Sandeep Jauhar, MD Cardiologist/Author
Sandeep Jauhar MD’s latest book, “Doctored,” touched a nerve in the Sermo community. Some physicians agreed with his bleak portrait of medicine in the US today, and some outright questioned his premise. Recently, Jauhar had the opportunity to address the community and discuss their concerns.
The question and answer is below, edited only for brevity or clarity.
Sandeep Jauhar MD, cardiologist
First, I want to thank you for this opportunity to engage with my Sermo colleagues. I really am a big fan of this website. I’ve learned more about real-world medicine from Sermo than just about any other source.
Question from Emergency Medicine Physician: Given the unequivocally serious challenges of the EMR rollout, its danger to patients and the obvious costs, which include risks to privacy, what solutions do you think require implementation to solve this? Several physicians on Sermo have recently voiced quitting a job (or even medicine!) over an unworkable EHR system, what can be done to prevent this?
Jauhar: I agree with you that a lot of EHR is total “cut-and-paste” crap. It encourages a lack of integrity in patient-doctor interactions. (Who really does a complete ROS or neuro exam on every patient?) The costs of EHR are astounding; you can’t blame self-employed docs for not wanting to implement it. Like so much in medicine, EHR is a good idea in theory, but horribly implemented in practice. I don’t have a solution, other than good old-fashioned iteration and improvement, with ample input from physicians. And perhaps hospitals, which have so much at stake in getting EHRs to their community doctors, need to subsidize the technology.
Question from an Endocrinologist: [referring to a recent Wall Street Journal post from Jauhar] While you (Dr. Jauhar) correctly identify the problem, you come up with solutions that have already failed miserably to enhance professional satisfaction for physicians and to demonstrate better care for patients. Why do you hesitate to offer free-market based solutions associated with elimination of artificial creations such as closed networks (both private & public), CPT/ICD Codes and price-fixing?
Why do you not mention Medicare’s unfair & unconstitutional RAC audits, the monopolistic influence of Certification Boards & their disastrous impact of physicians’ livelihood, the Federal protections for hospital committees when it comes to sham peer-review, as major causes of physician stress, burnout and even suicide?
Jauhar: It was a 2,300-word article in the Wall Street Journal. Limited scope for covering all the things you mention. My book does delve into some of it, however, so you should read it before you pass judgment. I don’t espouse free-market solutions because I don’t think medicine is a free market; knowledge among the major players is too asymmetrical. As for the other things you mentioned, I am in agreement. MOC is mostly crap! (I have to recertify in cardiology this year and take my CHF boards; that’s $10,000 to cover exams, review courses, hotels, and flights.) Physicians have almost no say in the process, resulting in a feeling of powerlessness. Medicare audits drive many physicians into despair (I have both seen and experienced it). So I am very sympathetic to your disdain of bureaucracy. Bureaucracy is as much a part of my professional life as it is yours.
A Comment from an Obstetrician: And all the $$ is going upstream. It’s not going to healthcare.
Jauhar: The amount of money going to insurance executives IS nauseating! Part of me wants to see us doctors take charge of our financial house, but I also reckon that most doctors (either by lack of training or proclivity) are not well equipped to do so.
Question from an Ophthalmologist:Who should decide the treatment options offered to our patients? Should an employed physician be constrained by the directives of the hospital, insurer or government who tells them what is in the best interest of their employer or the best interest of society, with respect to resource management?
I have remained in independent private practice for 25 years, as I am unable to resolve the ethical dilemma. I feel ethically driven to put the interests of my patients first. I am a dying breed. I am worried by this trend. I don’t want government telling me I am too old for a hip replacement or that I must wait beyond my likely life expectancy for treatment of my illness.
Care driven by the needs of the individual is ethical care.
Jauhar: Hospital directives are often unethical! When a hospital signs up an inferior but cheaper stent for financial reasons, few raise a hue and cry. If a doctor does it, he is labeled fraudulent, and incurs opprobrium or even jail time. Where I differ with you is about that hip replacement (or whatever) for the 90-year-old. Healthcare is already bankrupting the country. We need to make choices (and de facto rationing is already going on).
Question from an Emergency Room Physician: How do you justify your desire for more money and the unethical behavior that came from your sense of entitlement? Do you recognize the role that attitude plays in undermining health care policy debate? Do you understand that at your very lowest income you earn more than 99% of Americans?
Jauhar: Fine, agreed on the money thing. I have learned to tamp down my expectations, and I am happier for it. If you’ve read the book, you’ll already know that there is some redemption at the end. My starting salary as an academic cardiologist was about the average salary of a PCP today, and with educational debt, a new baby, and a wife who wasn’t working, it didn’t seem as large an amount as I had thought it would be when I was in training. It wasn’t enough to cover my expenses.
Question from a Pediatric Psychiatrist: What do you suggest we do to educate people about the tremendous waste of time, energy, and resources of defensive medicine? What do you say to people about all of the ways the government bureaucracy, the insurance companies and especially attorneys create hyper-vigilance, paranoia and over-attention to charts instead of patients for doctors?
Jauhar: Defensive medicine too often seems like a necessary evil to many of my colleagues. That message is getting out there, but the dissemination has been slow.
Question from Family Practitioner: You seem to say all doctors are looking for “loopholes” to make more profit. Do you think all of us doctors are so unethical? Do you see how spreading that accusation is harmful to the doctor-patient relationship and the healthcare system in general? It would be hard for us primary care docs to do procedures to drive up our bottom line. Also, you seem to indicate that there is no way to stay in business unless you do procedures for profit. Do you think that is true across the board?
Jauhar: I don’t think most doctors are unethical. Most doctors are good! (I say it in my book.) But there is a subset I have come across that behaves fraudulently. Has that not been the case in your experience?
I wrote a piece in the New York Times recently in which I note that physician incomes make up only 10-20% of healthcare costs. However, our decisions (whether to hospitalize a patient, order that MRI, etc) determine close to 80% of healthcare spending. Take doctors off the office treadmill – the biggest driver of that treadmill is decreasing reimbursements – and you will likely see healthcare savings. So I think doctors, especially PCPs, should be paid more, not less.
Question for Pain Medicine Physician: “Why is profit bad? Why should we be ashamed of making a profit? Is it inherently evil to exchange services for money? Are you selling your book at cost?”
Jauhar: Profit isn’t bad. But the pervading commercial consciousness, driven in large part by reimbursement cuts and a need to keep practices afloat, has created a lot of misery in the profession. I didn’t go into medicine to constantly have to think about money and business, and I suspect most of my colleagues didn’t either.
Comment from a Physician of Occupational Medicine: The problem is not Profit, the real problem is lack of accountability of all players in healthcare but physicians, so any solution that doesn’t hold all the stake holders accountable will fail.
Jauhar: We need accountability for all the players, including patients. The moral hazard of third-party payment is painfully obvious, and results in terrible waste. No doubt patients need more skin in the game.
As a physician do you have an opinion about Jauhar’s experience as a peer? Do you think his book “Doctored” portrays an accurate experience in medicine today? Sermo is an active community discussing the above topics and more. If you’re an M.D. or D.O. please join us.
Bio: Sandeep Jauhar is a practicing cardiologist and the author of “Intern: A Doctor’s Initiation” and the recent New York Times bestseller “Doctored: The Disillusionment of an American Physician.” He lives on Long Island with his wife and children.