In India, any discussion of the healthcare system oscillates between two poles. At one end of the oscillation, it is dominated by statistical breast-beating about the gap between demand and supply — of hospitals, hospital beds, doctors, nurses, medical colleges, etc. At the other end are concerns about the rising costs of healthcare, the disparity in access and the depredations of the insurance regime.
But rarely does the discussion traverse the ground between the two poles — the actual conditions in which the service providers (hospitals and doctors) function. In Doctored: The Disillusionment of an American Physician, which released last year, Sandeep Jauhar, a cardiologist at a prominent New York hospital, writes with withering honesty about his life as a highly qualified cog in the corporatized wheel of the American healthcare system.
Jauhar had written evocatively about his training in a New York hospital in his first book, Intern: A Doctor’s Initiation. Doctored continues where Intern left off, documenting his experiences with patients and colleagues in his first real job in New York’s Long Island Jewish Medical Center, a teaching hospital. “Nineteen years after starting college and a few months shy of my thirty-sixth birthday,” Jauhar is now, as the book opens, on the cusp of professional stability and financial prosperity. Or so he believes.
But it doesn’t take long for the eponymous disillusionment to set in. Jauhar struggles to come to terms with the reality that a hospital doctor is only worth as much as the revenue he brings in — measured in terms of relative value units (RVU), the values insurers place on medical services. “Whatever the economics,” he writes, “I quickly learnt that it was important to see as many patients as possible.”
But no matter how many patients you see or how many hours you work, it is never enough. Not surprisingly, pedaling furiously on a stationary bicycle is a recurring motif in the book.
Jauhar further learns that since medical procedures command a greater number of RVUs, the entire treatment process has become corrupted — to the detriment of the patient’s interests — so as to extract maximal profit from a skewed incentive regime. “As much as we hate to admit it, patients are a commodity,” observes Jauhar’s brother, also a doctor at the same hospital.
Jauhar provides innumerable anecdotes detailing the perverse ways in which the commercial imperative mediates the doctor-patient relationship, causing a terminal erosion of trust between the two. These include over-testing, making patients stay longer in the hospital than required, relying too much on diagnostic data and not enough on direct physical examination, hyper-specialization and compartmentalization of treatment, resulting in lack of co-ordination and dispersal of responsibility, doctors spending more time spent on paperwork than with patients, and inadequate rest and recovery time for medical staff, among others.
In Jauhar’s telling, the doctor-patient encounter is merely a procedural necessity that initiates the flow of funds from insurance companies to hospitals, with neither the doctor’s labour nor the patient’s welfare being as important as the extraction of surplus from their every encounter. Jauhar, naturally, is much exercised by his sub-par earnings which, despite his insane work hours, is not enough to cover the expenses of raising a family.
Under pressure to increase his income through private practice, he ties up with a Pakistani cardiologist, only to realize to his disgust that in order to make the partnership work he would have to force almost every patient who walks in to undergo echo cardiograms and stress tests, whether they needed them or not. If this puts him in a moral dilemma, he sinks into depression at the thought of having to ingratiate himself with other unprincipled businessmen-doctors for patient referrals.
Jauhar, like many others driven to the profession by idealistic notions of serving and caring for individuals, had not factored in income considerations when he decided to become a cardiologist. But now, in his mid-thirties, with financial responsibilities as a husband and father, he feels trapped as he realizes, rather late, that living by the Hippocratic Oath can be directly at odds with surviving in the profession.
Jauhar attributes what he calls the overutilization of healthcare services to defensive medicine practiced by doctors trying to avoid lawsuits. Another reason, especially for over-testing, is a reluctance to accept diagnostic uncertainty. “Everyone wants a number, a lab test, a simple objective measurement to make a diagnosis. If a physical exam can diagnose a pinched spinal nerve with only 90% probability, then there is an almost irresistible urge to get a thousand-dollar MRI to close the gap.”
His critique of the American healthcare system carries more weight not only because he is himself an insider of the system but also because he implicates himself in its sins. He unsparingly documents how he succumbed to its blandishments to varying degrees – sometimes explicitly, as he takes on paid speaking assignments for a pharmaceutical company, sometimes implicitly, as he aids a private practitioner’s racket of making money from unnecessary tests.
Though repelled, he carries on with racketeering private doctors for some years, stopping only when it becomes clear that he will never be any good at it. Jauhar notes, not without ironic self-consciousness, “Among my colleagues I see an emotional emptiness created by the relentless consideration of money… something fundamental is lost when physicians start thinking of medicine as a business.”
While Doctored is accurate in its diagnosis of the ills plaguing the medical profession today, the course of treatment it prescribes is vaguely idealistic, which is surprising given that the whole book is about the systemic crushing of any idealism.
Jauhar acknowledges that it might be too late now to rewind the clock to the times when everyone had their own family physician who commanded respect because he cared about his patient more than he cared about money-making or paperwork. Nevertheless, it is in the resuscitation of the human element in the doctor-patient relationship that Jauhar sees some hope of salvaging the prestige and trust his profession once commanded.
Doctored needs to be widely read and debated in India not only because the pathology it documents is a reality here as well, where the private sector accounts for 80% of outpatient care and 60% of inpatient care. It also deserves to be read for reasons that have nothing to do with its subject matter, for it is, all said and done, a supremely well-written, thought-provoking memoir that strikes the perfect balance between ideas and sentiment, the mind and the heart.