THE LAST WORD – NOVEMBER 2019

By Hujefa Vora, MD

Why do you want to become a doctor? I remember working so hard through high school and college thinking about this question. It confronted me at every turn of my early career. My friends would ask me the question when I skipped the Friday night poker parties. I spent weekends and holidays reading instead of lazing about with my friends. When I started college interviews, the question struck again. In college, my fraternity brothers would throw the question out randomly in study hall and keg parties. By the time I made it to my first medical school interview, I had plenty of practice answering anyone who asked.

How did you answer that question? I asked a few medical students just recently. Their idealism that bubbles up is infectious. I want to help people. I want to save lives. I want to work in a profession that gives my life meaning. Sure, money is important, but that’s not what medicine is all about. Medicine is all about life. If you practice medicine well, you can really make a difference. That meant that what we were searching for as students is the same meaning we give our patients. In that ideal world, the patient, their family, they come to us for help. We offer a kind touch, a warm smile, the wisdom of Osler, and suddenly everything is right with the world. What about the ideal patient?

The ideal patient loves their doctor. They come in with the most straight-forward of chief complaints. There is a weaving of the story. Everything comes together brilliantly, like something out of Harrison’s.  We go through the differential diagnosis and order exactly the right test, purely for confirmation purposes of course, and then the right treatment process begins. Pure medicine is an ideal that waltzes out of a textbook and into our hearts.  We hold our flag high, the idealism and the truth. As physicians, this is our happy place, our dream, everything that we worked so hard to achieve.

Residency changes that for most of us. The walls of Parkland grew into my soul. I once wrote that you can take the resident out of Parkland, but you can’t take Parkland out of the resident. It is something I said at our residency graduation. I meant it. I worked harder than I ever worked in medical school. There were moments when I couldn’t take another step, but I kept going. Part of me believes that as I wandered the halls of Parkland, I gave up parts of my very humanity. Patients became disease processes on some of those long call nights. The cliffs of my idealism began to get chipped away by fatigue and fear of failure. You see, the most difficult cross that residents bear is that idealism. They are not allowed to be wrong. Lives hang in the balance every time the pager goes off. When you are wrong, the chief would hold your feet to the fire at M&Ms. When you are wrong, people die, and lawyers make money.

By the time I reached my goal of private practice, like many of us, I realized that the goal was an illusion. I coveted the doctor-patient relationship ideal, but soon saw that my rubric was flawed. There are too many other players to account for. My reality dictated something very different from that ideal. It becomes evident that those players include family, friends, and “others.” The two most important of the others  who have inserted themselves into the doctor-patient relationship are the insurance companies and the government. They interfere not to  the betterment of my patient, but all too often to their detriment. The difference speaks to the underlying motivation of the parties involved. Patients are interested in better health. Family and friends are sometimes motivated by this as well, but sometimes are also motivated by ulterior issues that may be in direct conflict with this goal. Insurance companies…. Let’s face it. They are only motivated by one thing. Money. Sure, their bottom lines improve when patients are healthy and not sick, but when they do get sick, the insurance company is really only looking to minimize their potential liability. As for the government, their motivation now is primarily related to saving money as well. Presidential candidates, congressmen, and administrators may speak of loftier  goals, but as most of us have come to know, those noble intentions are only a means to acquiring more votes. Our idealism as physicians has been crushed by the weight of our reality. How does all of this help my patients? How does pointing and clicking all day long really save lives?

As for our ideal patient, they are gone too. Patients today are confused. There is a general mistrust that all patients now have for our healthcare delivery system. I believe that this mistrust stems from the interlopers that have placed themselves squarely  and forcibly into the doctor-patient relationship. As an example, I consider my own experience as a patient. I have catastrophic coverage insurance, which means a high deductible plan. I pay over $6000 a year into that plan. I see my personal physician once a year and a specialist every now and then. Because of that high deductible, all of these are also paid by me, not the insurance plan. My patients often ask me in the office what it is that they are paying for. In my own situation, I understand that I am paying into a plan in case of a catastrophe. Most of my patients are unable, however, to discern between the money they are paying the insurance company and the money a physician gets. When they do get an EOB, the numbers are jumbled messes that it takes an MBA to translate. The insurance company doesn’t really have a face. The only people that our patients can discuss this with, can vent their frustrations to, are our offices. Our ideal patient is now a confused consumer who doesn’t believe that they have gotten what it is they are paying for. Unfortunately, our patients misplace their mistrust by pointing their ire in the direction of their physicians, the only people they can talk to, rather than the faceless insurance company.

Our patients deserve better. That is the ideal. They deserve the doctor-patient relationship without all of the confusion, the interlopers, the others interfering. I don’t know how to fix this broken system though. Along with many of you, my colleagues, I want so badly to go back to that ideal of medicine. I wish I could offer some solutions. For now, all I can do is hope and pray that we can get this ship right again. I want to become a doctor again. My name is Hujefa Vora, and this is this month’s Last Word.