“As a patient, I do not want to hold hands with a robot and confide my health problems to a faceless entity. As a doctor, a patient, and a human being, I reject the currently shattered doctor-patient relationship.”
Healthcare in the United States is upside down. It tends to serve an “administocracy” at the top, with the patient at the bottom. This situation is not as it should be—or could be. We must, therefore, work together to turn healthcare right side up with the patient—with all of us—as the ultimate benefactor.
I have been a doctor for 60 years. During these years I have also, at times, been a patient. I have held the hands of my patients; I have been the one whose hand was held. I have received trust and given trust. The therapeutic decisions my patients and I reached were not previously subject to the interdiction of a third party. Now, I do not want to have my life’s role as a physician and surgeon—and my joy in the process—usurped by an administocracy. As a patient, I do not want to hold hands with a robot and confide my health problems to a faceless entity. As a doctor, a patient, and a human being, I reject the currently shattered doctor-patient relationship.
The inspiration to write my new book Healthcare Upside Down emerged from my six decades as a doctor and surgeon. I have witnessed dramatic changes in healthcare and its delivery since when I began. The standard global statistics, which are the undeniable facts of healthcare, offer compelling evidence that we are far from providing for our population what other countries provide. In every measurable category of healthcare—life expectancy, mortality rate, potential years of life lost, infant mortality, amenable mortality to healthcare, and healthcare access and availability—we rank below every Western European nation, Australia, New Zealand, and our neighbor Canada. We are number one in a single category: healthcare costs, where we exceed every nation, by spending 17.8% of our Gross National Product on this sector. Even with that degree of spending, Americans are not particularly satisfied with the healthcare they are receiving. A January, 2023 Gallup poll found that less than half of Americans consider healthcare in the United as deserving of the descriptors “Excellent” or “Good.”
The traditional doctor-patient relationship was based on the doctor earning the trust of the patient and the patient, in turn, relying on the doctor to take personal responsibility for the patient’s welfare. In today’s top-down administration of healthcare, doctors have become interchangeable employees, whose availability and expertise are regulated by a business model that serves the profit motive of medical administrators. These changes are well illustrated in the vocabulary of today: The hospital, clinic, and doctor’s office are now “the firm”; the doctor is “the provider”; and the patient has become “the client.”
It is time for “clients” to say: “No more.” It is time for “clients” to turn healthcare right side up by having their interests properly represented through professional organizations; politicians; and the press. Healthcare should never have become controversial. Our Declaration of Independence states that life, liberty, and the pursuit of happiness are our inalienable rights; healthcare encompasses these principles. Healthcare is part of the duty our nation has to its citizens.
I doubt that anyone would purchase a car or go to an entertainment venue under the conditions imposed on a consumer of American healthcare. The purchaser of a car insists on knowing the brand and the driving record before paying, not afterward. Would anyone buy tickets to a ball game, not told in advance who will be playing or when? Yet, we all pay blindly for every aspect of healthcare. This can take the form of paying out of pocket for a medical procedure when we were not told at the outset that we would owe anything at all.
Medicare and Medicaid alone typically account for approximately 42% of national healthcare spending. These programs are taxpayer funded as well as a portion of the 28% of national healthcare spending financed through private insurance programs, given that some of these plans are purchased through the Affordable Care Act or are offered through other government-sponsored programs. And even for those with private insurance plans or paying out of pocket, one typically is still required to pay a copay. At some point, we must ask the question: “Are we getting our money’s worth?”
Every day, throughout the United States, millions of Americans phone a healthcare facility, often with an urgent problem. They are answered by a robot, who, first, typically tells them to contact or go somewhere else (i.e., an emergency department). If the caller persists and presses the correct buttons, a typically less-than-friendly human voice will eventually answer and interrogate the caller. The interrogator frequently asks personal questions that may be in Health Insurance Portability and Accountability Act (HIPAA) violation. Even physicians themselves are not exempt from this system.
When trying to refer a patient to a fellow physician, I have, at times, declined to answer invasive questions from whichever person happened to answer the phone that day. As a result, I have been told that I will be reported because I refused to answer such questions and, thus, violated facility policy. Then, in many cases, if further communication is required, someone will almost certainly state that the particular physician or specialist needed is not available for several weeks or months, but that the patient can be added to a waiting list or try to make an appointment to see a different doctor. This new status quo clearly benefits the physician’s business interests over the needs of the patient.
I have talked to hospital administrators, and they have pointed out to me that today’s physicians generally enjoy being employees of this system. They relay that physicians happily relinquish aspects of their freedom and independence for a fixed income and the ability not to concern themselves with billing and similar paperwork. They opt for consistent hours, more days off, paid vacations, maternal and paternal leave, being able to refer cases to a hospitalist, and other perks. Less personal responsibility for specific patients may even be welcomed. As such, one would think that more and more talented young people would be lining up to become doctors.
But that is not what is happening at all. There is an increasing shortage of physicians, according to the American Medical Association. To compound the problem, more and more physicians are electing for early retirement, according to the Medical Group Management Association. This data indicates that the current American healthcare experiment is not a success. The best and most capable may not want to study to become doctors, given the new realities of today. All the while, physicians already in practice clearly want to get out. The healthcare system of today has failed not only the patient (all of us) but also the professionals who now just have a job instead of a calling. After six decades in the field, it pains me to admit that the American healthcare of today is not only in terrible shape but appears unlikely soon to heal itself for our shared future.
Henry Buchwald, M.D., Ph.D., is currently Professor Emeritus of Surgery and Biomedical Engineering at the University of Minnesota. He was a pioneer in bariatric surgery and the co-author and primary advocate of the concept of metabolic surgery. He is the author of over 360 peer-reviewed medical publications and has written (or contributed to) more than 100 books. His latest book is Healthcare Upside Down: A Critical Examination of Policy and Practice.
