In Jauhar’s first book, Intern, he explored his own journey into medicine and those first tough years in residency, when sleeplessness and overwork were common. This book takes a mid-life look at both his development as a doctor and the evolution of American medicine.
Over the last five decades, the practice of medicine here in the U.S. has changed considerably. Jauhar’s historical explanation of how we went from private fee-for-service practice, where doctors charged patients what they could afford, to our earliest instances of health insurance, to the introduction of Medicare in 1965 was fascinating. Medicare reimbursements changed medicine in unanticipated ways, and health management organizations (HMOs) were introduced in the early 1970s to (in theory) help keep costs under control.
As the system has developed from there, a confluence of factors has made it difficult for the doctor of today to really know you and have a relationship with you. First, there are the unintended consequences of the reimbursement system. And second, doctors understandably fear being sued for malpractice and must shoulder the necessary cost of expensive malpractice insurance.
What this creates, then, is a situation where doctors need to see as many patients as possible, and will be more inclined to order tests and procedures to both cover their own liability in case of a misdiagnosis and to be paid for those tests via reimbursement. In the early years of Medicare, many doctors’ salaries soared, but that trend has reversed for most physicians, thanks to reimbursement cuts and increased costs of practice. Another wrinkle here is that doctors’ salaries are linked to how much revenue they generate for the hospital, which can create misaligned incentives between good patient care and billing. For Jauhar, a hospital employee, this link isn’t as direct as it would be were he in private practice, but it’s still a consideration.
This book is an uneasy inside look at the many challenges doctors today must contend with. I’d recommend it for anyone thinking about going to medical school, as well as anyone interested in why our system is as it is currently. Jauhar is a smart, compassionate and worthy guide.
— LouAnn Lofton, firstname.lastname@example.org
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