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Medicare and insurance-company guidelines, for example, forbid cardiologists to hospitalize patients for a coronary angiogram unless the patient is desperately ill. Otherwise, it must be done on an outpatient basis. As a result, Los Angeles cardiology consultant Stephen Berens sometimes has his frail or elderly patients take a room in a nearby hotel the night before the procedure. If he decides the patient needs a temporary pacemaker during the angiogram, he often implants the device but does not charge for it, because the Medicare system denies payment except in cases of very obvious need. "To make them approve it, I'd have to exaggerate the risk of going without it," he says. Berens would once have charged $200 for the pacemaker; now he absorbs the cost.
More than a doctor's pride and cash flow may be at stake. Some physicians warn that the need to make rapid decisions, see more patients and control costs could result in faulty diagnoses. Promising but expensive treatments cannot be provided to everyone who needs them, so what is to prevent reserving such care for the rich? The new pressures on hospital care have also affected the way young doctors are trained. Doctors lose the sense of satisfaction that comes from having a personal relationship with patients and helping them through crises, since hospital stays are shorter, patients are sicker, and treatment time is more rushed.
Not only have the scientific and organizational landscapes of medicine changed; so too has the social and economic climate in which physicians practice. In order to sustain public support and federal funds, the medical community trumpets triumphs with abandon. Hospitals spent more than $1.3 billion last year on marketing and advertising. Small wonder that even the desperately sick are surprised when they are not cured. "The whole idea is false," argues author Richard Selzer, a retired surgeon in New Haven, Conn. "No one has ever got off the planet alive. The natural course is to be born, to flourish, to dwindle and to die. Yet the medical profession has encouraged people to think of the natural course as an adversary, to be fought off until the bitter end. Of course, doctors cannot live up to the expectations they have aroused."
Physicians certainly cannot hope to satisfy patients who, instructed by the consumer movement, have come to view medicine as a commodity like any other, despite the fact that it is unlike any other. Once people would no more price- shop for a doctor than they would for a church. But today some patients switch doctors for as little as a $5 saving on the price of a visit. "You can be a mediocre doctor and discount your fees enough to have all the business you want," observes James T. Galyon, an orthopedic surgeon in Memphis, "rather than trying to be a very fine doctor and achieving a professional reputation that will cause other doctors to refer patients to you. The loser in the long run is the patient."