I was having lunch with a medical student a number of years ago and asked him about his previous experiences in primary care. He hesitated for a moment, but having gotten to know me, he knew he could be honest.
“The last guy I was with saw mostly Medicaid patients, and mostly just wrote prescriptions for Vicodin. He didn’t really do much medicine, didn’t really spend time with patients.”
About 4% of American medical school graduates go into primary care medicine. Part of it is math: not many smart people leaving medical school with $200,000 of debt will choose specialties with the worst pay. But many of us are passionate about what we do and are willing to make the sacrifice (not much of one, really) and practice for lower pay and more bureaucracy. There are a number of ways to make up for this financial “shortfall”.
Medicaid—government-sponsored care for the poor—usually pays very, very poorly (although this may be changing). Some doctors see this as a disadvantage, and, like me, refuse to take Medicaid. Others see opportunity, enrolling thousands of Medicaid HMO patients, too many really. They collect the enrollment fees, so many that it’s nearly impossible to get an appointment. The system encourages bad practice.
I doubt this is all that common, but most physicians know of a colleague who engages in this sort of less-than-ethical behavior. Others engage in frankly criminal behavior, such as taking cash for narcotic prescriptions.
But these are a small minority. Most primary care docs work hard to take care of their patients. This may mean squeezing sick people into an already-crammed schedule, or spending time listening to patients that could otherwise be used to finish phone calls and paperwork. I start on time most days, but never finish on time—people just aren’t that predictable.
One of the most important things we can do as doctors is listen. Giving a patient time to talk will let them bring up more uncomfortable or painful complaints. It may give a widow comfort, or some hope to a man just diagnosed with cancer.
But compassion and a good ear must be matched by sound knowledge and a skeptical disposition. I learn a lot of medicine from my patients, colleagues, and my own reading. I also learn a lot from bad doctors.
There are a number of so-called holistic doctors in town who claim to practice “individualized” medicine. What this really means isn’t clear. My colleagues and I certainly individualize the treatment plans for all of our patients, using data gleaned from decades of scientific studies of large groups of patients. What “individualized” care seems to mean in this other context is “stuff I made up to make that patient feel more unique and special.”
Examples abound, such as “bioidentical hormones” (a fictional concept earning real dollars), and all sorts of dubious supplements, often sold from the office of the doctor who prescribes them—so you know it must be good! Most of these doctors have ways to earn money outside of insurance, such as the sales of supplements, unproven treatments, and other cash-on-the-barrel deals. These days, most medicines are relatively inexpensive (I can treat most heart patients with medications costing less than $30 per month). Patients should be very skeptical of doctors selling their own branded potions for obscene prices.
Being a real patient and a real doctor is work. There are no easy outs. When you have diabetes, you have to work at self-care, improving diet and exercise, inspecting your feet, taking medications properly. When you are the doctor treating the diabetes, you have to know the risks and benefits of various medications, which patients are likely to need them, which can try lifestyle changes first. You have to know to refer your diabetics to eye doctors, to give them the proper vaccinations, to check their urine for protein and what to do about it when it’s there.
Many of these so-called alternative doctors may do that (although in my experience, they refer the patients back to me for the “real medicine”). But they may also sell cinnamon supplements (shown in some studies to modify certain diabetes parameters, in others not to, but never shown to improve real outcomes like heart attack prevention). Others may sell fancy salt (really, I can’t make that up), pumping up it’s supposed salubrious properties (with a cost of $6/lb, vs. $8/25 lbs of normal salt).
These practices make patients feel good, feel cared for, and sate our thirst for the “old ways”, for a supposedly more natural way to health, which is, in a word, goatshit. Natural usually means “I made it up out using nice-sounding words.” Making things up, even with the most caring demeanor, is wrong. It is immoral.
All medicine involves uncertainty. You can’t be a doctor without tolerating a great deal of the discomfort of uncertainty. But decisions have to be made on sound science for them to be effective and ethical. Selling magic (except in the most Clarkeian sense) is not part of our job.
Our real job is hard, time-consuming, and not as profitable as the “holistic” medicine business. But it’s right for our patients.