A Better Way to Practice Medicine?

Looking at the relationship between doctor and patient, and the way healthcare is delivered in our country.

Where The Measure of Our Days, Jerome Groopman’s first book, chronicles a spiritual journey, Second Opinions takes a more political view, not only of the relationship between doctor and patient, but also of the way healthcare is delivered in our country. Several of the patients described in his books have been members of health maintenance organizations (HMOs). The Boston area where Groopman lives and works is perhaps America’s HMO heartland, but as a practitioner of experimental medicine, Groopman can afford to spend much more time with patients than most doctors. “As I wrote in one story, I fully understand that I have a very unusual position,” Groopman says. He has written critically of his contacts with managed-care plans—a point he elaborated during an interview.

 

I saw a psychologist with metastatic melanoma yesterday. I spent an hour and 40 minutes with him. Part of what I talked to him about was rye bread in New York. Right? You know? Whatever! In some respects that was as important as talking about what experimental drugs might work in such a serious and complicated illness. I don’t underestimate the importance of doing that. But one of the messages of Second Opinions is that there has to be a better way [to practice medicine] than we are doing now. Because physicians are unhappy, nurses are unhappy, patients are unhappy, families are unhappy. This is not a way that we want to care for people, or that we want to be paid for.

“You can’t take this dimension of experience and have it conform to the regimen in a factory. All the policy wonks in the world, in this University and others, will tell me that I am stargazing, but it just can’t be. I would rather pay more and be cared for well. I’m not making private-practice dollars but I bet there are a lot of physicians who would say, ‘I’d rather be fulfilled and not make a football player’s salary, but really enjoy my profession and return some level of civility and art and so on to it.’ And I, as a patient, would rather pay another $20 a week, or $30 a week, not to be in a managed-care plan that is going to give me a six-minute allotment for a follow-up visit. And I would argue this to the policy wonks.

“There’s a guy I take care of who has a very rare form of blood disease, a kind of myelofibrosis. He’s a really good guy, in his late fifties. His wife died 10 years ago of lymphoma and he raised their two boys. Now one is in college; the other one is finishing high school. My patient has a girlfriend who is 48, 10 years younger. [One day] I noticed there was something di≠erent about our conversation. There was something not quite right. If I had only six minutes to see him I would have checked his hemoglobin—which again was low—and he would have been set up for another set of transfusions. I would have charted his transfusion requirement and I would assume that he fit the normal decision tree related to this bone-marrow failure state—that it’s getting worse and he needs more blood. But I just talked to him, and I felt that something was strange. So I said, ‘Is everything okay in this relationship?’ And he said, you know, ‘She is not sexually satisfied.’

“Now that’s a pretty charged remark. So I put my stethoscope to the side, and I talked to him. And he said, ‘I’ve become impotent.’ Now there are a lot of reasons to become impotent, but it turns out that in a lot of people with chronic illness, testosterone levels go down, and testosterone is a critical hormone for the production of red blood cells. So I tested his testosterone level and it was in the sub-basement. We gave him testosterone injections and—it’s unusual—but he has not been transfused in 7 months.

“Do you know how much money I have saved the managed-care plan by taking an extra 10 minutes and talking to him as a person? It’s incredible. And I feel like there’s no way that a CAT scan or a blood test would have brought me this insight—that there was something [going on] beyond the obvious, which was his bone-marrow failure state. To gain that insight required my talking to him about life, and about a somewhat tense part of life, and if he didn’t feel comfortable with me as a person and know that I was genuinely interested in his broader enjoyment and fulfillment emotionally, he wouldn’t have talked about it. So I argue sometimes, from such anecdotes, to the managed-care people that you can make important diagnoses and you can get people to ‘comply,’ meaning adhere to taking their medicines, losing weight, [doing] preventive things, [improving] general health, by just spending more time with them.”

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