Ep 6 How Doctoring Used to Be
House calls, no insurance woes, time with the patient - these are beginning to be only a thing of the past with doctors and patients. Let's examine where we've come from.
Date: 5-17-22
Name of podcast: Dr. Patient
Episode title and number: Episode 6 How Doctoring Used to Be
Episode summary:
In the old days of medicine, doctors had more time and more freedom to practice their art as they saw fit. Nowadays many doctors are affiliated with big hospitals or groups, and have lost the freedom to design their day so to speak. Many don’t have a say over how much time they get with patients, how billing works and more. In this story you’ll hear a few stories about how things used to be, and also how those older healthcare providers see today’s healthcare delivery.
Guest(s): Anne Johnston, Dr. Jack Martin
Key Terms:
[08:30] EKG – short for Electrocardiogram, it’s a test that looks at the electrical activity of your heart.
[09:37] pacemaker – a device that’s implanted into the chest to regulate your heartbeat and rate
[10:05] – PVCs – Premature ventricular contraction, considered an “extra” heartbeat that originates in one of the lower chambers, ventricles, and leads to the feeling of fluttering or an extra heart beat
[10:08] – pacemaker in situ – a pacemaker that’s “in place”
[10:54] – echocardiogram, basically an ultrasound of your heart, it checks how blood is pumping in all parts of your heart and the main vessels
[29:28] – CME – Continuing Medical Education. Doctors need to log a certain number of hours per year to retain their medical license
Anne Johnston (Mom):
It's so different today. Rush, rush rush, for example, and, and you can't get to see a doctor and you can't get an appointment
Heather Johnston:
This is doctor patient, a podcast that examines all the aspects of the patient provider relationship. I'm your host, Heather Johnston, MD, a real life doctor and patient. Today's episode is about how medicine used to be practiced and received by patients. Before the expansion of Medicare and the rise of private insurance companies, things were done a little differently. And I think it's important to reflect back on what worked then that we've lost today. My first guest is Anne Johnston and yes, she is my Mom. I come from a big medical family. Both my parents, some siblings and a grandparent were all in healthcare in some shape, or form. And so the topics that this podcast examines were and are frequently dinner conversation in our house. My mom and I talked about her training, what she remembers about the early years of my dad being an internist, and tells a couple of stories of her own health care recently that bring to light some of the common challenges patients face, and how those are received by an older and aging population. A word about sound quality here, both interviews in this episode were done in someone's home with a handheld mic being passed back and forth. And that sound you'll hear during the second guests interview? That's called a grandfather clock, for those of you who don't know, just roll with it.
Anne Johnston (Mom):
I started as a nursing student in about 1950. I did four years of training, and then received another certification as an infectious disease nurse. Then I went to do plastic surgery, but didn't like it. So I left and went to private duty in London, I came to America. I got a job here in Chicago while I was in England, and came in 1957. And came to a hospital in Chicago. And nursing was so different was so different. So one of the differences was that in England, we had to do rounds with doctors. And we also had to learn about diseases. We had to know how to write a history of a patient. And we removed sutures, we shortened drains after surgery. We did a lot of things that the American nurse didn't do. Now, I think today, the nurses who are nurse practitioners do a lot of things that we did, and they're very well qualified. So it was different.
Heather Johnston:
When you think back to when you were a nurse. And then when you saw Dad in practice, also, what do you think is the most significant change in how healthcare providers - nurses and doctors - interact with their patients now versus back then? Well, I think one of the big differences is time. Time spent the doctor with the patient. My husband, who was a doctor to use has been one hour, 45 minutes or 30 minutes with each patient. And now you go and see a doctor and you're thinking, God, I really have to talk quickly. And I have to get it all so fast, or I will be out of here in 10 or 15 minutes, and I will have missed something. So I think time is the biggest change. I want to talk a little bit about trust. Where do you think trust has gone between patient and their doctor?
Anne Johnston (Mom):
Doctors, when I first came to America, were considered the the group of people that were most admired in the United States. And now I talk about medicine and doctor relationships with people, and people just, there isn't the trust anymore. It's it's more like a business transaction. Whereas before when you went to see your doctor, he really knew you. He knew how many children you had, what you did, he just knew you and now it is so rushed that you can't really form a relationship with a doctor anymore. You feel that they have one foot out the door as they come in the door.
Heather Johnston:
When dad was still practicing, do you remember him getting calls in the middle of the night and on weekends? And if so, was he ever upset by that or annoyed by that, or no? Not at all. He he had calls in the middle of the night. He was gone on Christmas days and we had small children and father was gone. He never complained about going out in the middle of the night to make a house call. In fact, if the patient needed hospital care, he will put them in his own car and drive them there rather than call an ambulance. He was that sort of doctor. He also had the ability to come home and immediately go to sleep. That's why he did the middle of the night feeding on our babies because he had the ability to go back to sleep immediately. And his wife didn't. I asked my mom to talk about her recent experiences with the health care system. This story is sort of crazy, but I think some of you will be able to relate to it anyway. It's a story about how the rules got in the way of meeting the needs of the patient and of the practical and moral right thing to do. I honestly think this kind of thing happened way less in the old days when doctors had a bit more freedom to their day. Once early in the morning, like 5:30am I fainted. And when I came to, I felt really weird. I mean, I was drenched in sweat, my heart was pounding. And I sort of crawled to the bed and lay down. I never felt so strange in my life. I mean, really strange. And I didn't do anything about it. And met my daughter in Costco, who said if you passed out, you have to see a doctor. So I went oh, yes, yes, daughter, brilliant daughter. So I decided to telephone. But the telephones weren't working. So I got in my car and drove to the office and walked through the door and said, It's really sorry to They didn't do anything? I mean, did they, did they examine you? bother anybody. But I had passed out, my daughter who was a doctor said I needed to be seen. So I was put in a room and the nurse came in and asked me questions. And I was wearing a heart monitor at the time that I passed out. So that was sort of a sign. And the nurse went to talk to my doctor, came back and told me I should drive to this suburb or that suburb two places because they weren't taking emergencies that day. And I thought, well, if I fainted in my house, what if I fainted in the car driving along way? I could kill somebody. So I just went home. Did they do an EKG, did they take your pulse anything?
Anne Johnston (Mom):
They might have taken my pulse and my blood pressure but I had no EKG. And then the results came in from the monitor that I'd been wearing. And it turned out that my heart had paused four times. Eight seconds, six seconds, four seconds and two seconds. And as soon as I called the doctor to tell her I got a call, panicked call back in about two minutes. sort of so sorry. But really, I feel that somebody should have dealt me dealt with me when I went in, especially as I was a long standing patient there. And I had never complained about anything that wasn't a real problem.
Heather Johnston:
and drive 20 or 30 minutes away to another clinic. This should not happen. A couple months after this experience, she had another problem getting through to her doctor's office.
Anne Johnston (Mom):
A couple of months ago, I started getting short of breath And I started getting numerous, numerous PVCs. And I have a pacemaker in situ. And I'm nearly 90. And so I called the phone number on the doctors cards. And the phone number, which was the same that I've been given for the pacemaker department, and no one ever answered the phone, it rang and rang and rang, and then it clicked off. And then I tried again, and again, again, I couldn't get through to the cardiology department. I couldn't get through to the pacemaker department, it was a nightmare. Finally, a nurse called me from cardiology, and they decided they would like to do an echocardiogram. This was beginning of February, but the first appointment was in April. And my daughter called, and managed to get it change to March. Eventually, about six or seven weeks later, I got to see a cardiology nurse, who was really nice, knowledgeable, wonderful rappore. And, but should it have taken six to eight weeks to get an appointment to be seen to get a test? What what what do ordinary people do? Should I have gone to the emergency room? But having been in charge of an emergency room, emergencies were considered things that had happened in the last 24-36 hours. And I had had this for a week or two before I began to get worried. So my son, who is a doctor came with me for the cardiology visit. And he said, just walk through the doors to the cardiology department and say, I need to be seen. And I thought well, they really couldn't turn your way because it would be such legal liability. But I've now learned that you are in a professional building. And so they can just say, no, you need to go to the emergency room. And by the way, we need an ambulance to transport you because of legal liability. So, oh, what a tangled we it is.
Heather Johnston:
Do you feel comfortable pushing back on a doctor?
Anne Johnston (Mom):
No, I don't. But I also think that I probably am a bit more mouthy than a lot of my friends. No, I think that I grew up you know, as a nurse, doctors were gods. I mean you didn't in the in the olden days in England. You really never said anything to a doctor. Course I found that in America, you could say a bit more. But I think that's almost ingrained. But I don't have the respect for doctors today that I did before, though I have some very good ones. Some of the doctors I have are good.
Heather Johnston:
What's your take on the internet being a patient? I'm asking because I think many of us think it has changed medicine forever, in multiple ways. And I'm curious what you think about that.
Anne Johnston (Mom):
People my age didn't grow up with computers, iPads, iPhones. It's a big mystery to me. And I think that being nearly 90, I'm reasonably good. But it is so difficult to deal with messages and, the other day, I received a report of an echocardiogram. It seems now that doctors have to send all lab results and things to the patient. Well, it was, you couldn't understand a word of it. It was reams and reams of mathematical equations and God knows what. And it seemed to me that was pretty foolish. Why didn't you see your doctor and your doctor explain in a manner in which you could understand what the test showed, not pages coming to you on your computer of algorithms and God knows what.
Heather Johnston:
Yeah, I think this happens a lot in medicine. And it seems like the move into technology, particularly in the arena of communication between doctors and patients, is really challenging for our aging population. And it's happening because it saves time and money to do it this way. But it's certainly not as hands on as things used to be and doesn't work for many patients. My second guest today is Dr. Jack Martin from Chicago, a pulmonologist for decades, starting in the 1970s. Dr. Martin and I chatted about what he sees as having changed in the delivery of medical care today. But we started by discussing how things were for him as the doctor, starting with billing. When I was in practice, I was working at a big academic medical center, the University of Chicago. There, after I finished with each patient, I had to check some boxes to indicate what's called the level of care that I gave. That lets the billing staff know how much to bill the insurance company and the patient for. The checkboxes incorporate how much time you spend in the room, how many questions you ask, how many organ systems you go over, how detailed you get, and how much help you ultimately give. But it used to be really, really different.
Dr. Jack Martin:
Well, when I started in practice, we never, there was people we just never billed. We never billed doctors, we didn't bill nurses, we never billed clergy. It just, you just didn't. That was
Heather Johnston:
out of respect
Dr. Jack Martin:
respect. Not a rule. We just didn't. And when we would charge patients, sometimes we'd charge patients that didn't have any, didn't have much money, we charge them less. And sometimes people that had more money, they'd pay for 15 minutes, they pay a few bucks more. That took care of the patient that didn't have any much, much of money, and so paid a little bit less. And then insurance came along where you had to document everything. And I don't know, that was the start of what I guess I would call what was the word we use mechanization. Yes, because it was just so many checkmarks. And if you didn't have the checkmarks, you should we weren't really supposed to bill them because that supposedly was fraud. But as I tell people who would listen, when a patient walks into my office, I don't write down that their eyes are not yellow, that they walk normally, that they don't limp, that they don't slur their words. I only put those things down if their eyes are yellow, if they slur their words. And so to have to put into a computer, all these things are normal, quite frankly, is a waste of my time. And it's a waste of the patient's time. And it's really stupid.
Heather Johnston:
You know that Joe is a clergy member who decided that Joe did not get a bill.
Dr. Jack Martin:
You did. You were the doctor.
Heather Johnston:
You the doctor.
Dr. Jack Martin:
You're the doctor, you decided.
Heather Johnston:
Doctors had power over billing? What? Unthinkable!
Dr. Jack Martin:
Absolutely, absolutely. That was the that was the nice thing about having your own practice. And this is just an aside, but I went to see the dentist, I don't know six or seven months ago. And it was just a routine kind of thing. And when I came out the lady at the desk handed me a slip of paper and there was no charge. I said what do you mean no charge? She said, Yeah. I said, Well, that can't be right. So the doctor came out and I said, and Chris this is wrong. I said there should be a charge. He said no, there's no charge. I said why is that. He says because I can. Just his practice, he said because I can. And I thought my god, how neat is that? Just how neat.
Heather Johnston:
Yeah, I don't know anyone that practices that way. I love that. Everyone I know is in a group, with a system you know bound by a million rules and they have nothing to do with billing at all. They would have no idea.
Dr. Jack Martin:
Yeah, it's it's and then when I read that the number of physicians who whose practices are owned by hospitals who fall into this I don't know corporate you gotta make this much money. You got to check these many boxes. You got to see that many patients, I say that, that to me is is sad. Because one of the nice things about medicine, and I had forgotten this when we were first talking is, you essentially owned your own business. And so when you own your own business, you put forth your own philosophy, your own. It's no different than having a candy store. If you own the candy store, it's your business. This is the way I treat my customers. This is the way I'll treat my patients. It was really neat. And now you go to work for the big candy factory. No, you can't do that. Now you got to sell so many boxes of candy. And we got to sell more nuts and more pecans than walnuts because we got a whole bunch of pecans we don't know what to do with.
Heather Johnston:
What are your relationships, like with your own doctors now?
Dr. Jack Martin:
So this physician I've only seen once, but it's a good relationship. It's practical, down to earth. Not in a hurry. I'm sure he fills out all the boxes and does all that. But he does it really quite well. The GI guy that I see, he doesn't have enough computer in his office. He told me one time how he did it. He said after all the patients leave. He said I dictate a summary then I have somebody do something with the computer that keeps the billing people happy. And I'm sure it costs him money not to not to have a computer. But he said, he said I can't practice that way.
Heather Johnston:
Yeah, I felt the same way in that ER. It felt very uncomfortable. You know, especially if you were trained before the time of the computers in the room, it feels really wrong. And on the patient end of it, I can say I do not like it when my doctor is typing on the computer while I'm talking. I really don't. I don't like that. It makes me feel like I'm not being listened to.
Dr. Jack Martin:
I I've never had occasion to do that. And I don't know, I don't think I could do a computer and deal with the patient at the same time. I don't think I have that skill.
Heather Johnston:
How about this? My Mom was short of breath a couple of weeks ago and the hospital provider set her up with a telehealth appointment with a pulmonologist.
Dr. Jack Martin:
I'm sorry I'm a little taken away. I don't think I could do that on a television screen. I, you know.
Heather Johnston:
Well certainly you can't hear their lung sounds
Dr. Jack Martin:
and no, you Oh, you can't oh right your can't. My daughter has a couple of kids and one of the kids was having trouble with breathing and she went to see the pediatrician and the pediatrician was listening to the kid through his shirt
Heather Johnston:
I hate that.
Dr. Jack Martin:
And she told him she said look, my dad's a pulmonologist. You can't hear a damn thing through that. Pull up his shirt and listen to this just
Heather Johnston:
Good for her good for her.
Dr. Jack Martin:
That's probably got to be edited out but it was and but just to tell you how bad things are, the AMA has a picture when they're talking about a doctor or somebody, some doctor listening to somebody through their shirt. And I think that's just absolutely gross.
Heather Johnston:
Me too.
Dr. Jack Martin:
and it just pisses me off.
Heather Johnston:
Actually one of the courses I taught at the U of C med school was physical diagnosis. I'm a stickler for the rules. I can't stand stuff like that. But I feel like now, there's so many things a doctor has to do in a day. I was interviewing, actually, I interviewed my brother a few weeks ago. He's a brilliant internist, really the smartest I've ever known. And he is the director of a county clinic in California. And just to hear about his day is ridiculous. It's ridiculous. He gets up at 4, because he wants to get to the office by 5 30. He starts work at 8. But he said on average, he has about 100 test results or chart updates or messages to answer every day. And if he doesn't go in at that time to do it, there is no time built into his day to be able to do that. And I've thought, how is it getting so much worse like this? And he doesn't. He's actually sort of a stickler also that things should be done the right way. But, you know, how is that, how is this right? He doesn't, there's no time in the day to communicate with anybody. He's too busy billing and checking boxes and seeing patients.
Dr. Jack Martin:
I never got paid for spending an hour or an hour and a half a day reading a journal or more than one journal. It just seemed to be, everything seemed to be have to be pushed in. And I'm not saying that physicians don't make a good living because they do. So do plumbers. They make a very good living. And there's a shortage of plumbers by the way. I told one of my grandkids I said be a plumber. I said right now, plumber walks into your house, it's a minimum of $125 for him to say, or her to say hello to you. And it's gonna get worse because nobody wants to go into plumbing. I said, it's very nice. At the end of the day you leave and you don't have any journals to read, you don't have any checkbox. There's no insurance to pay, they just pay you. It's not bad, it really isn't bad. And when you equate medicine and plumbing today, I think that's a sad state of affairs. That's not, that's not medicine.
Heather Johnston:
I wonder what needs to change? What do you think needs to change to bring the focus of those interactions back to the human scale, just having an interaction and a relationship with somebody?
Dr. Jack Martin:
I'm not sure it's gonna change. I think medicine is is going to continue to become more mechanized, if that's the right word. And it will be taken when you go to see the doctor will be taking, like taking your car to see a mechanic. They'll replace this, replace that, do this test, do that test, hook up the computer, and then they'll have a, then they'll have a program as to what you do. And there will be no place for you to have a discussion with the patient to say, well, listen, this is what they recommend, but I don't think that fits for you. And this is the reason why.
Heather Johnston:
I have been noticing lately when I go to the doctor that the medical assistants who come in first to take your vital signs. Now they just roll in a tower with an automatic blood pressure cuff and automatic, which also tells them they're your heart rate. All of it, it just is all like that. So no one really touches you anymore. You just like hooked up to this tower for a couple of seconds. And then all your numbers are done. And then you go into the office with the computer. It's just ridiculous. It's ridiculous, really. Yeah, I have found that it's good and bad to be a doctor patient. I know too much. Sometimes I think I know more about something than I do, like with the breast cancer thing. I was reading breast cancer journals. I'm not a breast surgeon, I don't know. But I read all the articles myself, because I don't trust anyone. I do find, I think that I think the doctors gets often gets special treatment a little you get a little more time, a little more conversation. I've wondered about that.
Dr. Jack Martin:
I think I think they probably do.
Heather Johnston:
But it might be because we are more engaging patients.
Dr. Jack Martin:
That could be and it couldn't be because, like in so much of the world, if you demand something, you tend to get it. So it might be just our demeanor, and and the way we behave is that we get more time because we don't give them a choice. We say no, wait, wait, why am I taking this pill again? I know most patients don't do that.
Heather Johnston:
Yeah. Is that the advice that you give to your family members, to question?
Dr. Jack Martin:
Oh, absolutely. Yeah, absolutely. Say just ask them what are they doing? And you know, if you have any questions say, well, what do you think about a second opinion? I had patients that say sometimes I just say once you get a second opinion, why not? Because it would make them feel better. I didn't think the results are gonna be any different. If they were that was great. I'd learn something too. But it's like, listen, I know this great guy at Rush, this great guy at the University of Chicago or a great guy at Northwestern. Why don't you go see him, see what they think about what we're doing.
Heather Johnston:
Yeah, I think that patients think that doctors will be upset by that. But most that I talked to say they are not upset by patients getting second opinions.
Dr. Jack Martin:
Oh, I think that's true. And I and I've told my family members that. I said, you know, when you say to a doctor, I think I'd like a second opinion, most of the doctors that I know say I think that's a great idea, why don't you. Because, for the same reason I just articulated. One is, that will make the patient feel better. And two, if they come back with a different second opinion, the doctors learned something at essentially no cost.
Heather Johnston:
Yeah. It's like free CME. That's right. So true. So true. Thanks for listening today. To catch up on more episodes and to get new ones delivered directly to you. Subscribe wherever you find your podcasts, Apple, Google, Spotify iHeartRadio and more. If you'd like to be a guest or have an idea for an episode, let me know at www.drpatientpodcast.com That's drpatientpodcast.com Here's the disclaimer. Even though I am a doctor, I'm not your doctor. These stories, my comments and all discussion is purely reflection about what's working in the healthcare system and what isn't. Don't use any medical information that you hear in these episodes to diagnose or treat yourself. If you have a question about your health, get in touch with your doctor or local health clinic.