Doctored: The Disillusionment of an American Physician - Softcover

Jauhar, Sandeep

Softcover

ISBN 10: 0374535337 ISBN 13: 9780374535339

Publisher: Farrar, Straus and Giroux, 2015

Synopsis

The New York Times Bestseller

"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." - Florence Williams, The New York Times (Science)

In his acclaimed memoir Intern, Sandeep Jauhar chronicled the formative years of his residency at a prestigious New York City hospital. "Doctored," his harrowing follow-up, observes the crisis of American medicine through the eyes of an attending cardiologist.

Hoping for the stability he needs to start a family, Jauhar accepts a position at a massive teaching hospital on the outskirts of Queens. With a decade's worth of elite medical training behind him, he is eager to settle down and reap the rewards of countless sleepless nights. Instead, he is confronted with sobering truths. Doctors' morale is low and getting lower. Blatant cronyism determines patient referrals, corporate ties distort medical decisions, and unnecessary tests are routinely performed in order to generate income. Meanwhile, a single patient in Jauhar's hospital might see fifteen specialists in one stay and still fail to receive a full picture of his actual condition.

Provoked by his unsettling experiences, Jauhar has written an introspective memoir that is also an impassioned plea for reform. With American medicine at a crossroads, "Doctored "is the important work of a writer unafraid to challenge the establishment and incite controversy.

About this title

About the Author:

Sandeep Jauhar, MD, PhD, is the director of the Heart Failure Program at Long Island Jewish Medical Center. He is the author of Intern , Doctored, and Heart: A History, and writes regularly for The New York Times. He lives with his wife and their son in New York City.

Excerpt. © Reprinted by permission. All rights reserved.:

ONE

Awakening

 

A young doctor means a new graveyard.

—German proverb

I had been pedaling furiously for nearly a decade—on a stationary bicycle. Medical school, internship, residency, and fellowship: my education seemed as if it would never end. So it was with no small measure of relief that in the late spring of 2004 I accepted a position as an attending cardiologist at Long Island Jewish Medical Center in New Hyde Park, New York. This was the last step in a long and grueling journey. After medical school I’d completed three years of hospital instruction in general internal medicine to earn the privilege to practice independently. After finishing this internship and residency, I’d elected to do a fellowship: three more years of study in cardiac diseases to further specialize. Now, with the fellowship concluded, I’d become an attending physician, the senior level of the hospital hierarchy, with ultimate responsibility for patients and junior doctors. Nineteen years after starting college and a few months shy of my thirty-sixth birthday, I finally had my first real job. The complexities of academic medical training had long since worn thin. I was ready to simplify, consolidate, and perhaps even reap some rewards for all those sleepless nights.

Cardiology was a natural career choice. I had trained as a physicist before going to medical school, and the heart, with its complex rhythms and oscillations, appealed to my predilection for patterns and logic. Heart disease was also no stranger in my family. Both my grandfathers had died of myocardial infarctions—one in his forties, ten years before I was born—so I had grown up with an awe of the heart as the executioner of men in the prime of their lives. Plus, the heart, with its symbolic meanings, had always occupied a special place in my (and the broader cultural) imagination. Take heart! Have a heart! He wears his heart on his sleeve.

Of course, I was nervous. Every new doctor should be. Cardiologists specialize in emergencies. The culture is fast-paced, pressured. I was going to have to learn to become quick and decisive in precarious situations. By nature I was slow and deliberate, and I had never felt comfortable acting on instinct—not exactly adaptive in a cardiac care unit where people can drop dead on you at any moment. In neuroscience there is the concept of the reflex arc, in which a threatening stimulus can effect a response without passing through the conscious brain—for example, when you see the taillight flash red on the car speeding in front of you and your foot automatically moves to the brake pedal. I was afraid that as a cardiologist I would now have to follow a similar reflex arc.

“Well begun is half done,” my father reminded me with his usual Aesopian wisdom. Dad possessed the annoying certitude that there were no more life lessons to be learned in this world, that whatever was worth knowing our forebears had already taught us. Traditional and moralistic, he liberally quoted proverbs and scriptures even if he didn’t always live by them. But when you think in axioms and parables, when the collective wisdom of the world can be distilled into the concentrated tonic of a few sayings, then you feel as though you have all the answers.

He had always wanted me to become a doctor—one trained at Stanford University, no less. That, he believed, would be the pinnacle of professional attainment. My family immigrated to the United States in 1977, when I was eight, to advance my father’s career as a plant geneticist, but in America my father never achieved the kind of success he felt he deserved—denied, he believed, by a racist university tenure system, which forced him to take postdoctoral positions with no long-term stability and left him embittered and in a constant state of conflict with professional colleagues. In medicine, my father explained, I would not be plagued with such insecurity.

One reason for my father’s struggles was that he always seemed to do things the wrong way. When I told him the mnemonic I had learned in school to remember the colors of the spectrum, he said: “Roy G. Biv? Oh, you mean Vibgyor!” He’d mow the lawn at night, waking the neighbors. He’d bring up controversial subjects like Sikh separatism or Kashmiri violence at low-key social gatherings. He’d trim our nails with a Gillette razor blade, twisting our fingers painfully so they wouldn’t get lacerated. As long as the nails got cut, it didn’t matter to my father how much we protested. That sort of encapsulated his personality: disciplined, unsentimental, focused solely on the task at hand.

My mother affectionately called him poottha, “awkward.” She accepted his idiosyncrasies with a kind of bemused resignation, as if they had been written in the stars. The eldest daughter of a wealthy New Delhi physician, she abided her station as the working wife of a discontented plant geneticist as though it had been ordained, just part of the deal of an arranged marriage, and she resolved to make the most of it. She didn’t believe in talk or analysis or drama, only in putting your best foot forward and grinding ahead, accepting your circumstances with dignity and grace. Yet for all her equanimity, she still regarded medicine as the hammer that would break her children out of the middle-class mold my father had set. She often told us she wanted her children to become doctors so people would stand when we walked into a room.

My apprehensions about my new job were only slightly mitigated by the fact that my older brother, Rajiv, an interventional cardiologist who performed invasive procedures, was already working at the same hospital. Rajiv was my parents’ firstborn, their pride. They had always favored him, and Rajiv demanded it, too. He knew the privileges of being the elder son in a traditional Indian family and guarded them closely, like a trust fund. Like most brothers close in age, we were fiercely competitive growing up, evenly matched at most things (Ping-Pong, chess, tennis), our rivalrous parity enforced by the unspoken fear that if one of us pulled away, we’d lose the other’s companionship. One sphere in which we were undoubtedly unequal was social relationships, however. Rajiv had the kind of gregarious and easygoing personality that I had always desired but somehow never could develop. The only time we had worked together professionally was during my internship at New York Hospital in Manhattan, where as a star senior cardiology fellow he unwittingly reminded me of my incompetence again and again. Toward the end of my own cardiology fellowship at NYU, he had invited me to apply to LIJ and had used his considerable influence to get me a job. Now he was in a position to guide me through another, perhaps more challenging apprenticeship.

At Long Island Jewish I would work as a cardiologist with a specialization in congestive heart failure. This was no small task: heart failure is the common final pathway for a host of cardiac diseases, including heart attacks, acute valve disorders, viral infections of the cardiac muscle, etc. There are many challenges in caring for these patients. They have multiple comorbid illnesses, such as diabetes and emphysema. Their symptoms—for instance, shortness of breath—are often nonspecific. They frequently have poor health literacy or cognitive impairment or are socially isolated because of their chronic disease. Despite these difficulties, I chose to specialize in heart failure because I wanted to develop close relationships with critically ill patients and provide long-term care, unlike my brother, who almost exclusively performs procedures and knows his patients mostly for the duration of an operation. I also wanted to be in a specialty where I would not have to perform surgical interventions. I’d never been especially good with my hands. Growing up, Rajiv had been the tinkerer and I had been the thinker. Of course, I knew this decision was going to involve a certain degree of monetary sacrifice. Heart failure is a money loser for most hospitals, which make most of their revenue from lucrative procedures like stents (wire mesh cylinders used to open blockages in the coronary arteries that feed the heart) and pacemakers, or hip replacements. In the American system doctors are paid much less for exercising their judgment than their fingers.

*   *   *

Dawn in July, a few weeks after starting my new job. Sirens puncture the early-morning stillness. I open my eyes. Twilight leaks through the window blinds, dissolving the gloom into tiny grains of black. I remain motionless, savoring the void. My wife, Sonia, is still sleeping—sleeping for two. I peer at the hazy sonogram framed on the windowsill. It is faded from the sunlight that beats on it daily, betraying nothing of the complications of the past few months.

I get up quietly and tiptoe to the bathroom. In the mirror I notice I’ve developed a touch of gray. A bracing splash, some bloody nicks, a suitable tie, and I am outside. It is a bright day, nearly cloudless, the skyline marred only by the steam drizzling out of a tower in the distance. I pull out of my building and drive north, past empty playgrounds and cracked brownstones and apartment complexes stacked like Lego blocks. Street sweepers are out in force, ravenously whirling over the grime and debris. I turn onto the FDR Drive. A few joggers are out on that lonely stretch of waterfront. A couple of miles on, I enter the blue-green expanse of the Triborough Bridge. Pigeons flutter off the ramparts. Across the shimmering East River, skyscrapers in Midtown are arrayed like an irregular bed of nails. I press on the gas pedal. The brilliant day is pulling me forward.

I was asked during job interviews how I planned to create a heart failure program. I replied that if you provided good care and vigilant monitoring and were responsive to patients’ needs, community physicians would refer their patients. I had no idea if this was actually true; but it sounded good, and I got the job. I promised to decrease lengths of stay, improve hospital performance measures, improve the discharge process, decrease readmissions, install a computerized database, enroll patients in clinical trials, write emergency room protocols, and start an intravenous infusion clinic. Eventually I wanted to hire a nurse practitioner, a dietitian, a social worker, and a physical therapist. But I had accomplished none of these things as I drove to work that July morning.

It was a few minutes past seven-thirty when I arrived at the hospital, and I was late for morning report. I pulled into the attending physicians’ lot and parked between two cars whose license plates read “BEAN DOC” and “GAS MD.” At the sliding glass doors leading into the lobby, two patients in teal hospital gowns were leaning on their IV poles, sucking hungrily on cigarettes. I skipped down a concrete stairwell to the basement. The corridors were deserted, save for a tardy first-year fellow racing ahead of me.

When I walked into the conference room, a fellow was presenting a case from overnight. About a dozen fellows and a half-dozen faculty members were there. The fellows rotated each month through the various cardiac subspecialties: electrophysiology (which focuses on arrhythmias, or heart rhythm disturbances), echocardiography (cardiac ultrasound), nuclear stress testing (which uses radioactive tracers to noninvasively detect coronary disease in hearts under stress from exercise or certain drugs), cardiac catheterization (Rajiv’s specialty), heart failure, the general consultative service, and the cardiac care unit (where the most critically ill patients of any subspecialty usually ended up). As faculty members we were responsible for teaching the fellows: scrubbing in with them on procedures, going on rounds with them, and instructing them over discussions at morning report or noon seminar. In the conference room, Rajiv and two of his interventional colleagues were sitting together, arms folded, legs crossed, in purple scrubs, like some sort of academic tribunal. My brother looked at me sharply, glanced at a phantom wristwatch, and winked. I quietly took a seat in the back.

The fellow was trying to explain his management of a critically ill patient the previous night. “The patient’s pulmonary artery saturation was in the mid-forties, so I ended up putting him on some dobutamine and gave him a little fluid back,” the fellow said. “He started putting out some urine, and his blood pressure went up. Over the next twelve hours, his oxygenation improved dramatically.”

Dr. Morrison, one of the interventional cardiologists, demanded to know why the fellow had given the patient intravenous fluid.

“At that point his central venous pressure was two,” the fellow said defensively, describing a state of dehydration. “His pulmonary artery diastolic pressure was six, and his wedge pressure was like eight.”

“And you’re sure the transducer was zeroed and level?” Morrison pressed him. “We see this a lot with the residents. They look up at the monitor and quote a pressure, but it’s just garbage.”

The fellow hesitated. “When we first put in the catheter, the wedge pressure was in the thirties—”

“Well, see, that’s what I’m saying,” Morrison interjected, as if the fellow had just made his point. “This guy wasn’t dehydrated! He was in florid heart failure. This is a textbook case of acute heart failure, from the frothy sputum to the missed myocardial infarction.”

“Anyway, good case,” the chief fellow said, trying to move things along.

“What this patient really needs is a doctor,” Dr. Morrison added caustically.

“As opposed to a plumber like us?” Rajiv shot back, coming to the fellow’s defense.

“Exactly,” Morrison replied, laughing. (Interventional cardiologists who relieve coronary obstructions with stents are often disparagingly referred to as plumbers.)

Looking around the room, I reminded myself how lucky I was to be working at a teaching hospital where residents and fellows would be making rounds on my patients and assisting me on cases. LIJ is one of the largest teaching facilities on Long Island, sitting on fifty acres on the Queens–Long Island border, housing nearly eight hundred beds, and employing seven hundred physicians on its full-time faculty. The evidence shows that patients treated for several common medical disorders, including heart failure, heart attack, and stroke, fare better at major teaching hospitals and have better overall survival. One reason may simply be redundancy: residents and fellows may be annoying when you’re reciting the details of your fainting episode for the third time in the middle of the night—“So tell me, did you pass out before or after you hit the floor?”—but so many pairs of eyes on each patient mean things don’t get overlooked. Eighty percent of medical diagnoses can probably be made on the basis of a patient’s history, and the more people asking, the more likely doctors are to get it right. Another factor is the sheer number of patients treated at the average teaching hospital. Patient mortality tends to drop as doctors get more experience. Would you rather have angioplasty performed by a cardiologist who does two hundred a year—or twenty?

Though I’d been hired to start a heart failure program, I’d been informed that for the first year or so I’d also be assuming frequent responsibility for the cardiac care unit (CCU), where I’d be treating not only patients with heart failure but also those with other, more general cardiac problems (myocardial infarctions, arrhythmias, etc.) to help me build up my practice. So after morning report, I headed up to the CCU, where I was substituting for Dr. Vaccaro, the director, who wa...

About this edition

• Publisher: Farrar, Straus and Giroux
• Publication date: 2015
• ISBN 10: 0374535337
• ISBN 13: 9780374535339
• Binding: Paperback
• Number of pages: 288