Old and Sick in America: There’s No One In Charge
This is the first in a two-part series. To read the second part, click here.
My sister and I are Boomers and physicians: I am a general internist, she is an oncologist. Our father, who died in 2003 at 79, lived a healthy life: he didn’t smoke, played tennis until his cardiac bypass and ate properly. But his parents died of cardiovascular disease in their 50s, and at 70, my father’s genetics caught up with him. He had strokes, heart attacks, congestive heart failure and kidney disease. He fell and broke his hip.
Nevertheless, he did all right, working in his store outside Boston and vacationing in Vermont, until his final year. That year was a nightmare—he was in the hospital and rehab more than he was at home. My sister drove up from New Jersey, I flew in from Maryland, even though our schedules were tight and it was difficult to arrange leave.
The worst part, though, was that there was no one in charge. Health care professionals in white coats and scrubs rushed in and out of his room—they might introduce themselves, or not. We rarely saw the same doctor for more than a day or two. We saw few attending physicians, sometimes we did not know their names. Yes, my father had an internist, who checked faithfully every day at 6:00 a.m., but then was unavailable, busy seeing patients in his office, as all internists must these days.
And yet my father only got worse. I am not sure that the treatment he received, at one of the leading hospitals in the country, did not hasten his death.
Modern Medicine: Information Overload and the Rise of Specialties
Within living memory, if you were sick, you went to see your family doctor. He (it was always a ‘he’ then) was often someone from the community, whose children might go to school with yours, who might attend your church or patronize your store. Norman Rockwell drew him on the cover of the Saturday Evening Post. If you had a complicated problem, or needed surgery, he might recommend a specialist, then follow up afterwards. Over time, you got to know and trust one another. Your doctor could tell when something was wrong with you.
In some rural parts of the country, and in many places in the world, including the developed world, this is still the case.
Nevertheless, in the last 50 years, the science of medicine has been completely transformed. What we know, and what we can do, is expanding exponentially. There are tens of thousands of medical journals. There are thousands of medicines, potent and expensive, hundreds of procedures, thousands of tests. No one can keep track of it all, or even most of it. So physicians have specialized and subspecialized. We have general cardiologists, but there are also subspecialists for arrythmias (the heart’s electrical system), valve problems, heart failure, congenital cardiac anomalies and coronary artery disease. We have other specialists for other organs: kidneys, lungs, brain. Oncologists subspecialize in cancer of particular organ systems: the gastrointestinal tract, the nervous system, the blood stream. And that is just medicine: there are corresponding surgeons for different organ systems too.
The new medical knowledge has changed our ideas about disease. Once, disease was an episodic event: you got cancer, or pneumonia: you were treated, you recovered or you died. Now we understand that each episode of disease, and its treatment, may be related to the next—cancer treatment may weaken your immune system, leaving you vulnerable to infections a healthy person would clear. Or a heart attack in the past might make medication for a new illness problematic. The past is prologue.
This makes continuity of care, being followed by the same doctor over time, something we took for granted 50 years ago, critical now, especially for frail, elderly patients with complex medical problems accumulated over a lifetime. A doctor who has worked with a patient over the years, so knows the person--particularly what is “normal” for him and what is not--and also knows medicine well enough to integrate the information going to and from the specialists—can make all the difference. Given modern medicine, today every complex patient needs a team. But the team needs a leader—not just a coordinator to make appointments, arrange for services and answer simple questions, but an expert a patient and family can rely on, over time, for advice and direction through the modern medical maze. There is still a nurse-in-charge in every hospital unit. There needs to be a doctor-in-charge of every sick, complicated patient.
As in every large, teaching hospital, my father had specialists who rotated every few weeks, accompanied by house staff and students who rotated on different, sometimes very short schedules. Each one took care of my father for a few weeks at most, sometimes just a few days. I doubt many of them knew much about him, his medical history or his current medical problems—he was just another note to write or quiz to take in a long busy day, one problem in a homework set from school. Everyone was responsible—so no one was. I have rotated as an attending in a smaller teaching hospital, and I saw this every day. It is an accident waiting to happen.
Since my father died in 2003, things have improved in some hospitals, especially those without major teaching and research commitments. There are now hospitalists, general internists and others who admit patients and direct their care, working with specialists as needed, until the patients are discharged. Obviously no one can or should work 24/7, but at least there are only two or three per patient, so they can get to know the patient, and he or she, and the family, can get to know them.
For many families, however, the outpatient setting, where more and more modern medicine takes place (as it should—a hospital is a dangerous place if you don’t need to be there), is as chaotic as ever. Many frail elderly see 10 or more doctors. Maybe those doctors communicate with one another. Evidence suggests that often they don’t. As the Baby Boomer—the silver tsunami—hits the difficult decades, we will need hospitalists outside the hospital, to closely follow complex patients over time and direct their care. Otherwise chaos will spawn catastrophe.
As it happens, there was once such a specialty, doctors trained to care for patients too complex for general practitioners. It was called internal medicine, the discipline in which I trained. The modern hospitalist, at least at a hospital of any size, is an internist. For many years, however, internal medicine has also provided the perfect background for a young doctor who wished to subspecialize, to move into a field where he or she could command more money and respect, and more confidently keep abreast of a narrower range of detailed information. In the meantime, in attractive urban areas with plenty of doctors and hospitals, general practitioners, who did just one year of internship after four years of medical school, have disappeared.
Primary Care is Not The Answer
So as specialists took over the more interesting and often more remunerative work, general internists were left with general practice, the aches and pains and routine physicals of the worried well, as well as some sick who could not afford to access the specialists. Since anyone with a medical license could go into general practice, in desirable areas many of these “primary care” doctors might compete for patients—and in the last 20 years, for insurance contracts—which drove fees down. Ambitious physicians could make money only by steadily increasing the volume of patients passing through their offices, reducing the time spent with each one. As you know, an outpatient visit to your primary care physician today is rarely more than 10 or 15 minutes. (Vendors of electronic medical records assure physicians that automating records will cut “face time” even further).
Yet few general doctors feel comfortable handling a serious medical question (let alone two or three) in 10 or 15 minutes, so primary care tends to focus on healthy patients with less serious questions, or on “prevention”: mammograms up to date? Adult vaccinations up to date? One can also counsel about diet, exercise, smoking and safe sex. And then there are colds, urinary tract infections, straightforward hypertension or high cholesterol, routine physicals (there is no empirical evidence that annual physicals are useful). Given a healthy patient, the likelihood of missing something serious is low. The problem is, no one needs seven years of medical training for most of these issues, so insurers (and patients) will not pay much. So physicians need to see even more patients, faster. Primary care has become a vicious cycle of high volume, low value—the Walmart of medicine. Or maybe the Sears: midlevel professionals—nurse practitioners and physician assistants—can do this work just as well for less, like Walmart.