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Anger management in medicine
“Anyone can be become angry — that is easy. But to be angry with the right person, to the right degree, at the right time, for the right purpose, and in the right way — this is not easy.” – Aristotle
Doctors in the United States are angry. I mean, they are livid and for many reasons. Most importantly, they believe we have lost control of our profession. Examples abound. Economic issues have forced many of us out of our practices and into organizations that dictate how we will care for patients. We have been chained to computers and made to worship the monitor. Doctor bashing occurs daily in the media. The public has been told that our work can be done as well, if not better, by people with significantly less training. We have been given more to do to “maintain” our professional standing without considering how all of that additional time will affect our ability to practice good medicine or to maintain our family lives. We have watched our residents and medical students disconnect from patient care in the name of preserving their rest without a shred of data to prove that it makes any difference. SGR, mandatory compliance training for irrelevant conditions, ICD-10, the Sunshine Act. The list is seemingly endless.
And our patients are unhappy too. They decry procedure denials, long waiting times, the brevity of their visits and contact with their doctors through “portals.” A computer monitor and keyboard has been inserted into their anticipated “face-to-face” encounter and their history is told in fragmented parts as their physician’s attention is now focused on the electronic health record (EHR). Their physicians and staff now spend more time with “pre-certifications” than with them. Their care has become fragmented and complex and is no more affordable. In fact, rising deductibles render many of the tests we order out of reach. Since they have a difficult time communicating with their doctors, they are forced to rely on the media and television snake-oil doctors for medical information. They feel manipulated and deceived, and perhaps they have been!
I recently came across a particularly egregious example that sent me through the roof and inspired this essay. Mrs. Moneypenny (not her real name) is one of those people who lights up your patient list. In her late 70s and widowed, she is an energetic and active woman who is an avid reader. The first portion of her appointment with me is spent discussing my novels. She has been an excellent critic, pointing out the strengths and weaknesses of my writing, and making suggestions for improvement.
Mrs. Moneypenny has a long history of hypertension and mild type 2 diabetes, and about 2 years ago developed atrial fibrillation that disabled her, despite excellent rate control and anticoagulation. We tried a few drugs and electrical cardioversion without success. I suggested a trial of dofetilide (Tikosyn, Pfizer); she agreed, and we admitted her for drug loading. She converted to sinus rhythm within 48 hours and felt better.
Ceding control
About a year later, she came to my office for a “continuing care” appointment, bringing with her a letter she had received from her insurance company. She was advised to ask her physician about changing from brand-name dofetilide to a generic. Such requests have become commonplace. I frequently agree if a generic is available, if the price really is less, if the condition is not serious and if it doesn’t involve a change to another chemical entity with repeat dose titration.
“Mrs. Moneypenny, there is no generic equivalent for dofetilide,” I advised.
“They think there is, Dr. Kowey. I talked to my primary care doctor and he said it was OK with him. He just wanted me to ask you what dose to write for.”
“May I see the letter, Mrs. Money-penny?”
I was rendered breathless. The agent that the insurance company was advocating was quinidine. Quinidine!
“This is insane,” I said before I realized it. I tried to calm down and went on to describe to Mrs. Moneypenny the many reasons why quinidine was a poor idea, most importantly that it was a completely different drug with a vastly dissimilar safety profile. She was disappointed because she assumed it was cheaper. She was spending an enormous amount of money on her prescriptions, mired in the Medicare “doughnut hole.” It was also the reason she was still on warfarin, an inferior anticoagulant. I was able to make things a little better when my nurse practitioner enrolled her in a program to help with her drug costs.
After her visit, my secretary and I spent the next 3 hours calling the insurance company. I finally received a call back from a physician I had trained. She explained that the medical directors had no knowledge of this particular letter, that it was likely to have been initiated by the pharmacy department, and that she would look into it. I am still waiting. A retraction has not been forthcoming.
When I later commiserated with one of my best friends from residency, he replied, “Pete [my residency nickname], it’s our own damn fault.” I didn’t like that answer. It’s much easier to blame somebody else, like the president or Congress or the CEO of an insurance company. But I’m afraid my buddy was right: Much of what has happened is our fault. When government got into medicine and the corporate world realized there was big money to be made, we practitioners were required to spend increasing amounts of time on the business side of things. To help ease our burden, we chose to cede control of our practices, our hospitals, our professional organizations, insurance companies and oversight agencies to people who are not doctors. Sure, some of them have an MD after their name, but the truth is that many of them left practice because they didn’t like it or weren’t good at it. Many never practiced. The minority who are true clinicians are overwhelmed, trying to keep too many balls in the air. They don’t last long before they burn out.
Don’t misunderstand. Many of the people who are representing us and making decisions are smart and well-intentioned people who can add tremendously to the building of a quality health care system. But they cannot be allowed to function in a vacuum. We must find a plausible way for real doctors to be in the room when decisions are made about medical care at all levels. This includes pharmacy decisions, guidelines, payment allocations, training, maintenance of competence and work allotments.
Follow FDA structure
One federal system that works well, in my opinion, is the advisory committee structure at the FDA. I have participated in these advisory committees for years. Since the meetings are completely open to the public, we have had a chance to see the process in action. A good clinician, whether at the meeting representing industry or sitting on the advisory committee itself, helps colleagues understand how and why a specific product can or can’t improve the care of patients with a specific disease. And they offer suggestions about labeling drugs and devices to promote proper use. The FDA also saw fit to place patients and consumers on advisory committees. Their comments, and those of the invited public, have played a vital role in helping the FDA reach decisions that make sense for doctors and patients. Concern about conflicts of interest has limited expertise on some of these committees, but deliberations are kept on track by the clinicians on both sides of the aisle who understand and manage patients with the diseases in question.
To improve our current situation, difficult but necessary action is required. I’m advocating a major commitment from doctors who are currently inundated with work and other commitments. We can’t pay them what they’re worth, but we can compensate them for at least a portion of their time. As with the FDA paradigm, there will need to be a significant effort to prepare for and to participate in meetings so they can offer the best advice.
And the process has to be transparent. Doctors need to know where and how they are being represented and by whom, and why decisions are made that have a major impact on the way they deliver medical care, and on their lives. It would be best to have open meetings with public voting, just like the FDA.
In the meantime, clinicians cannot succumb to their anger. We cannot become so bitter and despondent that we withdraw. We must stop discouraging bright young people from pursuing a medical career. And we must continue to be ombudsmen for our patients. When we see a problem, we have to speak up and bring it to the appropriate forum for discussion and rectification. We have to be willing to choke back or at least channel our ire, provide cogent information, answer questions patiently and advocate for our patients relentlessly. We have to be willing to take the time to point out why Dr. Oz is wrong and not just casually dismiss his nonsense, and to educate our patients and their families about the results of proper clinical trials that form the basis of our recommendations. We have to be scrupulously honest and willing to admit when we don’t know an answer. We have to apprise our patients about all varieties of conflict of interest, not just financial, when they truly exist. And we have to remember that we have a critical place in our patients’ lives. We, and no one else, are their reliable and inestimable compass that they use to navigate through a complex health care system trying to do the most important thing: maintain their good health and happiness.
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- Peter R. Kowey, MD, FACC, FAHA, FHRS, is from Lankenau Heart Institute and Jefferson Medical College in Philadelphia. He is also the Cardiology Today Arrhythmia Disorders Section Editor. Kowey can be reached at koweyp@mlhs.org.
Disclosure: Kowey reports no relevant financial disclosures.