The oddest part of all this may be that though doctors feel harried, though they feel pressured to see more patients, studies actually show that patients spend more time with their physicians than they did ten years ago. Dr. Edward W. Campion, deputy editor of the New England Journal of Medicine, suggests office visits only seem short. The reason, he believes, is "because there is more to do, more to think about, and more that is expected." Has medicine simply gotten to be a tougher profession? Consider that one third of primary-care physicians believe the scope of their practice has increased in the past two years. And, alarmingly, one quarter say it's greater than it should be. Your internist, the doctor you saw when something -- you weren't sure what -- ailed you, was once the person who organized, who managed, your care. Now look: "The notion that the internist commands the field is absolutely gone," says David Rothman, a professor of social medicine at Columbia Medical School.
From the doctor's point of view, it can get worse when a patient is admitted to the hospital. Now hospitals have their own doctors working the case -- a new category called hospitalists. "It's easy to get forced out of the loop. You're not always part of the team," says Gerald Leventhal, a Manhattan internist. You have to be pushy. The sicker your patient, the more you're excluded. If a patient ends up in the ICU, for instance, specialists and subspecialists take charge. "And nobody even calls you to tell you your patient had a coronary last night," says Leventhal. "Then when you arrive the next day and the family asks what happened, you look like a jackass."
People tell pollsters they still trust their doctors more than just about anybody else. (Patients in general don't seem to share doctors' discontent.) At the same time, patients increasingly act as if one physician is pretty much the same as another. Lots of patients fork over nothing but a co-pay, the mandatory cash outlay that can be as low as $10, or even $2. "What do you value a physician at if you pay $2?" asks Stracher, who says that sometimes, for that amount, patients blithely skip even bringing along money. For two bucks, patients sometimes don't show up. Or they get the idea that -- guess what? -- doctors are only worth a few dollars. Fox recalls a patient with a $10 co-pay. She had a small tumor in a lymph node and wanted a second opinion on surgery. She was upset and nervous, and Fox spent more than 30 minutes calming and examining her. In the end, he assured her, she didn't need surgery. "That's the best $10 I ever spent," she gushed, leaving Fox nonplussed. To the patient, he thought, "that's what I'm worth."
The stable doctor-patient relationship, the building block of every successful practice, is pretty much a thing of the past. Once, doctors attended patients' bar mitzvahs and weddings. And doctors will tell you that following a patient over a long period actually makes for better care. These days, though, patients are attached to insurance companies that shuffle them around based on price considerations. You save the lives of two members of their family, then their insurance company changes because they change jobs, and they switch doctors. "It's like I used to go to Macy's to get pots and pans; now I go to Bloomingdale's," says Breslaw.
"Doctors are lumped in with hospital colleagues as "health-care providers," which rankles. "I'm no health-care provider," says one, sounding like McCoy on Star Trek. "I'm a doctor."
Some patients don't mind. One of the rights they've recently asserted is the right to convenience -- their convenience. Now they find your name on the Internet and head your way because your office is close to theirs. Some doctors have already adapted. Horowitz knows that patients near his Wall Street office will call their internists back home in Westchester only to learn the next available appointment is in a week. What if they're sick today? At Horowitz's office, anyone can be seen the same day.
Patients are demanding in other ways, too. These days, they want to be partners in their care. They trundle into the doctor's office with a sheaf of printouts. Never before has so much information been available. They've got answers, or challenges. Many doctors like an informed patient. Still, it may be true, as Rothman argues, that the doctor's monopoly of medical knowledge is disappearing, particularly, he points out, with regard to young, well-educated, upper-middle-income women. Some time-pressured physicians clearly don't appreciate another demanding voice in their ears. "Suddenly they ask for records," explains a New York allergist. "But patients can't understand records, and now they need an explanation. That's not part of what I have to do. I don't have to be in a position to interpret records to patients."
Badgered on all sides, physicians seem to have come down with an old-fashioned case of alienation, the kind hourly workers used to suffer. "There's a sense they are doing this to us. They are the insurance companies. They is the government," says Cassel.
As Fox explains, "I don't have any clout." Insurance companies have clout, institutions have clout, even patients have some. And so, just like any disgruntled worker, doctors -- doctors! -- are turning to unions. "We get more calls than we can handle these days: otolaryngology groups, orthopedists, groups that used to be fat and happy," says Bruce Elwell, an organizer for the Doctors Council, which is affiliated with the Service Employees International Union and the AFL-CIO, the same organization that, it's worth noting, represents hospital maintenance workers. Lately, Fox, the Scarsdale otolaryngologist and lifelong Republican, has become an organizer himself. But Fox has signed on with the AMA's newly formed union -- he's on the board. "The anger is still with me," he says by way of explanation.
Some doctors encourage their children not to be physicians. Some doctors say they wouldn't do it again. And some are actually leaving. Robert Aldrich has been a cardiologist for 22 years in Morris County, New Jersey, an hour from Manhattan. Or at least he was. On July 1, in the midst of his prime earning years, he bought an inn in Vermont. It's not retirement, exactly. "We have to earn a living," he says.
But that will be a pleasure compared with what he's leaving. "I feel in charge again," says Aldrich, who dreamed of a career in medicine from the age of 9. "I feel free again, released from prison."
Next week, New York debuts Tough Medicine, a column by Joanne Kaufman that will explore issues on the minds of both medical practitioners and patients in the changing world of health care in the city.