Heartsick

“Hello, Miz Lucy,” I would say as my father led me into the patient exam room. Miz Lucy, a diminutive retired schoolteacher, would be sitting in the chair, gussied up to the nines, with gnarled hands and feet shod in heavy stockings and thick orthopedic shoes. My father, a general internist in a small southern town, would have me touch her swollen hands as he injected the gold that would help her pain. She would exclaim about my growth, my successes in school, and would mention how the good doctor had saved her life more than once. Later, she would drive by our house in her ancient green Cadillac to make sure that he was home in case she needed him or to drop off her special cookies. At Christmas time, our kitchen counter was always covered with cakes, pies, or crocheted afghans made by grateful patients like Miz Lucy.

I remember making a house call with my father on a wintery Sunday afternoon. We drove up to a small house in which a sad, weathered-looking man with slumped shoulders sat in a wheelchair.

“Arthur,” my dad would say as he took off his coat and opened up his massive black bag, “how are you?” And the murmuring would start. I would sit on the sofa in the quiet, empty house and watch as my father talked with Arthur. Later, on the drive home, my father would tell me how, as a young man, Arthur had dived into a quarry pond and severed his spinal cord.

And then there was Margaret. Struck down by polio at the age of 9 in a tiny farm town up in the county, Margaret survived in an iron lung; her brother had died. Her mother had cared for her all her life, even moving to a major university town long enough to help Margaret get a college degree. Margaret, only her head visible while her wasted body was encased in the huge tubular machine, would ask me about my latest book while my father inspected her mother's diabetic foot ulcer or assessed Margaret's recurrent parotitis. Margaret's mother eventually developed dementia and, before she died, cursed the daughter whom she had cared for all her life. To this day, my now-retired father still visits weekly, to discuss books, to bring medicines. I still visit at Christmas with my father, taking my children along with me.

These memories are my most enduring and are at the heart of why I became a physician. Now, after nearly 15 years in various practices, having raised my children and finally settled down in a group practice of dedicated, like-minded colleagues, I am glad that I kept the name that connects me to my father and to his legacy of doctoring. I have a dream and the guts to begin to fulfill it, a dream of building a practice with my Miz Lucys and Arthurs and Margarets. My dream is to provide superb medical care as I get to know them over time, to be their physician in my sense of the word, and to grow old with them.

But managed care is threatening that dream. “Growth and profit,” the business executive writes on the blackboard as he explains that the practice of assigning patients to individual physicians has been abolished and that patients may sign up with any physician, regardless of known waits for routine or urgent care.

“For a panel size of 4000, we will pay you x more dollars in salary than for the current 2000 patients you are managing,” he intones. Our protests are not acknowledged, and our reluctance to add more patients to already jammed practices is seen as “slothful and needy.”

As the months go by, my established patients become more unhappy as it becomes more difficult for them to see me. My new patients are enraged at the more than 3 months' wait for a physical. They feel betrayed by the slick advertisements and come-ons. In the office, they sit with lists written on the backs of envelopes to remind them to discuss their headaches, constipation, elevated cholesterol and hormone levels. There just doesn't seem to be enough time for them to begin to trust me, nor for me to understand the person behind the list. I dread looking at my daily schedule and long for the short, uncomplicated medical encounter. My face no longer lights up in anticipation of opening the handwritten letter in my mailbox. Nowadays, these are much less likely to be testimonies to my care and much more likely to be complaints about the referral, the waits, or the most recent visit.

My Middle Eastern patient comes to see me. As always, she wears traditional Muslim clothing, her round face peering out of her headdress. Widowed and alone, she is suing her employer for sexual harassment in a long, arduous battle that will determine whether she can continue in the research career that she loves. I have been so impressed with the pluck and courage of this shy, lonely woman fighting to survive in a radically different culture. Our visits usually move quickly through the hypertension and the knee pain to the real reason for her visit: my support, my affirmation, and my reassurance that she will be all right. I see the hurt in her eyes as I am pushed for time one day and brusquely cut short our discussion.

A new patient calls me on the phone. She has menstrual irregularities, insomnia, and mood swings, and the suspicion that she is menopausal has added the stress of a major life transition to her already present difficulties. The wait for an appointment with me is unacceptably long to her. Although I have never seen her, on paper I am already her physician, and she is angry and irritated. I call her back, having already added extra patients to my session that day. Sitting in my office with my elbows on a stack of charts that all bear notes asking me to call patients, I am overwhelmed and vaguely realize that our conversation hasn't gone well. Many weeks later, when we finally meet, my new patient forcefully condemns my lack of compassion on the phone and is uninterested in both my abject apologies and my explanations about “HMO panel sizes” and “time pressures.” I know that she has labeled me arrogant and insensitive, and the sense of failure on my part is enormous. Although I spend time rationalizing and working through the experience, her diatribe against me remains one of the most painful moments in my 15 years of doctoring.

I begin to feel as if I am in a war. I speak out at meetings but feel small and unheard. I want to ask the managers and my bosses, “Where do you get your health care, and if your elderly mother is ill, do you want her to see the kind of physician you are attempting to create?” It is the practitioners and patients who will reap what these corporatized leaders have sown.

What about my dream? It has nothing to do with income, with status, or with having built a more cost-effective medical machine but is about the deep satisfaction that my interpersonal relationships and skills with my patients over the years will bring. Above all else, the physician–patient relationship must be preserved. I do not see this happening, despite my dedication to it and my efforts to sound an alarm and rouse my colleagues to action. I feel a helplessness as I face this inexorable attack. I am simply heartsick.

• Copyright ©2004 by the American College of Physicians