Few Places Have More Medical Debt Than Dallas-Fort Worth, but Hospitals There Are Thriving
by Noam Levey - Kaiser Health News - September 28, 2022
PROSPER, Texas — Almost everything about the opening of the 2019 Prosper High School Eagles’ football season was big.
The game in this Dallas-Fort Worth suburb began with fireworks and a four-airplane flyover. A trained eagle soared over the field. And some 12,000 fans filled the team’s new stadium, a $53 million colossus with the largest video screen of any high school venue in Texas. Atop the stadium was also a big name: Children’s Health.
Business has been good for the billion-dollar pediatric hospital system, which agreed to pay $2.5 million to put its name on the Prosper stadium. Other Dallas-Fort Worth medical systems have also thrived. Though exempt from taxes as nonprofit institutions, several, including Children’s, notched double-digit margins in recent years, outperforming many of the area’s Fortune 500 companies.
But patients aren’t sharing in the good times. Of the nation’s 20 most populous counties, none has a higher concentration of medical debt than Tarrant County, home to Fort Worth. Second is Dallas County, credit bureau data shows.
The mismatched fortunes of hospitals and their patients reach well beyond this corner of Texas. Nationwide, many hospitals have grown wealthy, spending lavishly on advertising, team sponsorships, and even spas, while patients are squeezed by skyrocketing medical prices and rising deductibles.
A KHN review of hospital finances in the country’s 306 hospital markets found that several of the most profitable markets also have some of the highest levels of patient debt.
Overall, about a third of the 100 million adults in the U.S. with health care debt owe money for a hospitalization, according to a poll conducted by KFF for this project. Close to half of those owe at least $5,000. About a quarter owe $10,000 or more.
Many are pursued by collectors when they can’t pay their bills or hospitals sell the debt.
“The fact is, if you walk into a hospital today, chances are you are going to walk out with debt, even if you have insurance,” said Allison Sesso, chief executive of RIP Medical Debt, a nonprofit that buys debt from hospitals and debt collectors so patients won’t have to pay it.
Community Shadowed by Debt
Across the Dallas-Fort Worth metro area — the nation’s fourth-largest — the impact has been devastating.
“Medical debt is forcing people here to make incredibly agonizing choices,” said Toby Savitz, programs director at Pathfinders, a Fort Worth nonprofit that assists people with credit problems. Savitz estimated that at least half their clients have medical debt. Many are scrimping on food, neglecting rent, even ending up homeless, she said, “and this is not just low-income people.”
David Zipprich, a Fort Worth businessman and grandfather, was forced out of retirement after hospitalizations left him owing more than $200,000.
Zipprich, 64, had spent a career in financial consulting. He owned a small bungalow in a historical neighborhood near the Fort Worth rail yards. His daughters, both teachers, and his four grandchildren lived nearby. He had health insurance and some savings, and he’d paid off his mortgage.
Then in early 2020, Zipprich landed in the hospital. While driving, his blood sugar dropped precipitously, causing him to black out and crash his car.
Three months later, after he was diagnosed with diabetes, another complication led to another hospitalization. In December 2020, covid-19 put him there yet again. “I look back at that year and feel lucky I even survived,” Zipprich said.
But even with insurance, Zipprich was inundated with debt notices and calls from collectors. His credit score plummeted below 600, and he had to refinance his home. “My stress was off the charts,” he said, sitting in his neatly kept living room with his Shih Tzu, Murphy.
Overall in Tarrant County, 27% of residents with credit reports have medical debt on their records, credit bureau data analyzed by KHN and the nonprofit Urban Institute shows. In Dallas County, it’s 22.5%.
That’s more than five times the rate in the largest counties in New York, data shows. The Texans also owe a lot more — the median amount of medical debt on credit records in Tarrant and Dallas counties is nearly $1,000, compared with $400 or less in New York.
Last year, Zipprich returned to work, taking a job in New Jersey that required he commute back and forth to Texas. He recently quit, citing the strain of so much travel. He’s now job hunting again. “I never thought this would happen to me,” he said.
Who Is Responsible?
Even small debts can have potentially dangerous consequences, discouraging patients from seeking needed care. Angie Johnson, a 28-year-old schoolteacher, cut short her honeymoon so she and her husband could pay off more than $1,100 she owed a physical therapy center owned by Baylor Scott & White, a mammoth Dallas-based hospital system.
Johnson said the center, where she’d gone after a knee injury, initially said her visits would cost $60. “Then they billed me hundreds,” she said. “I don’t go to the doctor unless I absolutely have to because it’s so expensive.”
Who Is Responsible?
Even small debts can have potentially dangerous consequences, discouraging patients from seeking needed care. Angie Johnson, a 28-year-old schoolteacher, cut short her honeymoon so she and her husband could pay off more than $1,100 she owed a physical therapy center owned by Baylor Scott & White, a mammoth Dallas-based hospital system.
Johnson said the center, where she’d gone after a knee injury, initially said her visits would cost $60. “Then they billed me hundreds,” she said. “I don’t go to the doctor unless I absolutely have to because it’s so expensive.”
Angie Johnson of Waxahachie, Texas, cut short her honeymoon so that she and her husband could pay off more than $1,100 she owed a physical therapy center owned by a Dallas-based hospital system. (Laura Buckman for KHN and NPR)
Hospital industry leaders blame the patient debt on health insurers, citing the rise of high-deductible plans and other efforts that limit coverage. “The last thing that hospitals want is for their patients to face financial barriers,” said Molly Smith who leads public policy at the American Hospital Association. “Hospitals are in there trying to work on behalf of patients.”
Despite repeated requests from KHN, none of the medical systems around Dallas-Fort Worth would discuss their finances or the debt carried by patients.
But Smith and other hospital leaders point to billions of dollars of free or discounted care that hospitals nationwide provide every year. “Hospitals have been pretty darn generous,” said Stephen Love, president of the Dallas-Fort Worth Hospital Council. “If other parts of the community did as much as hospitals, we wouldn’t be in this problem.”
Unlike drug companies, device makers, and many physician practices, most U.S. hospitals are nonprofit and must provide charity care as a condition of their tax-exempt status.
Regardless of tax status, medical centers in markets with high medical debt do provide more charity care, according to an analysis by KHN and the Urban Institute, a Washington think tank. That’s important, said Dr. Vikas Saini, president of the Lown Institute, a nonprofit that grades hospitals on their quality and community benefits. But he asked: “Is a hospital truly serving its community if it’s pushing so many into debt?”
Around Dallas-Fort Worth, major medical systems frequently tout their commitment to the region and its patients.
When Texas Health Resources, a Dallas-based nonprofit system with more than $5 billion in annual revenue, opened a new hospital tower in Fort Worth earlier this year, Barclay Berdan, the system’s chief executive, said the building “reinforces Texas Health’s long-standing commitment to the Fort Worth community.” The nine-story, $300 million tower is one of more than a half-dozen new hospitals and major expansions around the Dallas-Fort Worth area since 2018.
The big building spree has been accompanied by big bottom lines.
From 2018 to 2021, Texas Health, which owns hospitals in North Texas, had an average operating margin of almost 6%, according to a KHN analysis of publicly available financial reports.
Other major systems in the area, including Baylor, Children’s Health, and HCA, the nation’s largest for-profit hospital company, did even better, KHN found. Cook Children’s, the region’s second major pediatric system, had an average operating margin of nearly 12%.
By comparison, profits at most of the 25 Fortune 500 companies based around Dallas-Fort Worth, such as ExxonMobil, were less than 6% in 2019, according to Fortune data.
Approaching a Tipping Point
Hospitals have thrived in other markets with high patient debt, KHN found.
In Charlotte, North Carolina, where a quarter of residents have medical debt on their credit reports, hospitals recorded an average operating margin of 13.6% from 2017 to 2019.
The average margin at hospitals in and around Gainesville and Lakeland, two central Florida markets where a quarter of residents also carry medical debt, topped 9%. In Tulsa, Oklahoma, which has the same level of debt, margins have averaged 8.5%.
Overall, U.S. hospitals recorded their most profitable year on record in 2019, with an aggregate operating margin of 6.5%, according to the federal Medicare Payment Advisory Commission. Total margins, which include income from investments, were even higher.
“You might think that hospitals in communities where patients have a lot of debt would be less profitable, but that doesn’t seem to be the case,” said Anuj Gangopadhyaya, a senior Urban Institute researcher who worked with KHN on an analysis of hospital finance and consumer debt data in U.S. hospital markets.
In fact, the analysis found, there is no apparent relationship between the profits of hospitals in a market and how much medical debt residents have. So while hospitals in places like Charlotte and Tulsa may be comfortably in the black, in other places with high patient debt such as Amarillo, Texas, and Columbia, South Carolina, hospitals are struggling, data shows.
Industry experts say the most profitable medical centers — like those around Dallas-Fort Worth — have developed business models that allow them to prosper even if their patients can’t pay.
One key is prices. These hospitals maximize what they charge for everything from a complex surgery to a dose of aspirin. Most of those charges are picked up by health insurers, which still pay a much larger share of hospital bills than patients do, even those with the highest deductibles.
Across the country, many medical systems have strengthened their market power in recent years by consolidating, buying up smaller hospitals and physician practices, which enables the hospital systems to charge even more.
Dallas-Fort Worth has the highest medical prices in Texas, according to the Health Care Cost Institute, a nonprofit that tracks costs nationwide. And in a state where most markets have relatively low medical prices, in-patient care at Dallas-Fort Worth hospitals was 13% more expensive than the national median in 2020.
In addition to charging more, the most profitable hospitals frequently squeeze more savings from their operations, holding down what they pay workers, for example, and securing better contracts from suppliers. “Hospitals have had to get leaner and meaner,” said Kevin Holloran, a senior director at Fitch Ratings who tracks nonprofit health systems for the bond rating firm.
It’s unclear how much longer this business model can endure.
Across the country, many small and rural hospitals have closed in recent years. Even some larger systems are now losing money, as inflation and rising labor costs put new pressure on bottom lines.
As bills rise, hospitals are having a harder time collecting. Last year, nearly 1 in 5 patient bills generated by hospitals for people with insurance topped $7,500, according to an analysis of hospital billing records by Crowe LLP, a Chicago-based accounting and consulting firm. That was more than triple the rate in 2018.
“These are bills that fewer and fewer patients out there can afford,” said Brian Sanderson, a senior Crowe health care consultant and former hospital executive. Indeed, hospitals manage to collect less than 17% of patient balances that exceed $7,500, according to Crowe’s analysis.
“The rates at which patient balances are growing is just unsustainable for our health systems,” Sanderson said, predicting that most will never be able to collect bills of this size. “It’s trending to the ridiculous.”
Robert Earley, a former Texas state legislator who used to head Fort Worth’s public health system, compared today’s hospitals to shrimpers in the Gulf Coast district he once represented.
“They wanted to pull so much shrimp out of the bay that they didn’t think about whether there’d be any there long term,” Earley said, recalling his constituents’ struggles. “I worry that those of us in health care aren’t asking ourselves enough if this system is sustainable.”
To explore connections between hospital profits and patient debt, KHN and the Urban Institute examined data from each of the nation’s 306 hospital markets, also known as hospital referral regions.
Researchers calculated medical debt in each hospital referral region using 2019 credit bureau data maintained by the Urban Institute. They then compared the debt load in each market to the average operating margin for hospitals in that market over three years from 2017 to 2019, weighting each hospital’s margin by the number of adjusted admissions.
The margins data comes from hospital cost reports that hospitals file annually with the federal Centers for Medicare & Medicaid Services. These reports are aggregated by the nonprofit Rand Corp., which supplied the data to KHN and the Urban Institute.
As Hospitals Close Children’s Units, Where Does That Leave Lachlan?
Adult beds are more lucrative than children’s beds. So as institutions look to boost profit margins, pediatrics is often among the first services to be cut.
by Emily Baumgaertner - NYT - October 11, 2022
Adult beds are more lucrative than children’s beds. So as institutions look to boost profit margins, pediatrics is often among the first services to be cut.
BROKEN ARROW, Okla. — It was Lachlan Rutledge’s sixth birthday, but as he mustered a laborious breath and blew out one candle, it was his mother who made a wish: for a pediatric hospital bed in northeast Oklahoma.
The kindergartner has a connective tissue disorder, severe allergies and asthma. Those conditions repeatedly landed him in the pediatric intensive care unit at Ascension St. John Medical Center in Tulsa, with collapsed veins and oxygen levels so low, he was unresponsive to his mother’s voice.
But in April the hospital closed its children’s floor to make room for more adult beds. So on a September morning, after coming down with Covid for the fourth time and with what looked like bilateral pneumonia, Lachlan was struggling to breathe in an overcrowded emergency room at the Children’s Hospital at Saint Francis — the only remaining inpatient pediatric option in Tulsa.
“We’re always preparing for battle. It’s just a question of where we’re going to fight,” said his mother, Aurora Rutledge, looking frightened as she twisted the blond ringlets that poked out from under Lachlan’s Spider-Man headphones.
Hospitals around the country, from regional medical centers to smaller local facilities are closing down pediatric units. The reason is stark economics: Institutions make more money from adult patients.
In April, Henrico Doctors’ Hospital in Richmond, Va., ended its pediatric inpatient services. In July, Tufts Children’s Hospital in Boston followed suit. Shriners Children’s New England said it will close its inpatient unit by the end of the year. Pediatric units in Colorado Springs, Raleigh, N.C., and Doylestown, Pa., have closed as well.
“They’re asking: Should we take care of kids we don’t make any money off of, or use the bed for an adult who needs a bunch of expensive tests?” said Dr. Daniel Rauch, chief of pediatric hospital medicine for Tufts Medicine, who headed its general pediatric unit until it closed over the summer. “If you’re a hospital, that’s a no-brainer.”
Many hospitals have converted children’s beds to adult I.C.U. beds during the pandemic and are reluctant to change them back. Now, staff shortages, inflation — drug costs have increased 37 percent per patient compared to prepandemic levels — low Medicaid reimbursement and dwindling federal subsidies granted during the pandemic have left some health centers operating on negative margins and eager to prioritize the most profitable patients.
Young patients like Lachlan, who has private insurance, occupy beds to recover from infections or asthma attacks but don’t undergo lucrative, billable procedures — like joint or heart surgeries — that are more common among aging patients.
Physician reimbursement through Medicaid, the insurance program for low-income people, is often only about 70 percent of the amount reimbursed through Medicare, the insurance program for elderly people of all incomes. More than a third of children in the United States are enrolled in Medicaid.
There have been no aggressive legislative efforts to keep hospitals from closing or shrinking their pediatric units. Democratic senators introduced a bill last year to grant funding to specialized children’s hospitals to improve their infrastructure, but it has not moved past the assigned committee.
Health policy experts say an important solution would be to encourage hospitals to care for children by increasing Medicaid reimbursement rates. But even higher Medicaid and private rates wouldn’t come close to what hospitals can charge for remunerative adult procedures, and with many state budgets already strained, experts say the regulatory move is unrealistic.
Hospitals that no longer admit children rely on transferring them to pediatric units at other hospitals. But when even the largest pediatric floors in the country are at capacity, the pileup of critically ill children in E.R.s can cause patients’ conditions to worsen.
An E.R. crush
“Picu kids don’t belong here,” an overwhelmed E.R. doctor in a small Boston area hospital wrote two weeks ago to his hospital’s chief medical officer in an expletive-ridden text message reviewed by The Times. (P.I.C.U. is the acronym for pediatric I.C.U. The text message was shared on the condition that the hospital not be identified.)
Every I.C.U. for children in Boston was full at the time, and the nearest open beds were in New Haven, Conn., and Vermont. The doctor who sent the text message considered intubating the child in the E.R. while he waited for a closer bed to become available.
As children return to school, waves of illnesses are overrunning many of the units that remain.
“Forget the two-week January crush. We couldn’t find beds in May or August or September,” said Dr. Melissa Mauro-Small, the chief of pediatrics at Signature Healthcare Brockton Hospital, near Boston. “There is no more respiratory season. It’s respiratory season year-round.”
A hospital in Plymouth, Mass., that had not transferred a patient to Dr. Mauro-Small’s hospital in a decade did so six times in 10 days recently, she said. The E.R. staff at Lowell General Hospital outside Boston had to ask eight hospitals across New England whether they had room for an intubated 2-year-old, according to patient charts reviewed by The Times. It transferred another patient to the closest I.C.U. bed available — in Maine.
“At some point, this was going to become a crisis,” Dr. Mauro-Small said. “And here we are.”
St. John Medical Center in Tulsa had been a community treasure for almost a century when Ascension acquired it in 2013. The closure of the pediatric unit triggered opposition from both families and referring pediatricians.
Dr. Michael Stratton, a pediatrician in Muskogee, Okla., said Ascension St. John had been “the number one place to send a child,” and its pediatric unit closure had been “such a huge disservice to all of eastern Oklahoma.”
A spokeswoman for Ascension St. John, where Lachlan had been admitted to the I.C.U. three times before the closure, declined to be interviewed but said in an email that the closure was driven by a demand for more adult beds. She also pointed to past statements that said the Children’s Hospital at Saint Francis was “more than capable of picking up the slack.”
A spokeswoman for the Children’s Hospital at Saint Francis said that it had occasionally reached full capacity and that the staff transferred about 23 patients to other facilities, including in Arkansas, so far this year.
The E.R. “was busy even prior to the closure of the St. John’s pediatric unit,” she said. Still, she said the hospital had not become overburdened. “Volume is fairly consistent with what we usually see on a seasonal basis,” she said.
Some Oklahoman families with chronically ill children say they routinely drive to Memphis, St. Louis and Rochester, Minn., for care. The distances cause financial strain and, in the worst cases, cause them to forgo care, said Katy Kozhimannil, director of the University of Minnesota Rural Health Research Center.
For those in rural communities, pediatric closures have made travel to what Dr. Rauch calls “bread-and-butter pediatrics” untenable. Sixteen-year-old Johnny in Childress, Texas, had to be home-schooled so he could travel eight hours to Dallas for dialysis treatment three times a week, according to his doctor.
Jamaal Bets His Medicine, a 2-year-old with an autoimmune disease in Fort Kipp, Mont., routinely takes an 11-hour trip to Billings, Mont., to receive infusions, his mother, Patricia, said.
‘Children are not small adults’
The decline of local access to children’s inpatient care began over a decade ago and accelerated during the pandemic. Between 2008 and 2018 — the most recent national data available — pediatric inpatient units in the United States decreased almost 20 percent, and nearly a quarter of children found themselves farther from their nearest pediatric unit.
The steepest decline in pediatric inpatient beds was in rural regions, where large health systems acquired community hospitals and consolidated pediatrics to one campus.
Centering pediatric care in specialized centers can erode a local hospital’s ability to care for a critically ill child, doctors say.
“Children are not small adults,” said Dr. Meredith Volle, a pediatrician at Southern Illinois University School of Medicine in Springfield, Ill., who routinely sees patients who travel from two to three hours away. The number of pediatric beds in Illinois has declined, and 48 of its counties now have no pediatrician at all.
“When nurses and respiratory therapists become less comfortable with children’s cases, when the units don’t have child-sized equipment,” Dr. Volle said, “at a certain point, you really shouldn’t treat kids anymore because you don’t treat them often enough to be good at it.”
Critically ill children are four times as likely to die in hospitals and twice as likely to die in trauma centers that scored low on a “pediatric readiness” test, according to research. Only one-third of children in a national research survey had access to an emergency department deemed highly “pediatric-ready,” and of those, nine out of 10 lived closer to a less-prepared one.
A parent who is unaware of the wide variability, said Dr. Katherine Remick, the executive director of the National Pediatric Readiness Quality Initiative, “could make a split-second decision that changes their child’s fate.”
Lachlan’s life
The Rutledge family lives in Broken Arrow, a sunny Tulsa suburb with a frozen custard shop and a dentistry called Super Smiles. Their front porch is home to potted succulents, an abandoned scooter and a 140-pound Great Dane named Thor.
But their lives are far from ordinary. The last time Lachlan needed to see an allergy specialist, his mother packed the car with his nebulizer and medications for a 14-hour drive to Denver, leaving her husband, their two other sons and her mother, who was undergoing chemotherapy, for two weeks. Later, when doctors told her that Lachlan’s disorder appeared to be causing stomach ulcers — but that the sole pediatric gastroenterologist at Saint Francis wasn’t available for months — she began planning a journey to Dallas.
On the September morning that Lachlan was in St. Francis struggling to breathe, the E.R. was so busy that Ms. Rutledge hooked him up to a pulse oximeter herself, quieting the monitor’s settings so it wouldn’t frighten him every time his heart rate spiked.
Lachlan tugged at his collar bone, his chest looking retracted. Five hours later, he still hadn’t been admitted. Ms. Rutledge’s hands trembled and tears streamed down her face.
“I know you guys are exhausted at this hospital, and I get it,” she shouted, leaning over Lachlan’s bed to level her eyes with the attending physician on the other side. “But you will not send this child home so he can watch his own vitals drop.”
Lachlan was discharged from the E.R. after 10 hours with a course of steroids to fight the inflammation in his lungs. He sleeps in his parents’ bedroom so they can check his oxygen levels and administer nebulizer treatments every few hours throughout the night.
https://www.blogger.com/blog/post/edit/3936036848977011940/7450453546278410190
A Crisis of Burnout Among Doctors
To the Editor:
Re “New Survey Suggests an Alarming Increase in Physician Burnout” (news article, Sept. 30):
There is a crisis brewing within the health care industry. More than half the physicians in this country suffer from burnout, and roughly 300 to 400 die by suicide each year. Common causes of burnout include increased administrative tasks, long hours, frustration with the electronic health records system and insufficient compensation.
Interestingly, the burnout rate among independent physicians in New York City, at 13.5 percent, is dramatically lower than the national average of 54.4 percent.
However, there has been a significant decline in independent physicians because of the policies put in place by the Affordable Care Act that favor larger corporations and hospitals. As a result, independent medical practices are increasingly being acquired by hospitals and large corporations, which tend to put profits before patients and exercise absolute control.
While there’s little growth in the number of physicians entering the work force, there has been a more than 3,000 percent increase in health care administrators over the last four decades. Unless the increasing power of hospital and practice administrators is curtailed, the situation will only get worse.
Congress needs to act now.
Bhupendra O. KhatriMilwaukee
The writer is a neurologist and the author of “Healthcare 911: How America’s Broken Healthcare System Is Driving Doctors to Despair, Depriving Patients of Care, and Destroying Our Reputation in the World.”
https://www.nytimes.com/2022/10/17/opinion/letters/doctors-mental-health.html
Lessons From a ‘Difficult Patient’
Sal was the kind of patient that doctors strive to avoid. But for one medical student, he provided an education in compassion.
Sal was 58 when I was assigned his case. Sal had been diagnosed with cystic fibrosis in the 1960s and was considered an old survivor; all his friends who had been diagnosed at the same time, including his younger brother, were dead.
I was 21, a few weeks out of college and one of the youngest students in my medical school class. Our assignment, to follow patients with chronic diseases to their clinic appointments, felt like a formality to my classmates whose parents were doctors and who already knew what went on in hospitals. But for me it was eye-opening.
On the day of our first appointment, I stood waiting for Sal on the freshly buffed floor of our hospital’s clinic lobby, fidgeting with my white coat and trying to hold my clipboard in a way that looked natural. The morning wave of physicians and researchers speed-walked past me to the elevators, coffee or cellphone in hand, eyebrows furrowed.
After 30 minutes passed with no sign of Sal, I called his cellphone. He wouldn’t be coming for his appointment today, he said, and would have to call back; he was on a call with the clinic receptionist, giving her a piece of his mind. Before I could respond, he hung up.
I looked up and saw, three cubicles away, a receptionist on the phone. She was red in the face; she kept starting to speak and then stopping, as if being interrupted. Eventually she hung up, sighed and walked over to a neighboring receptionist, gesturing back at her phone.
My phone buzzed in my pocket: Sal. This week was terrible, he said, because he had caught a cold. It was no use blowing a whole afternoon by going to a routine checkup. It was a waste of time, he said — time he didn’t have.
In the body shop
As we talked, I learned that colds are a major concern for people with cystic fibrosis; for many it is the cause of death. “I’m stressed out,” Sal said, adding an expletive. I asked if instead of trying to ride this out himself, he might let a doctor help him. He was reluctant but eventually agreed to come to the clinic. But when I asked to squeeze Sal into the afternoon schedule, the receptionist looked incredulous: Was I sure the doctor really wanted to see Sal?
Sal, I was learning, was what medical people call a “difficult patient,” one who doctors avoid. I watched him quiz his new doctors to see if they had read his chart carefully. How many of the bacteria species that colonize the lungs of cystic fibrosis patients could they name? He rewarded correct answers with even harder questions about local antibiotic resistance patterns. If the doctor said he or she didn’t know, Sal glared quietly; if they made up an answer, he was merciless.
After Sal’s appointments, I stayed behind with the doctors who were discussing his case. They set aside their medical differences of opinion and found solidarity in complaining about him: Did he have any idea that everyone else waited graciously for whoever was available, while he demanded a new doctor every other visit?
Sal’s pulmonologist of 30 years had retired, and the clinic had been struggling for months to figure out who would take on Sal’s case. Since not many cystic fibrosis patients had made it to Sal’s age, Sal suspected that many adult pulmonologists, especially the older ones, saw his ailment as a pediatric problem that they wouldn’t have to deal with, and ignored its nuances. In the case of several doctors I met, he was right.
The next year of medical school I went from being an observer to having patients of my own in the hospital. My job was to write medical to-do lists for each patient, covering every organ system. I learned a 21-point inspection of sorts to troubleshoot each malfunctioning part, as if my patients were machines in a body shop.
My supervising doctors showed me how to set the rates at which my patients’ kidneys produced urine and their lungs expelled carbon dioxide. They made these decisions quickly, with little self-doubt. Hormones, fluids, wires, tubes, sedatives, paralytics; the bone’s ability to remodel, the heart’s strength to contract — I was responsible for all of these things and had limited time to make all these plans. Don’t worry, I was told, we’ll start you with easy patients.
One such patient was a man who needed emergency surgery to remove an oxygen-starved section of his intestines. The remaining segment was brought through his skin and stitched beside his belly button, a plastic bag taped around the opening where stool now left his body.
When I woke him up before dawn to examine his wound, he did not resist or chide me for my cold hands, as Sal would have. He didn’t challenge the plan or ask follow-up questions. Rounds on him never took more time than I had allotted. My colleagues were right: He was an easy assignment for a medical student, because he was a shell of a person.
The nurses in the I.C.U. told me they had seen many patients like him — that critically ill patients often detach themselves from what they must endure. They asked me to imagine waking up defecating out of my abdominal wall and if it would change who I thought I was. Patients on the brink of death are not demanding and inquisitive like Sal. They are formless putty in the hospital’s hands.
A year and a half on the wards and a few hundred patients later, I had become better at breaking people down into their medical machine parts. My evaluators judged this skill during medical rounds, when we distilled patients’ histories into a single sentence, a feat made easier with patients like the man with bowel surgery. These patients succinctly told me what would fill in the blanks of my medical one-liner and didn’t cloud the picture with any personal thoughts of their own.
Passive patients were “easy” because we doctors could efficiently take total control. But once patients left the clinic we could promptly absolve ourselves of that responsibility. I had no idea what happened, for instance, when my patient with bowel surgery had to figure out how to do groceries and clean his bag of stool himself.
A three-ring history
That summer, I visited Sal’s house in South Philly, and he took me for a drive in his yellow Viper. “The great thing about not having kids is all the disposable income my wife and I have for fast cars,” Sal said. (Male cystic fibrosis patients lose the ducts that enable sperm to be ejaculated, rendering them infertile.) We sped along back roads to his favorite Italian restaurant.
On the mantel of Sal’s home were photos of him and his younger brother. Next to these was a pile of medical binders. Sal kept daily records of his lung function, his muscle strength and his respiratory symptoms, compiling statistics monthly and yearly. He did this manually, before the advent of FitBits and Apple Watches. He also collected clinical trials and review articles on cystic fibrosis. Sal was on his third five-inch binder.
The doctors made fun of Sal’s tomes and took bets on who would catch the hot potato next month and be expected to wade through his thousands of pages in 30 minutes. I thought of the meticulous attention to his disease that these binders embodied. How absurd that this asset was perceived as an albatross.
It was my first lesson in recognizing patient qualities that benefited their health but not the doctor’s workflow. Doctors did not commend patients who expected to understand all their test results, or who pushed back against treatments that were only weakly supported by evidence, or who wanted to talk to a doctor on the phone instead of waiting a week and missing a half-day of work for an in-person appointment.
The only patients deemed more difficult than insistent patients like Sal were his opposites: patients so overwhelmed that they stopped wanting to pay any attention to their illnesses at all. They are well known to every doctor: a dialysis patient, gray from uremia, eyes glazed over when asked why she missed her last session; a double amputee now bed-bound, refusing home visits; a boy with severe food allergies who won’t carry his EpiPen with him.
Sal did not bring his binders to his next appointment. They were becoming too cumbersome, he said, so he had started to simply jot down any crucial notes. These all had the same upshot: Sal was growing sicker and weaker. During one appointment I sat in on, Sal complained that he could not lift as much as he could the previous year: Why was that? And what could he do about it?
The doctor pointed to his own gray hairs — advancing age, nothing to be done about it. I expected Sal to press the doctor to back up this proclamation with numbers and parameters for lung function, or to demand a new doctor. Instead, he was quiet for the rest of the appointment and seemed to shrink into himself on the examining table.
Later that week Sal wrote me an email: Prepare a speech for those moments, like the one that week, when patients come to you at the end of their rope, and you have no more solutions to offer, he said. I think I was studying for an exam, and brushed off the message.
Cultivating distance
By now I was almost done with medical school. As we neared the end of our rotations, actors were hired to play patients and give us feedback on our bedside manner. They said things like, “It made me feel better when you looked me in the eye to break bad news.” We laughed, half-insulted, half-guilty.
I practiced “therapeutic distancing” to make decisions about patients coolly and unemotionally. I didn’t share much about myself or display vulnerability or uncertainty. I practiced not thinking about my patients once I got home.
With Sal I maintained none of these conventions. He and I continued to email back and forth. I sent updates about medical school, vacation travels, relationships and my plans for the future; Sal updated me on his declining health. Then one day my email to Sal bounced back, because he had died.
Years later in my training, on a late night home from the hospital, I reread Sal’s emails. Bathed in the blue light of my laptop screen, his advice about preparing a speech spoke to me as if from a ghost. I now had a command of anatomy, pathophysiology and pharmacology. I had impressed my supervisors and diligently maintained therapeutic distance. I was finally starting to become confident as a doctor. Why, then, did I feel so empty?
At first, the speech I wrote was for him. I told Sal that he should not blame himself any longer for growing weaker. He had fought his ailment valiantly, and his brother’s photo could occupy that space on the mantel alone now, without the binders. For a while I wished I had given him this speech, but I knew why I didn’t: I wasn’t his doctor.
Sal did not seem to want speeches of that sort from his actual doctors. He had become unpleasant toward members of the clinic staff, distrustful of everyone before his appointment even started. If Sal was told there were no prescriptions or procedures to fix the problem he was describing, he would condemn his team’s command of medicine and declare the appointment a waste of time.
It was not just we who had mechanized Sal; he had mechanized us, too. He expected near-infinite knowledge from his doctors on technical matters but dismissed their opinions as individuals. Sal had come to expect only a machinist’s answers from doctors, and at some point that became all he would accept.
The weight of knowledge
Now I am the speed-walking supervisor asking my medical students to provide a one-line simplification of a person’s suffering. My focus is on which diagnoses would be most dangerous to miss and how behind I am with my other patients. I often tune out the personal stuff.
Modern medicine has trained me and my fellow doctors to pin patients down, like beetles to be examined on a bulletin board. Their free motion impairs our efficient taxonomy of them. Unsurprisingly, patients do not feel well understood while pinned on the paper roll of an exam table. But how else can we cover everything we must in an appointment lasting 30 minutes or less?
To its credit, medicine has tried to shift further toward seeing patients on their terms, with telehealth visits, open notes and hospital services at home. But even with these, the titanic burden of medical knowledge to which doctors must do justice can crush opportunities for intimate conversation.
I know none of my patients today as I knew Sal, and none of them know me as Sal knew me. Even if I had infinite time for them, patients treat me differently as a full-blown doctor. I carry responsibilities — to be knowledgeable, skilled, punctual — that Sal did not hold me to when he took me under his wing.
Now the speech that Sal inspired is directed inward. I tell myself that patients reach the end of their ropes for medical reasons, personal reasons and often a mix of the two. Sometimes just managing the medical reasons is challenge enough for me, and that’s OK. But when I’m the “patient” at a bank or courtroom or post office, I’m reminded of what competency feels like without humanity. That helps me summon that timid young woman on the buffed lobby floor, who knew nothing about medicine but earned her first patient’s trust by being kind and sincere. She has started seeing patients again.
To the Editor:
While we appreciate the attention to the issue of physician burnout in light of the Covid-19 pandemic, we wish to highlight a critical part of this story: The survey discussed in the article demonstrated that female physicians were twice as likely to report burnout.
As physicians, we are no different from the public. We have children, parents and loved ones who depend on us. In the pandemic, female physicians disproportionately took on child care, schooling, household and work-from-home tasks compared with male counterparts. Larger studies show how work-life interference — worse for those with caregiving responsibilities — contributed to burnout.
Repairing physician burnout requires looking beyond patient encounters to examine policies and resources that support caregiving and address the burdens that female physicians face. Programs like the Covid-19 Fund to Retain Clinical Scientists are concrete ways to systematically counteract burnout and support retention of women and caregivers in our work force. It’s imperative to act.
Anna Volerman
Bree Andrews
Vineet Arora
Chicago
Dr.
Volerman is an associate professor of medicine and pediatrics, Dr.
Andrews is a chief wellness and vitality officer and Dr. Arora is the
dean for medical education at University of Chicago Medicine.
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