist in private practice. When I
asked him whether he'd be willing to work with some of my patients, he
quickly said no. Why, he said, would he want to tackle difficult cases like
that when he can take someone suffering from severe allergies and make them
better in a day?
Doctors are being lured away from primary care by economic factors as well.
Eighty percent of medical students have to borrow money for medical school.
The expected median debt of this year's graduating class is about $120,000
for state medical schools and $150,000 for private, according to the American
Association of Medical Colleges. At the same time, medical students face a
candy store of career choices, all with widely varying earning (and
debt-reduction) potential.
I, for instance, am a medical school professor with a practice devoted to
patients with medically unexplained symptoms such as fatigue and pain. My
patients often have complex medical histories and feel they're at the end of
their rope. If a patient has Medicare coverage for disability caused by an
illness, Medicare will reimburse me $196 for each hour of interaction with
that patient. After expenses and other charges, I'll keep $86, a very good
hourly salary.
But consider the neuroradiologist, who specializes in interpreting brain
MRIs. Just a few years ago, it would take a radiologist a long time to
organize and view many sheets of a patient's X-ray films, but today, thanks
to computerization, the well-trained neuroradiologist can assess dozens of
images of the brain in just a few minutes. He or she can probably read a
patient's images and dictate a report in about 15 minutes. At my previous
institution, the hourly reimbursement from Medicare was $492, and the
doctor's take-home totaled $216, a substantially better salary than mine.
Physicians in a procedure-driven specialty such as neuroradiology - and
there are many others, such as cardiology and anesthesiology - always earn
more than patient-centric doctors. American medical students are aware of
this as they make their career choices. And fewer and fewer are choosing
patient-oriented medicine: In 1996, American graduates filled 76 percent of
residency training slots in family medicine, while in 2002, they filled only
48 percent. We see similar shifts in general internal medicine. The
remaining positions are filled by foreign-born and foreign-trained medical
school graduates. They pass the same qualifying tests for licensure as
American graduates, but cultural diversity and varying communication skills
may affect their approach to patients and their ability to hear subtleties in
their patients' stories.
Society has come up with a partial solution to the growing gap in primary
care providers: 'physician extenders.' These master's level health-care
professionals are trained to deal with commonly occurring, easy-to-diagnose
problems: a flu, hay fever, a splinter, even severe chest pain. Usually,
however, they haven't had enough training to give them the know-how to sort
through a complex medical history to arrive at a diagnosis that isn't
immediately evident. When they're stuck, they have to call the physician, and
by then, the 30-minute visit is very often over. The patient is left hanging
and disappointed - on his or her own to figure out what to do next. The
inevitable result: patients falling between the cracks of classical medicine.
There's one silver lining in this situation: the increasing number of women
choosing medicine as a profession. Approximately 50 percent of most medical
schools' entering classes today are women. This trend may work to offset a
major patient complaint - that doctors don't spend enough time listening to
them. Research studies show that women in general and women physicians in
particular are better listeners than men. Since the turn toward more women in
medicine is relatively recent, I'm not sure which path the young female
doctor will choose, but I can say anecdotally that quite a few of my own
female students seem to be choosing primary care - either family or internal
medicine. I hope that in the next few years, their presence may help offset
the dearth of U.S.-trained doctors in primary care.
Meanwhile, what are patients with an elusive diagnosis to do? If they're
fortunate enough to live near a medical school, they can search the doctor
list for generalists. Physicians in academic centers are encouraged to see
patients as part of their duties, and they often have more time than their
colleagues in the community. More important, patients can help themselves by
knowing more about their bodies, how they work and what can go wrong with
them.
But finally, patients will have to understand that finding a doctor who has
the time to listen, diagnose correctly and then know how to treat them is
going to get harder and harder. Reversing the trend away from
patient-oriented and toward procedure-oriented medicine will require
attention by legislators as well as medical educators. Reducing the debt of
newly minted doctors who choose primary care might be one way of doing this.
Cutting back on both the number of postgraduate training positions in
procedural medicine and the salary paid such trainees, while raising the
salaries of those in primary care, could be another.
None of this will happen, though, unless patients make their voices heard.
Otherwise, they may just find themselves on their own the next time puzzling
symptoms arise.
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