Under the weather

A recent New York Times article contrasted the medical career of Dr. Kate Dewar with the careers of her grandfather (Dr. William II) and father (Dr. William III), who were also medical doctors. The most obvious difference, that Dr. Kate is female and a mother of twins, partially explains the other differences noted in the article.

She chose not to go into private practice, opting instead to work 36 hours a week as an emergency room physician. The Times called her decision "part of a sweeping cultural overhaul" that finds young doctors "taking salaried jobs, working fewer hours, often going part time and even choosing specialties based on family reasons. The beepers and cellphones that once leashed doctors to their patients and practices on nights, weekends and holidays are being abandoned. Metaphorically, medicine has gone from being an individual to a team sport."

Dr. Kate's choice also reflects her individual temperament. She wasn't that interested in treating chronic conditions like heart disease and diabetes: "I like it when people get better, but I'd rather it happen right in front of my eyes and not years later. . . . I like to fix stuff and then move on."

Kate Dewar won't ever know intimately her patients as her father and grandfather did. That's also part of a trend. Dr. Abraham Verghese, author of the bestselling novel Cutting for Stone, is a professor at Stanford University's medical school. He wrote in the New England Journal of Medicine about two approaches to medicine-one traditional and the other expedient.

In the traditional approach, "The body is the text, a text that is changing and must be frequently inspected, palpated, percussed, and auscultated [listening to body sounds]." That contrasts with the expedient way, where the "patient is still at the center, but more as an icon for another entity clothed in binary garments: the 'iPatient.'"

He says many hospital doctors pay scant attention to the real patient. Instead they huddle around monitors filled with patient data. It's the emergency room docs who do the scanning, testing, and diagnosing "so that interns meet a fully formed iPatient long before seeing the real patient." When doctors don't spend time observing patients, "simple diagnoses and new developments are overlooked, while tests, consultations, and procedures that might not be needed are ordered."

All this came to mind when I visited recently Drs. John and Alieta Eck, married physicians who share a medical practice in north central New Jersey. They also run a free clinic in Zarephath, N.J., that opened in 2003 and now sees 300-400 patients per month during the 12 hours a week it is open (see "Patients & partners," Nov. 21, 2009).

The current clinic is tiny and located in a flood plain, so it is expanding to a new location on higher ground across the road. The new clinic will have six exam rooms and a small lab. Another room will house a dental chair. There will be large bathrooms, a room for volunteers, a pharmacy, and classrooms for teaching.

The Ecks would love to train physicians to be good clinicians there. They see more pathology in the clinics than residents see in hospitals, and the need to provide low-cost care requires them to become the kind of clinicians Dr. Verghese describes.

They listen carefully to their patients' stories. Covered by the Federal Tort Claims Act, which gives free federal medical malpractice coverage for work done at free clinics, they don't have to order unnecessary tests to ward off lawsuits. They are free, as Alieta Eck says, "to use common sense and treat the patient rather than looking over my shoulder at the lawyer waiting in the wings."

John Eck describes one clinic visit: A woman in her mid-40s comes in with a lower-chest pain that's going up her neck. She has a fast heart rate. As he examines her, he finds her thyroid is a little tender. He thinks maybe that's why her heart is racing. He gives her a baby aspirin and beta blocker and tells her to come back. When she returns the symptoms are gone.

Dr. Eck notes that most doctors would have referred the patient to the emergency room: "If you only get paid $10 from Medicaid, why would you assume liability? Of course you would send her to an emergency room." There the patient would get a stress test or a stress thallium test along with a bill for $10,000. "The system can't afford the current system," he says. Dr. Verghese described it as "a healthcare system in which our menu has no prices, we can order filet mignon at every meal."

Despite the satisfaction inherent in the work, the Ecks find it hard to recruit physicians to volunteer at the clinic. They speculate that the stress and time demands of running a private practice keep many from volunteering.

That's why they are proposing an alternative: What if New Jersey did away with Medicaid altogether? What if the state encouraged more doctors to voluntarily care for the poor at free clinics like Zarephath? And what if, in exchange, the state would provide doctors with malpractice coverage in their private practices, relieving them of that financial burden and discouraging frivolous lawsuits, since the state, like the federal government, is less likely to settle nuisance suits than private insurers are.

They believe the result would be better care for the poor and financial savings overall: "If the state were to say we will protect doctors, the doctors would order fewer tests. A good doctor who is a good clinician will give better care."

Verghese, from his different vantage point, similarly concludes that today's system is bad for budgets, doctors, and patients. Tending to the iPatient, he writes, "can't begin to compare with the joy, excitement, intellectual pleasure, pride, disappointment, and lessons in humility that trainees might experience by learning from the real patient's body examined at the bedside." Verghese describes the careful physical exam as ritual, which "strengthens the patient--physician relationship and enhances the Samaritan role of doctors-all rarely discussed reasons why we should maintain our physical-diagnosis skills."

Verghese concludes with a cry for better medical training to produce better clinicians, those who understand "the bedside is hallowed ground, the place where fellow human beings allow us the privilege of looking at, touching, and listening to their bodies. Our skills and discernment must be worthy of such trust." But that's unlikely to happen unless we make our medical system hospitable once again to doctors like the Ecks and the elder Dewars.