“Vacations? Are you kidding?” Mark Fox is a physician. he’s got a handlebar mustache, a sharp widow’s peak, a bright tie, and his own private practice in Scarsdale. He’s 53, in the prime of his career, and just now, seated behind the desk with a life-size plastic nose on it – he’s an ear-and-nose specialist – he is recalling how he used to take vacations. “Every winter and every summer,” he says. Photos of high-mountain camping near Mount Rainier hang on his office walls. First the summer vacations disappeared. “Haven’t had one in five years.” This year he skipped the winter vacation. Fox’s own doctor has urged him to take some time off. He doesn’t disagree. “I have increased stress, high blood pressure,” he says. He’s so wound up by the time he gets home from the office that his wife won’t talk to him for an hour afterward. He’s watched a couple of physician friends undergo open-heart surgery. Still, he’s reluctant. His income dropped 25 percent in one recent year. And if he’s not working, he’s not only losing income. “I’m still paying for the overhead,” he says, and it’s doubled in recent years. So what does he do? “I tighten my belt and get a headache,” he says.
Dr. Bernard Schayes, a 43-year-old internist on the Upper East Side, is the kind of doctor who puts his cell-phone number on his office answering machine. He likes to be available to patients. Of course, when he was starting out, availability was easier – he lived around the corner in a two-bedroom apartment. But he had two kids and private-school bills of $30,000 a year. (He also owned a Mercedes and a Jaguar.) Then his income dropped. “There’s no way to live in the city anymore,” he says. He moved to Roslyn, Long Island, where his children attend public school. Now he wakes at 5 a.m. and gets in his Acura, occasionally fielding phone calls from patients on the way. First, he heads to his part-time job at a nursing home, where he works before his own office hours begin.
Not long ago, doctors had it all. They did challenging work – they saved lives! – and didn’t have to worry about money: They earned tons. They regularly visited the Mercedes dealership. They island-hopped on vacation. They owned the best real estate. Their kids went to private schools. Everybody wanted to marry a doctor. Or be one. Half a dozen years ago, most doctors – three fourths in one survey – were happy.
No longer. Doctors still say it’s a privilege to be a physician, to intervene in people’s lives in times of need. “But there’s a gloom now,” says one family doctor. “A lot of sitting around the dinner table and asking each other, ‘Where did we go wrong?’ “
“The general population decided we weren’t worth all that much,” says Dr. Bernard Schayes. Or, as he sometimes puts it, “people decided they wanted us to drive Acuras.”
Doctors have lost ground. Insurance companies have ganged up on them. “I have anxiety about staying in business,” says an internist who’s put his own money toward payroll. The trouble isn’t just financial. Perks, privileges, esteem (self-esteem too) have all been hit. Many physicians work longer hours. And now, it seems, all kinds of people – including clerks! – are telling them what to do.
Now, announces the New England Journal of Medicine, “many American doctors are unhappy with the quality of their professional lives.” The literature on this reads like the intake form at a depression clinic: “increasing marginalization,” “discontent,” “confused,” “angry,” “insulted.” (Is it any wonder med-school applications are down again this year?) Yes, the doctor is in, but in case you haven’t noticed, there’s a good chance he’s seething. “It’s no fun being a doctor anymore,” is the way one puts it.
Medicine hasn’t always been a path to privilege. For most of this century, doctors might have been stars in high school and college, but they were solid upper-middle-class earners, a notch above your general contractor, maybe. Then, starting in the sixties, Congress enacted Medicaid for the poor and Medicare for the elderly. The number of paying customers per doctor eventually quadrupled. “That was the goose that laid the golden egg,” says Dr. Jerome Breslaw, a Manhattan gastroenterologist who began practicing in 1973. Doctors bought themselves Mercedeses, Cadillacs, Beemers. They went from upper class socially to upper class financially. Even in the eighties, when family doctor Mark Horowitz attended medical school, he thought, “Doctors are rich people.” Mostly, he was right. Society’s bargain with physicians seemed to be this: Spend ten years training, then you’ll be taken care of. Shortly after Dr. Schayes, the Upper East Side internist who owned a Jaguar and a Mercedes, left his residency, he worked hard – including nights and weekends – but in the early nineties he earned upwards of $300,000 a year.
By the mid-nineties, circumstances had changed. “The general population decided we weren’t worth all that much,” says Schayes. Or, as he sometimes thinks of it, “people decided they wanted us to drive Acuras.”
Actually, it was business that first made that calculation, since in large part business footed the bill for double-digit medical-cost inflation. Managed care was one result. This insurance scheme was sometimes hailed as a way to encourage preventive medicine and ensure quality, but its initial intent was to trim costs. Doctors could once charge as much as they wanted – a rare thing in business. In medicine, the law of supply and demand didn’t seem to hold. No matter how many doctors crowded into one area – like Manhattan – fees seemed to do nothing but rise.
One way managed-care companies attacked costs was simply to reduce doctors’ fees. “Where a fee was $1,000, now a doctor is getting $300,” says Andrew Kleinman, a plastic surgeon in Westchester County. Once, patients were responsible for the shortfall. In managed care, physicians swallow the loss. “The insurance industry has created a slave workforce out of the doctor,” says Moshe Rubin, a gastroenterologist at Columbia. That may be an overstatement, but no doubt that’s how it feels. And as if reduced fees weren’t enough, insurance companies have sometimes, willy-nilly, not reimbursed anything. “We’re fed up but we’re taking it,” says Kleinman. Not always. (Recently, a group led by Kleinman went to the New York State attorney general’s office, which threatened to sue before Aetna settled.)
Reduced revenue is only part of doctors’ new burden. Managed-care companies also created all kinds of paperwork, tons of it, which they, using the jargon of the day, outsourced. In this case, they outsourced it to doctors. Suddenly, physicians had to beef up their staffs. Steven Fochios, an internist, has one employee who handles almost nothing but the referrals required by managed-care companies. Ten years ago, Fox had one assistant; now he has four staffers to deal with the 64 different insurance plans he takes, most of which have different rules. His overhead accounts for almost 60 percent of revenue.
Reduced fees and increased expenses put pressure on income, especially of primary-care doctors and pediatricians – the doctors most of us see most of the time. “I never expected that as my career progressed, my income would contract,” says Mark Horowitz, a family doctor. “In the mid-nineties, it was easy to save and invest. Now there’s less money in the kitty at the end of the month.” These days, after eight years of training, a 30-year-old pediatrician can expect to earn $95,000. Starting internists probably earn $100,000 to $110,000. Not bad, perhaps. But the first year at one of the city’s better law firms – that’s after just three years of law school – will bring you close to $150,000. “And I can be on vacation and I’m always available to my lawyer friends,” points out Adam Stracher, an internist at Cornell Medical Center. “And they have secretaries. They have expense accounts. You think we get tickets to Knicks games from our firm?”
Lately, lots of doctors have to pick up work on the side. Horowitz works as a medical consultant at Juilliard. One doctor got involved with a dot-com for a few years – which was the last time he flew business-class. Some physicians augment their incomes by selling herbs, food supplements, cosmetics, even household cleaners in their offices. Schayes sells vitamins. “I buy wholesale and sell retail,” he says. “It was kind of embarrassing at first. But at the end of the year it makes a big difference.” Last year, Schayes, an M.D. approaching the height of his earning power, earned about $120,000 – which doesn’t come close to buying what people once thought of as the M.D. lifestyle. Soon, Schayes figures, his wife will have to go back to work. She hasn’t worked in five years while the kids grow up. “She doesn’t want to, but I’m making her,” says Schayes. “Besides, she’s a lawyer. Her earning potential is greater than mine.”
Income isn’t the only factor squeezing the fun out of doctoring – and maybe not the key one. After all, doctors earn about $160,000 on average, which makes them affluent, by any measure. “I actually believe the biggest issues are not economic,” says Dahlia Remler, an economist at Columbia.
Once, as Ed Salsberg, head of the Center for Health Workforce Studies, explains, “everything in health care revolved around physicians. They were king of the hill.” Accordingly, they were treated in a kingly fashion. Every 50-year-old nurse remembers fetching coffee for a doctor, giving up her chair so he could sit down. The hidden curriculum of medical school is that the doctor is the decision-maker, the brain, the star. But these days, most doctors are just another member of the team. Teamwork is emphasized. Health care is thought to be a system, not something one person does to another. And so doctors have got a new title: health-care provider, a category that includes nurses and lab techs. That alone drives doctors crazy. It’s like a demotion. “I’m no health-care provider,” says one NYU doc testily, sounding like McCoy from Star Trek. “I’m a doctor.”
Along with power, doctors had autonomy. But now the insurance companies behave like supervisory adults, like scolds suggesting – implicitly, of course – that doctors can’t be entirely trusted. “You used to have a conversation with a patient and come to agreement,” recalls Breslaw. Once, for instance, doctors could prescribe as many MRIs as they felt necessary. Managed-care companies, however, now insist they have to approve such expensive tests in advance.
These days, physicians have to get on the phone and plead their case. And with whom? “Now if I need to order a scan, I need to call not a nurse, not a doctor, but an uneducated technician,” says Rubin, the Columbia gastroenterologist. Of course, no one in the industry doubts that too many unnecessary expensive tests were prescribed in the past – especially when doctors happened to own the CT or MRI scanners. What’s more, as Christine Cassel, chair of geriatrics at Mount Sinai, says, “if you look at the literature on quality of care, there were huge divergences.”
Different diseases are treated differently in different places with different results. Doctors haven’t always taken responsibility for making sure quality is up to snuff. Still, doctors’ pride hinged on a belief that the decisions they made mattered. Now, at every turn, insurance companies generate standards of care, templates that ride herd on them, as if they were unruly kids. “It is an insult, it’s infuriating,” says Rubin. “Though after a few years you stop taking it personally.”
It’s not just insurance companies that now oversee – and subtly undermine – doctors. At one time, most physicians were their own bosses, entrepreneurs who set up their own small businesses. That was part of the fun. “Now,” says Fox, who is just such an entrepreneur, “I’m a dinosaur.” There has been a vast, largely unnoticed change in the organization of the medical labor force. The solo practitioner, the one most of us grew up trusting, is nearly out of business. From now on, doctors will be employees like everyone else. Just 4 percent of new doctors in New York say they plan to open their own practices. As an employee, the doctor has a fixed retirement age and a set lunch hour – not that physicians ever take expense-account lunches. (This isn’t the business world!) As employees, a lot of physicians won’t have secretaries anymore, not their own anyhow. At Mount Sinai, specialists who once had assistants now have answering machines. Yes, there’s a receptionist, a billing department. But they work for the administration, just like the doctor. “I can’t hire or fire secretaries,” explained one specialist at Montefiore. “I have no control over staff.” Sure, you can always write up a secretary for misbehavior, but then a receptionist can write you up, too. “If we say one wrong thing, they go to the compliance office,” said one doctor who was reported for raising her voice. “Apparently, I have to be on perfect behavior.”
The world has changed on the middle-aged doctor. And, to add insult to injury, the younger generation doesn’t seem quite as upset. “We’re less insane with it,” says Stracher, 37 years old. “Our expectations are different. We didn’t know a different way.”
Making sure patients actually get better is still the responsibility of physicians, as malpractice insurers remind them. (And despite complaints, there’s scant evidence that quality of care has decreased in recent years.) Still, these days, other values besides quality guide doctors through their day. Efficiency, productivity: That’s what physicians hear. And just like factory workers at the beginning of the century, doctoring has been rationalized to increase productivity. In many practices, the system, even the building, has been redesigned to push the pace. Doctoring has been broken down into its component parts. Assistants take blood pressure. Nurse practitioners take histories. Physicians show up for the flourish, to review the treatment plan, as one puts it.
“This does not signify inferior care or second-class citizenship!” doctors Bruce Yaffe and Ronald Ruden felt obliged to alert their patients in a handout. The current system conserves the doctor’s time. And time – this is the point – is limited. Increasingly, salaried doctors get paid based on how many patients they see. Even at academic institutions, the elite centers where research and teaching have thrived, docs now have monthly quotas of patients. If they don’t make their numbers, they’re called in to explain why. “We are the new factory workers,” says one gynecologist. She may be right. “I have the feeling of being squeezed to see more patients to gain the same income,” echoes a colleague. Extraneous activities – that is, non-income-producing – are less possible these days. Those, for instance, who’d like to devote more time to research increasingly look to drug companies. “You can’t do that on the academic side anymore,” says Dr. Rajiv Patni, who recently took a job at Pfizer. Teaching, too, is valued less. “The Department of Medicine must reduce its budget,” explained a blunt letter to one Montefiore doctor, whose teaching salary was cut by a significant amount.
Maybe doctors once felt like kings of the hill. These days, a lot feel “like interchangeable parts,” as one physician-employee put it. “A businessman looks at you and sees a medical license that he is going to plug into a slot in his organization,” complained one physician. Of course, one reason employers can treat doctors this way is simple: There are too many of them. Doctors traditionally gained power by controlling supply and demand. No longer. In the past ten years, the number of docs has increased by 30 percent. (That doesn’t even include physician assistants or nurse practitioners, who sometimes run independent medical offices. “In the future your doctor may be a nurse” is the warning issued by the American Nurses Association.) And as far as demand goes, doctors have never been overly worried about bringing in new groups of patients (like the 40 million uninsured Americans).
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.