The Doctor is Out

Sickened by the shift to managed care, more physicians are claiming disability, moving into administration or leaving medicine altogether

Anna Navarro spends her work life counseling people who are unhappy in their chosen professions and don't know where to turn. People who've invested so much energy, money and hope in a particular career that the prospect of doing something else paralyzes them.

When Navarro started her St. Louis-based firm, Work Transitions, 17 years ago, that group didn't include physicians. Now they account for one-third to one-half of her clients. "They're showing up even more frequently than teachers, lawyers and social workers," she notes wryly. "These are very bright people with a very limited perspective on the world. When they start getting unhappy with medicine, their whole world caves in."

One of her clients is Dr. Edward A. Palank, 53, a practicing cardiologist for 25 years who rose to the directorship of the New England Heart Institute. He heard about Navarro through the fast-souring medical grapevine, just as a corporate hospital merger and angry community backlash had taken the last bit of joy out of his practice. Humbly, he worked with Navarro for months, finally forging a plan to start his own medical-communications firm and several other endeavors.

Palank grew up watching patients come to see his dad, a general practitioner who set up his office in their house. "Medicine was what I wanted to do from second grade on," he recalls wistfully. "The only semblance of managed care in my dad's day was the barter system: We'd get the plumbing fixed if my dad provided an office visit.

"The doctor-patient relationship is what it's all about," he insists. "Can't be measured." There's always been room for improvement, of course: "Physicians wait, on average, only 17 seconds before interrupting a patient," Palank groans. "Now, with managed care, there's even less emphasis on listening. You have management saying, 'Do this,' and HMOs saying, 'Do it this way.'"

He misses the patients but not the frustrations. "If someone has a hot belly and it's an appendix, you take the appendix out," he says. "At 2 in the morning you don't make a conference call or develop a consensus, you act. That's what makes you a good clinician. Now, you have to check on the procedure, you incur a financial penalty if you do not discharge the patient, you have to follow algorithms and you really should not deviate.

"It may be the correct standard 90 percent of the time," he concedes, "but your ability to treat that other 10 percent is.... " He breaks off, then mutters, "Your hand will get slapped. You will have to explain to some secretary who has no knowledge of medicine and is checking off boxes. I once testified before the Labor Commission about someone entitled to disability, and it was denied because the diagnosis I gave them wasn't on their list."

Tired of Arguing
Dr. Sara Lawson (not her real name) is a 43-year-old gynecologist on the West Coast. She, too, is consulting Navarro, trying to figure out whether to restructure her practice or explore options outside medicine. In an effort to explain, she blurts out a story about a patient who called on a Saturday morning, about to leave town but panicked by a mysterious swelling in her vagina. Lawson surprised herself by sending the woman to the ER instead of seeing her, which would have violated HMO rules, disrupted her family's day and earned her about $10 in reimbursement.

"When you decrease reimbursement so low, you can't motivate somebody to do a procedure," she says later. "At $200-$400 for a hysterectomy, why would I want to go to the hospital to do the hysterectomy, then round on the patient for two days, when I can just stay in the office?"

Lawson sounds callous, speaking these thoughts out loud. And she's not happy about it. "When I first started, I'd see a patient any day of the week if they needed to be seen," she points out. "Managed care has deteriorated the physician-patient relationship. The contractual, financial relationship is no longer between the physician and the patient; it's between the physician and an insurance company who doesn't always have the patient's best interests at heart."

A single parent whose bankbook doesn't reflect the bucks people assume, Lawson's paying for naivete. She tried five years to make a go of it in solo practice -- took out loans to buy medical equipment and leased office space, then couldn't fill the rooms with patients. When she succumbed and got herself onto some HMO panels, she found herself busier than she could stand -- but money was still tight. So was the vise of paperwork.

"If I want to do a procedure," she explains, "I have to submit paperwork, diagnosis, procedure, support it, send copies of the ultrasound, medical exam, history...." Managed-care companies don't often deny major procedures, she adds fairly, but they shun preventive screenings (like a $200 bone-mineral-density screen) and drag their feet on covering promising new -- and therefore expensive -- medications (such as raloxifene, a new "smart" estrogen that maintains bone mass in menopause without increasing the risk of cancer).

Lawson's tired of arguing. "I had a patient who was 42 and had an ovarian cyst," she recalls, "and when I tried to get her surgery authorized, the vice medical director said, 'Is she having pain? Why does she need to have it taken out?' I said, 'It's a cyst -- you don't know what it might be.' She said, 'Well, it's not cancer.' I said, 'How do you know?' The odds were low, but it was possible. Finally, I said, 'Look, it's standard of care (accepted managed-care protocol) to remove this.' Then they agreed."

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