As a medical school student in the 1980s, Dora Calott Wang expected to practice Marcus Welby medicine that would lead her to intimate, long-lasting relationships with her patients. Instead, she found herself a helpless bystander to the disintegration of the doctor-patient bond by a profit-driven health insurance industry.
In her book The Kitchen Shrink, Wang delivers an insider's view of what your doctor is really doing while you are waiting for your appointment, why most physicians seem more interested in paperwork than in having a conversation with you, and why some patients get better medical care than others.
In a series of heart-wrenching narratives plucked from her 20-plus year career, Wang, a psychiatrist, creates a stark portrait of the American medical industry: There's Selena, an 18-year-old girl who died after her insurance company refused coverage for a liver transplant; there's a colleague, overworked by a hospital that had to demand more from its doctors so it could afford to keep the doors open, who neglected her own health to tragic consequences; and there are stories of how a failing and ignored mental health system is leaving the ill with nowhere to turn for help. (Read an excerpt from The Kitchen Shrink.)
AARP Bulletin talked with Wang about her experiences as a doctor, her views on managed care and her hopes for the future of medicine.
Q. You came of age in the medical profession as it was transitioning to managed care. Can you compare the way doctoring was when you were in medical school to what it is now?
A. I started medical school in 1985. Each life was considered equally precious, regardless of insurance status or social economic class, and I don't think that is the way it is now. In the early 1980s, medicine got deregulated, along with the airline industry and the financial industry. Wall Street and for-profit corporations were encouraged to get into medical care. But profit and medical care are just not compatible.
Q. In the book, you tell the story of Selena, an 18-year-old liver failure patient suffering from depression. How does her experience illustrate what you believe to be wrong with health care today?
A. I realized that the patient and the doctors were not in charge of final medical decisions anymore. The ultimate decision lay with the insurance company because they held the purse strings. The health care reform bill signed into law a year ago is tremendous progress, and certainly I applaud the people who are brave enough to actually address the issue.
Q. What about health care reform addresses your concerns?
A. Mostly I am encouraged that finally everybody knows it's a problem. Health care reform has made it illegal for insurance companies to cancel coverage when patients get sick. This was happening, and now that's illegal.
Q. Insurers may say in response to your ideas that they can't operate in a world of miracles. They have to look at the bottom line. Can we anymore justify a "by any means necessary" ideal in a time when our health care technology itself is just so expensive?
A. There's no simple solution. Health care is the first new life-sustaining resource since food, water and shelter. The story of the fair distribution of water and medical care is going to be for our entire future. It's going to define civilizations; it's a huge matter.
Q. What do you wish that patients understood about what it means to be a doctor today?
A. As patients, we give our money to insurance companies for our health insurance. It's to the insurance company's advantage to hang on to that money. So they require doctors to do all kinds of paperwork in order to extract this money from the company. At one point I outright apologized to one of my patients: "I'm sorry I have to be filling out all of this paperwork. I would rather just be talking to you, but I have to get this paperwork done." That's not why we go into medicine. But insurance companies require so much paperwork it just crowds time for patients.
Q. As a psychiatrist, you've also witnessed a shift from talk therapy to medication as the primary treatment for mental illness. You lament this change, but given the success of drugs such as Prozac, do we even need talk therapy anymore?
A. The problem is that it's very difficult for psychiatrists to do talk therapy and still stay open. And yet I just cannot fathom how it's possible to practice good psychiatry without understanding the patient. I had a patient with new onset panic attacks. I tried different medications on her. She wasn't getting any better. So finally I said, "Let's just talk about things." I realized that this patient had had a trauma when she was younger and, years later in her 40s, somehow this memory was getting triggered in her again. As soon as we did some work around that trauma, her panic attacks got better. It was that work that got her better, not the medications.
Q. Do you think there is a correlation between the difficulty in acquiring mental health care and acts of violence, such as the Gabrielle Giffords shooting, which was allegedly perpetrated by someone who was mentally ill?
A. First of all, the chronically mentally ill are not more prone to violence, especially if they are treated. But if they are not treated, they can certainly be more prone to violence. I remember a time if we psychiatrists or mental health professionals thought somebody was dangerous, we'd do everything in our power to try to help this person and keep society safe. But it's no longer in my control who I even see as patients. The insurance companies decide that now.
Q. Considering your experience, what is your advice to aspiring physicians?
A. I think that doctors need to be part of the change that's needed in health care. Medical students and doctors need to take a role as people who truly understand what is involved in care. I wanted to just inform people of what's happening in our health care system right now, and I hope that makes a difference. We have the truth on our side, and the truth is more powerful than profit.
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