As an avid reader of physicians’ memoirs, I dove into Sandeep Jauhar’s, Doctored: The Disillusionment of an American Physician, prepared for an unveiling of our dysfunctional health care system. I half expected to fall into a story about a physician who pursues his passion for practicing medicine in the face of overwhelming odds and surfaces as the victor. That isn’t what Doctored is about. It’s value lies in the author’s ability to let readers see behind the curtain of a physician’s life and pursuit of a profession that isn’t what it once was. Although not hopeful for physicians and patients alike, Doctored is a moving and well-written memoir that showcases the author’s struggle to practice medicine while confronting a number of personal and ethical challenges.
Because I’ve interviewed so many physicians for my books, The Take-Charge Patient and Critical Conditions, I understood the author’s exasperation with the time-crunch with patients, low reimbursements from health insurance, frustrations with health insurance denials, and massive amounts of paperwork. I’ve heard the same from almost all of the doctors I’ve spoken to.
As a cardiologist at a teaching hospital outside of Queens, Sandeep Jauhar struggles to earn an income to support a wife and growing family. He deals with unscrupulous doctors who over-test for profit and in the name of defensive medicine. He is a physician trying to do the right thing by his patients but at the same time earn enough money to put food on the table. Unlike many of his cohorts who take it for granted that prescribing unnecessary tests for unsuspecting patients is the only way to increase their incomes, Jauhar questions his journey as a cardiologist, challenges the idea of using patients to bilk health insurance companies.
However, Jauhar does in fact join the peccant group of physicians who compromise their integrity to make more money. What saves him from being an unlikeable narrator is his conscience, his discomfort with selling out.
Jauhar casts a dark shadow on many physicians, calling our attention to ulterior motives to boost referrals, another word for kickbacks from other doctors. He writes, “Referrals are also a way for cash-strapped doctors to generate business.” Giving an example of three physicians who all agree to call one another when an issue with a patient arises that is outside the scope of their expertise, he offers a clear picture of the dirty referral process. “It’s hard not to view a referral as an overture from another physician, and it is equally hard not to return the favor.”
Ever wonder about your doctor’s referral to a specialist? Read this book and you’ll find out information to consider.
Jauhar is certainly caught in a bind, not unlike many other doctors who go into medicine because they want to care for patients, only to discover they can’t manage financially unless they make other choices. In conflict with the business of medicine, Jauhar reveals the underbelly of the physician population. He takes on work for cardiologists who perform needless stress tests for young patients, echocardiograms, and more.
His family pressures him to socialize with other doctors in effort to snare referrals. Jauhar is judged for resisting the doctor parties that lead to financial rewards, for not wanting to use tried and true strategies for manipulating others for gain. Contrary to his integrity, he does it anyway.
Throughout Doctored we are privy to interesting patient stories to illustrate ethical challenges faced by Jauhar. There are morality tales in the cardiac wing of the hospital, in treating end-of life patients whose families want them to survive no matter what, in sending patients to specialist after specialist in effort to find an accurate diagnosis for what ails them.
Jauhar’s doubts bleed into the competency of other physicians and their ability to accurately diagnose. His own father suffered with chronic headaches. After a slew of prescribed drugs, from muscle relaxers and antidepressants to prednisone, his father then submitted to a battery of tests requiring a hospital stay. Those tests turned up very little in the way of a diagnosis. His father was seen by an array of specialists but “no one could tell him what was wrong.” Even when his father’s doctor did show up to see him in the hospital, Jauhar writes, “she spent no more than a couple of minutes with my father then rushed off.”
All of us patients can relate to that.
Jauhar’s father eventually stopped the medications on his own and after two weeks the headaches disappeared. So much for modern medicine.
When Jauhar’s wife, Sonia, was pregnant with their second child, the chief of obstetrics at Cleveland Clinic performed a fetal ultrasound. They were told the baby was a girl. That opinion turned out to be wrong. They were having a boy, a fact conveyed by a Rastafarian man on a beach in Anguilla where Jauhar and his wife had vacationed previous to the ultrasound. The significance of this portrayal is greater than one might think. It sheds light on a deeper premise in the book—that even the best doctors can be wrong, and someone with no medical training can get it right.
Jauhar laments diagnostic workup of the past and explains that diagnosis used to be based on observation and physical exam of the patient. He points out that these tools appear to be obsolete today and states that doctors are so uncomfortable with uncertainty that they rely on tests and numbers. The obvious is overlooked, not just because of physician over-confidence but because of fear of missing something that might result in being sued for malpractice.
Using his own misdiagnosis of a patient as an example of how physicians mistakenly come to erroneous conclusions, Jauhar describes a patient, an intern, who sees him for chest pain. He shows us how easily misdiagnosis comes into play by his own diagnostic error. This patient did not have pericarditis as Jauhar thought, but a heart attack. Jauhar missed it, causing the patient to suffer through the night with extreme pain. After discovering his faulty diagnosis, he even acted in ways that some doctors might when first learning of their own misdiagnoses–he initially blamed everybody else.
Jauhar writes, “Most doctors are afraid to take responsibility for medical errors.” However, he does eventually do the right thing. This is where we align with him, feel empathy toward an imperfect human being. He admits his mistake to his patient and says, “I thought you had pericarditis. I was obviously wrong. I’m sorry.”
Assuming the patient would not want to be treated by him again, Jauhar asks if he’d been given a referral to another cardiologist. The patient insisted on sticking with him as his doctor. And the point is clear that it is the apology, the relationship between doctor and patient, which increases patient loyalty and reduces potential malice when a medical error occurs.
Most patients have been treated like objects at one point or another so many will relate to Jauhar’s description of patients dismissed by doctors who just don’t care. He recounts a conversation with a nurse about the assumption that most patients are unwilling to ask questions and divulge personal information to doctors, something they do with nurses. When asked why, the nurse responded with, “Because they have a relationship with me.”
Jauhar consistently alludes to the lack of time for the doctor-patient relationship, something that is still considered a cornerstone of quality care, even the heart of care. He draws the conclusion that it is the time pressure that contributes to medical errors and the lack of physician and patient satisfaction.
Doctored isn’t a comfortable read, but a compelling one. I found myself not wanting to continue reading at times, overwhelmed by the road blocks doctors and patients face today. There were times when I felt slimed by the horror stories about deceptive physicians, wondering just how much of the same I’d been subjected to as a patient with a chronic pain condition lasting 16 months when I received 10 misdiagnoses from 11 physicians.
Jauhar does offer a few solutions to overuse of health care and to dwindling time with patients. I won’t go into all of them, but I’m happy to report that better-informed patients are one of the more potent solutions that Jauhar recommends. “If patients are more involved in medical decision-making, there would be more restraints on doctors’ behavior, thus decreasing unnecessary testing.”
Not exactly the reason I was hoping for but active participation on the part of the patient is crucial to increasing quality of care and safety.