What's the biggest barrier to practicing medicine today? Insurance companies, said Joel Gallant, MD, of the Southwest CARE Center in Santa Fe, NM. That's his answer to just one of the 10 Questions the 鶹ý staff is asking clinicians, researchers, and medical thought leaders to get their personal views on their chosen profession. In this series, we share their uncensored responses.
Gallant is Medical Director of Specialty Services at Southwest CARE Center, an adjunct professor of medicine in the Division of Infectious Diseases at the Johns Hopkins University School of Medicine, and a clinical professor of medicine at the University of New Mexico, Division of Infectious Diseases. He is an expert on HIV infection and AIDS, and has published and spoken widely on the subject. Here are his answers:
1. What's the biggest barrier to practicing medicine today?
Insurance companies, which have been inserted into the relationship between doctor and patient in our patched-together excuse for a healthcare "system." The Affordable Care Act has improved healthcare access and outcomes, but in an effort to get it passed, the government option was thrown under the bus, and it seems inconceivable that we'll ever have a single payer system in the United States. Insurance companies now decide what drugs we can prescribe and what tests we can order, while increasing administrative costs and serving as a major source of headache and job dissatisfaction among healthcare providers. Healthcare in the United States is vastly more expensive than in most other industrialized countries, and our health outcomes are far worse.
2. What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds, tests, etc.) and how did you respond?
As an HIV doctor, I've been somewhat insulated from the lack of universal healthcare in the U.S. Even before passage of the Affordable Care Act, people with HIV infection could still get good medical care through the Ryan White program, at least for their HIV disease. But Ryan White doesn't cover everything, and I remember being forced to hospitalize patients for what should have been outpatient procedures or treatments because it was the only way to get them paid for. It made no sense from a cost perspective and it wasn't good for the patients, but it was sometimes the only way to get them the treatment they needed. Passage of the ACA has helped, especially in those states that expanded Medicaid, but we still need Ryan White, which provides the kind of comprehensive services that keep people in care, on treatment, and -- by extension -- unable to transmit HIV infection to others. The question we need to ask as a society is why we don't provide that kind of comprehensive care for everyone.
3. What do you most often wish you could say to patients, but don't?
The words I dread hearing most from patients -- especially common in Santa Fe -- are "Doc, I know my body!" These are the words patients say before rejecting my advice. I wish I could say, "No, in fact you don't know your body. You can't tell when your viral load goes up, or your liver enzymes are elevated, or when your cholesterol or blood pressure are too high. You're coming to me because I sometimes know things about your body that you don't. That's why we have doctors!"
4. If you could change or eliminate something about the healthcare system, what would it be?
I won't repeat my rant about the insurance industry: My first priority would be to replace it with a single-payer system, or at least to have the parallel government option that was initially proposed with the ACA. Short of that change (which would seem revolutionary only in the U.S.), my next priority would be to close the gaping disparities in compensation between the so-called "cognitive specialties" and procedural ones. As a society, we reward doctors handsomely for doing things to patients, while those who "merely" care for patients are paid poorly. This, together with the rising debt burden among young doctors, means that fewer medical graduates are going into primary care or specialties like infectious diseases, and we end up with an imbalance between the doctors we have and the doctors we need. In my own field of infectious diseases, it's hard to recruit fellows when they know that they would make more money as internists or hospitalists, and would see their income decline after doing three more years of training. This is incredibly short-sighted at a time when we're facing the threats of emerging or re-emerging infectious diseases such as Ebola, chikungunya, drug-resistant bacterial infections, and vaccine-preventable infections, and when we face declining capacity to treat our ever growing HIV and hepatitis C epidemics.
5. What is the most important piece of advice for healthcare providers just starting out today?
I'd love to say "follow your passion" and chose the career that excites you, but I understand the harsh economic realities. After 9 years in University of California system in the halcyon "pre-Proposition 13 era," I finished medical school with $20,000 in low-interest debt. It was easy for me to follow my passion and choose a field in infectious diseases, now the lowest paid medical specialty. Would I have done the same thing if my debt had been $150,000? Maybe not. Money aside, I can say that I have always been stimulated my field, my colleagues, and my patients, and can look back on an immensely rewarding career.
6. What is your "elevator" pitch to persuade someone to pursue a career in medicine?
You could be a hedge fund manager or a corporate CEO and make a lot more money. But at the end of your life, wouldn't you rather know that you made a difference in the lives of thousands of people, and that you looked forward to going to work every morning?
7. What is the most rewarding aspect of being a healthcare provider?
As an HIV doctor, I've had the privilege to witness the discovery of a new disease, its evolution into a global pandemic, the discovery of its cause and pathogenesis, and the rapid development of highly effective treatment and prevention. It was often a painful journey, but an incredibly rewarding one. We're not done yet. We still don't have a vaccine or a cure. I might be retired by then (or worse!), but you never know. We've come a long way in just 34 years.
8. What is the most memorable research published since you became a physician and why?
In my field I would include the first reported cases of AIDS in 1981 (just before I entered medical school), the discovery that HIV infection could be completely suppressed with combination antiretroviral therapy, but not eliminated because of the long-lived latent reservoir, and the confirmation that suppressive antiretroviral therapy prevents transmission. I hope I'll read about a preventive vaccine or cure someday, but I'll probably have let my journal subscriptions lapse by then and will have to learn about it on NPR, the New York Times, or from my nursing home attendant.
9. Do you have a favorite medical-themed book, movie, or TV show?
There are so many classic books that should be on every physician's reading list, including William Carlos Williams' The Doctor Stories, Tolstoy's The Death of Ivan Ilyich, Sinclair Lewis' Arrowsmith, and everything by the late great Oliver Sacks, to name just a few. In my own field, Abraham Verghese's moving and compassionate memoir, My Own Country, stands out, along with And the Band Played On, Randy Shilts' often infuriating history of the early U.S. AIDS epidemic. Both are must-reads for every young student or doctor who wasn't around during the dark days before HIV infection became just another treatable condition. I'll mention one movie among many: In addition to being gripping, believable, and scientifically sound, "Contagion" made a compelling case for robust funding of the CDC and our public health infrastructure, which we've let slide in recent years.
10. What is your advice to other physicians on how to avoid burnout?
In the 80s and early 90s, burnout was an almost inevitable result of the daily personal tragedies associated with the AIDS epidemic. Today burnout is more likely to come from time spent on paperwork, required training sessions, Meaningful Use, and fighting with insurance companies to get patients what they need. We dealt with the first kind of burnout with support groups, counseling sessions, and memorial services. It's harder to know how to deal with the contemporary kind. The only suggestion I can offer is to try to work for an organization that lets you practice medicine, hiring others to do the work that can be done by someone with less than at least 7 years of post-graduate school education and training. Avoiding routine is also critical. I've been fortunate to have had a wonderfully varied career, which has included a mixture of patient care, clinical research, teaching and lecturing, international travel and collaborations, consulting, and writing books, articles, and blogs for lay readers. Academic careers offer variety and reduce the likelihood of boredom and routine, but they've become more challenging because of NIH cutbacks. Although I'm no longer employed by a university, I've managed to maintain many of those activities in my new position. I may feel stressed or overworked sometimes, but I am never bored or burned out.