It's easy to imagine that doctors don't get sick. Surely the hygienic shield of the sterile white coat guards them from ever having to put on the flapping gown and flimsy bracelet, climb meekly into the crisp bed and be at the mercy of the U.S. health-care system. And if somehow they did enter the hospital as a patient, physicians ought to have every advantage: an insider's knowledge, access to top specialists, built-in second opinions, no waiting, no insane bureaucratic battles and no loss of identity or dignity when you turn into the "bilateral mastectomy in Room 402." But it doesn't usually work that way. While doctors are often in a better position than most of us to spot the hazards in the hospital and the holes in their care, they can't necessarily fix them. They can't even avoid them when they become patients themselves. l When Dr. Lisa Friedman felt the lump in her breast in the summer of 2001, she did—nothing. "I just sat on it," she says, "because I clicked into the mode of being physician, not patient, and I thought, 'Most lumps are not cancer, I'll just watch this.'" That was her first mistake.
By September Friedman had watched long enough. An internist in a practice that covers much of southern Wisconsin, she went to her radiology department to schedule a mammogram. The administrators turned her down: her HMO paid for routine mammograms every two years, and she'd had one 18 months before. "I said, 'Wait a minute, I feel a lump. This is not routine.' They still wouldn't let me do it." This is the stuff bad movies are made of. Friedman had to appeal to the HMO's board of directors. "I said, 'I'll pay for my own mammogram. Just let me get it done.'" She won her appeal and finally had the test. "They didn't even have to do a biopsy," she says. "The radiologist just looked at it and said, 'Oh, my God. You've got breast cancer.'"
The education of Lisa Friedman, patient, had begun. Like any other patient—and perhaps even more so—she had to drag information out of her physicians. "They were treating me like I was knowledgeable, but they weren't listening to me." When she found out that the cancer had spread to several places in one breast, Friedman told her surgeon there was no need to preserve her breast for cosmetic reasons; she was more concerned that the cancer be entirely removed. She asked for a mastectomy—but she was told that a lumpectomy would do the job fine. "I went along with it," she said. That was her second mistake. Her breast was riddled with tumors. "They ended up doing three lumpectomies. They were cutting away at my breast until I had no breast left. I said, 'Will you please take it all off?'"
Friedman's doctors weren't incompetent. They didn't operate on the wrong breast or give her the wrong drugs or commit any egregious medical errors—and that is the whole point. While there are bad doctors practicing bad medicine who go undetected, that's not what scares other physicians the most. Instead, they have watched the system become deformed over the years by fear of litigation, by insurance costs, by rising competition, by billowing bureaucracy and even by improvements in technology that introduce new risks even as they reduce old ones. So doctors resist having tests done if they aren't absolutely sure they are needed. They weigh the advantages of teaching hospitals at which you're more likely to find the genius diagnostician vs. community hospitals where you may be less likely to bring home a nasty hospital-acquired infection. They avoid having elective surgery in July, when the new doctors are just starting their internships in teaching hospitals, but recognize that older, more experienced physicians may not be up to date on the best standards of care.
Most doctors freely admit that they do everything they can to work the system. "As much as we all value fairness, if you think you can get some special attention for someone who's important to you ... I don't know anybody who would not play that card," says Michael McKee, vice chairman of psychology and psychiatry at the Cleveland Clinic. But talk to doctors about their experiences and you'll be surprised by how little power they have to bend the system to their will. This is one abiding irony of progress. The most wondrous technology exists that can pinpoint the exact location of a tumor, thread a tiny catheter up into the brain to open a clogged artery, pulverize a kidney stone without breaking the skin. But the simple stuff—like getting an mri on time, being given the right drugs at the right time, making sure everyone knows which side of your brain to operate on—can cause the biggest problems. "A patient with anything but the simplest needs is traversing a very complicated system across many handoffs and locations and players," says Dr. Donald Berwick, a pediatrician and president of the Institute for Healthcare Improvement. "And as the machine gets more complicated, there are more ways it can break."
http://www.time.com/time/printout/0,8816,1185743,00.html
