In ‘Doctored,’ Shortcomings of Health Care and Doctor
Sandeep Jauhar’s new memoir, “Doctored: The Disillusionment of an American Physician,” tells the story of two midlife crises: the author’s own, and that of modern American medicine, now in about its fourth decade under managed care. Both prove to be frustratingly intransigent, with only small signs of hope.
Dr. Jauhar has traveled the paths of personal and professional angst before, in his 2007 medical memoir, “Intern: A Doctor’s Initiation,” which recounts his trying first year of residency at New York Hospital in Manhattan. In that book, he wrote: “For me, it was a disillusioning time; I spent much of it in a state of crisis and doubt.”
Life as a full-fledged physician doesn’t become much better, at least not for Dr. Jauhar, who takes his first job at Long Island Jewish Medical Center and becomes the director of its heart failure program. (He is also an occasional contributor to The New York Times.) Full of ideals about saving lives and providing compassionate, ethical care, he finds himself underpaid, overworked and pressured to cut corners in every direction.
In this, we gather, he is not alone. “Doctored” describes a profession that is like so many of its patients: full of malaise and desperation. Doctors are reported to commit suicide at a higher rate than other professionals, and Dr. Jauhar cites a 2008 survey in which only 6 percent of 12,000 physicians rated their morale as positive.
Then again, Dr. Jauhar is constitutionally dissatisfied. Just ask his father, who says of his wife, the author’s mother, “Like you, she is not a happy person.” (Some of the best scenes feature the father, who comes across as comically histrionic, neurotic and self-absorbed. “If you lose your job,” he tells his son, “we are finished. I will be the first to have a heart attack!” And then he tosses in: “And make some friends, Sandeep. You have no friends.”) Then Dr. Jauhar has his wife to contend with. Also a doctor, she keeps putting off her own job to stay home with their toddler, while telling her husband to bring home more money. “Money doesn’t buy happiness,” he counters. “Yes it does!” she replies.
The author is sometimes operatic in his complaints. Worried about his mounting pressures, he writes, “My obligations were like the concrete embankments along the expressway, preventing me from getting off.” He tries yoga, psychiatry, jogging in the rain. He describes his stomach troubles, his sleeplessness, his bad moods.
To relieve the money stress, he does something he dreaded and hoped to avoid: He moonlights on weekends and evenings for a private cardiology practice. It’s in these Faustian passages on the commerce of medicine that the memoir becomes an extraordinary, brave and even shocking document. Dr. Jauhar’s sharply observed anxieties make him a compelling writer and an astute critic of the wasteful, mercenary, cronyistic and often corrupt practice of medicine today.
He is brutally honest, not just about his own shortcomings, but about those of colleagues, bosses and institutions. There is the cardiologist who pressures him to perform expensive, unneeded diagnostic tests; the hospital, which wants him to see patients for ever-shorter sessions; the pharmaceutical company that pays him on the side to give “lectures” but will let him use only its slides and data.
Dr. Jauhar sees a 74-year-old patient who has been referred to the hospital for heart-valve surgery. He recommends against the operation because she is frail, her symptoms are managed by medicine, and the surgery is risky. But he is told to approve it anyway so he doesn’t insult the referring physician. “If you mess up relations with a referer,” his mentor says, “you can get fired.”
If things are broken in the world of managed care, there’s plenty of blame to go around. The insurance companies have taken away doctors’ autonomy. The fee-for-service model leads to overtesting, disorganization and redundancy. The fee incentives and a culture of liability lead to what Dr. Jauhar calls “wanton consultation.” As Alexander the Great once put it, “I am dying from the treatment of too many physicians.”
But it’s not just the system, Dr. Jauhar writes. Many of the doctors themselves are greedy, defensive and untrustworthy — including, at times, himself.
Of his collusion in ordering unnecessary nuclear stress tests, he writes: “Of course, good intentions didn’t exonerate me. Even beyond the wasted money, what about the false positives, the radiation exposure, the downstream invasive procedures?”
He added, “I used to despise the unethical behavior of doctors in private practice, but in reality, I was no better than they were.”
In trying to appease his wife, he ends up hating himself. Although it seems to take him a painfully long time, he finally figures out they can reduce household expenses by moving out of Manhattan. Focusing on just one job, he can strive to be the kind of doctor he hoped to be. And that means the kind of doctor who not just treats patients but cares for them.
Caring for people is why most doctors go into medicine in the first place. Dr. Jauhar’s greatest joy comes from these small day-to-day exchanges, even if his time with patients is short and increasingly circumscribed. Yet in the profession as a whole, the trust that patients place in their doctors has never been more at risk.
Perhaps the solution to both midlife crises is “doctors focusing on the their noble craft, their relationships with patients, the stuff over which we have some control.”
“Ultimately,” he concludes, “this may be the best hope for our professional salvation.”