Robert A Harrington, MD, Sandeep Jauhar, MD, PhD

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February 05, 2015

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Editor's Note: In this episode, Bob Harrington interviews cardiologist Sandeep Jauhar, a New York Times contributor and author of Doctored: The Disillusionment of an American Physician . This New York Times best seller chronicles Dr Jauhar's experience at a practice where unnecessary tests were routinely performed to generate income.

Robert A Harrington, MD: Hi. This is Bob Harrington from Stanford University on theheart.org and Medscape Cardiology. We have covered a number of topics on this show over the course of the past couple of months, some in the realm of science, some in the realm of medical education, some in the realm of the changing dynamics of cardiovascular practice. Today, I am honored and excited to speak to one of the cardiology community's bestselling authors to get a perspective based on a recent book that he has written and current views of American cardiology that come up time and time again, whether it is in conversations with colleagues, posts on Medscape Cardiology, or discussions at national meetings.

And some of those themes reflect the changes in American cardiology from being the domain of the independent, entrepreneurial physician to employees of larger healthcare systems. In the academic realm, we've moved from a time where funding from agencies like the [National Institutes of Health] NIH was plentiful to a time where we are all scrambling for research dollars.

But there are deeper themes here and maybe more pervasive themes. There are the themes of the expectations of our patients. The expectations, frankly, of ourselves as physicians, as people who spent their 20s and 30s in training and what awaits us on the other side. There is that very, very difficult topic of how we maintain balance in our lives around our professional commitments and our personal obligations to ourselves and to our families.

So today, I am really honored to have with me as a guest, Dr Sandeep Jauhar. Dr Jauhar is the director of the heart-failure program at Long Island Jewish Medical Center. He is a frequent contributor to the New York Times and, most important for this conversation, he is the author of the recent New York Times best-selling book entitled Doctored: The Disillusionment of an American Physician. Dr Jauhar, thanks for joining us here today on Medscape Cardiology.

Sandeep Jauhar, MD: Thank you, Bob.

When Doctors Were Respected

Dr Harrington: Let's start out for our listeners who may have not read your book (hopefully this will be a good opportunity for them to do so), but for those who haven't read it, could you give us a little background and, you know, let's start with where you grew up, where you went to college as an undergraduate, what you studied in college, et cetera, and then we will go from there?

Dr Jauhar: I was born in India. I lived there for a few years, and my father was a plant cytogeneticist, and so he traveled quite a bit, and we ended up moving to Wales, where I lived for a few years. We moved back to India for a year. When we moved back, it was 1976. It was during the emergency rule of Indira Gandhi, and academics were under a lot of pressure and speech was being stifled. A lot of things were going on, so my father decided that he wanted to move the family to the United States, so we moved to the US in 1977. I grew up in California. I ended up going to UC Berkeley for undergraduate. I studied physics, and then I wasn't sure exactly what I wanted to do with my life. I considered medical school. I considered law school. I ended up deciding to stay at Berkeley, and I got a PhD in physics. Toward the end of my graduate training, I decided I did want to become a doctor, much to my parents' chagrin after all that training. I ended up going to Washington University in St Louis for medical school, and then I moved to New York for my postgraduate training.

Dr Harrington: Before we get to the postgraduate training, talk to me about the physics PhD and then the decision to go to medical school. One of the challenges that we have in American medicine is that fewer of our medical students come from the physical sciences, the quantitative sciences, things like engineering. Many of our medical students have a biologic basis of their education.

What drew you, as a physicist, to medical school?

Dr Jauhar: I grew up in a fairly conservative immigrant Indian family. My parents always wanted me to become a doctor. My mother used to say when we were growing up that she wanted her kids to become doctors so that people would stand when we walked into a room. That was the way that doctors were perceived in her generation. Doctors still get quite a bit of respect in India, especially when she was growing up—she was the daughter of a fairly prominent New Delhi internist. My parents always wanted me to pursue medicine, but I was interested in so many different things, and I didn't know if medicine was going to appeal to me on an intellectual level, because I had so many other interests.

It turns out that it did, but at that time when I was deciding on a career, I wasn't sure. My father used to say that nonscience is nonsense. He was a geneticist and was very rigid about what made sense to him. I was very attracted to the humanities and social sciences; I always enjoyed writing when I was in school. I was also very interested in physics, the universe, and quantitative things, and so when I went to Berkeley, I decided I didn't want to do medicine, but hard science was the next best thing. I was genuinely interested in learning about quantum mechanics and relativity, so I got my undergraduate degree in physics. Toward the end (after I went to graduate school) I was working on a research project, and as you probably know, being a scientist and anyone out there who has done basic research, the progress is very slow and so it was for me. Everything will be set up to do an experiment and then a piece of equipment will break down. It took me 6 years to get my PhD, and toward the end of it I started asking, "Is this really what I want to be doing? Can I make more of an impact doing something else?" That was when medicine started to reenter my mind.

Escaping the Ivory Tower

Dr Harrington: Then you go off to Wash U, which is one of America's great science-based medical schools. My view over the years has been that there are two types of science PhDs who go to medical school. One is a group who fully intend to tie their area of science to their clinical observations and that would be the classic MD, PhD who is interested in pursuing an investigative career in medicine. Then there is the group who have decided that science, as a life, is not for them and they become interested in the clinical aspect of medicine. Which category did you fall in when you went off to medical school?

Dr Jauhar: I am not sure either one. I was very interested in science, but, quite honestly, I didn't want to make research a big part of my career. I was done with it by the time I finished my PhD.

I spent 6 years working on a very esoteric object called a quantum dot, which is like an artificial atom that you can fabricate in the laboratory. I did all sorts of cool experiments. Single-electron tunneling through quantum dots and using photons to push electrons from one energy level to another, and they were really cool experiments and got published in some of the top journals, but there was part of me that just wasn't satisfied

Dr Harrington: You didn't see yourself doing this?

Dr Jauhar: My brother came to visit me once when I was in graduate school. He was actually doing his residency in San Diego in internal medicine, and he looked around the lobby and said, "Boy, this really is the ivory tower." I thought, you know what, I have got to get out of this place. I want to be part of the real world and what he was doing started to intensely appeal to me (seeing people, helping people). At the time, a very good friend of mine became sick with lupus and in an effort to help her I was going to support-group meetings, calling doctors, and it occurred to me that medicine was really the best way to get out of the ivory tower.

I went to medical school, I didn't want to be part of a laboratory, but at the same time I was very interested in science and deep thinking about topics. That is why graduate school appealed to me in the first place—doing the deep dive. I wanted to continue to do that but not necessarily at the single-electron level.

The Lure of Cardiology

Dr Harrington: I certainly understand that. Then you get to medical school, you decide to pursue internal-medicine training and ultimately cardiology and then the extension of that, heart failure.

Walk me through that transition. Was internal medicine the draw, or was cardiology the draw and internal medicine was just the necessary step along the way? What were you thinking at that point? Had you decided you wanted to be a cardiologist?

Dr Jauhar: You asked about how my science background influenced my career choices, and being a physicist I had this predilection for rhythms and patterns and logical thinking, and cardiology just made sense in a way that no other subspecialty in internal medicine did. It seemed like it was more conceptual, and I could think through things and I could apply some of the concepts that were very natural and intuitive to me. Pressure gradients and flow and dynamical systems and all those things propelled me toward cardiology. It didn't hurt that cardiology is very well regarded in the Indian community, and a lot of my peers were interested in cardiology. So there are a number of reasons, but in the end if I were going to point my finger at one thing, it was my physics background and the way I thought about things that made cardiology a natural fit.

Dr Harrington: Certainly the appeal to many of us is the simple beauty of it. The physiology, as you have described, is something that even an early medical student can get their head around, and whether you are talking about the physiology of coronary blood flow or you are talking about the physiology of the electrical system of the heart, they are areas that people can conceptually understand, and how to take care of a patient, at least in part, depends upon understanding the physiology of their particular cardiac system.

So where did you do your internal-medicine and your cardiology training?

Dr Jauhar: I was at New York Presbyterian at Cornell on the Upper East Side of Manhattan for my internship and residency, and I subsequently wrote about my internship in my first book, which was called Intern: A Doctor's Initiation , which came out in 2008.

And then after I finished my residency, I went to NYU for cardiology training and then during my cardiology fellowship, I spent about 6 months at Columbia, which is the top heart-failure transplant program in the Northeast, maybe in the country, and I got specialized training in heart failure.

Dr Harrington: If you think about Cornell and some of the great cardiologists from there, NYU, some of the early work intracoronary fibrinolysis, and then Columbia, as you have rightly described, a great place for both heart-failure care and heart-failure research. You have certainly been at some of the best places across the country, and I am guessing that cardiology continued to excite you throughout your training period.

Dr Jauhar: Yes, absolutely. When I started my cardiology fellowship I wasn't sure which area of cardiology I wanted to do. Being a physicist, I was interested in cardiac electrophysiology and I was very interested in arrhythmias, but I was all thumbs. I wasn't really that good in the lab doing procedures. My brother is also a cardiologist. He is an interventional cardiologist, and when we were growing up he was the tinkerer and, for lack of a better word, I was the thinker. I like to think about arrhythmias and intracardiac recordings, they all made sense, but being in the lab, putting in a pacemaker, those are things I didn't feel that I was very good at.

I wanted to develop relationships with patients. That was really important to me and was one of the reasons why I decided to go into internal medicine. Heart failure seemed like a great way to combine my interest in electrophysiology, in the failing heart, the physiology of right-heart caths and hemodynamics but also in taking care of very sick patients. Developing long-term relationships with patients who are near the end of life and really being an internist was very important to me.

Dr Harrington: That all comes out beautifully in the book, where you describe why heart failure attracted you. You are absolutely right about this intersection of physiology, electrophysiology. Heart failure is a great area for people who like to think about the physiology of the heart and at the same time, it is a place for people with communication skills, the ability to feel as though they are the physician overseeing the care of that patient. It sounds like a wise choice.

Now we jump to when you leave the ivory towers, if you will, of New York City, where academic cardiology is quite prominent at all the places you had been, and you move out to Long Island Jewish, where you take your first academic job, which becomes that transition from trainee to independence.

Talk to me about why you chose academic medicine. This is a constant tension in your book going back and forth between whether you want to be in private practice or to remain in an academic job. I never get the sense, Dr Jauhar, as to what it was that made you say, ah, I need to stay in academics. I am devoted to a life of inquiry. I am devoted to a life of scholarship and wrapped around that will be my care of patients. What was the attraction?

Dr Jauhar: There are many things. I wanted to be around trainees. I genuinely enjoy teaching. I wanted to be in the CCU running rounds, interacting with interns and residents and fellows. That was part of it. I also didn't want to think too much about the business aspects of running a practice. It just wasn't something that appealed to me, and I think that is true for a lot of doctors. One of the reasons for the growing disillusionment in the profession is that so many physicians have to think in business terms to keep their practices afloat. They have to think about reimbursement and overhead; things that didn't attract them to medicine. We go into medicine to help people or because we are intellectually stimulated by it, but in the vast majority of cases, it's not because we want to make a lot of money or want to be entrepreneurs running our own practices, and that certainly was the case for me.

I thought academics was the right fit for me, and when I spoke with one of my mentors at NYU and asked if I should apply for private practice or academics (I was leaning toward academics) he said, "You know, the most important question that you need to ask is how much money do you want to make. Is making a lot of money really important to you?" I said, "Well, it's not," and he said, "Well, then, do academics, but there is a ceiling on how much you are going to make." I said, "That's fine." I wanted to do the other things like teach and do clinical research and be around people who are academically oriented and also just to not have to think about business.

Dr Harrington: Yeah, it is an interesting discussion. I have similar conversations with trainees and I flip the question and usually say, "Tell me what makes you want to get up in the morning? What excites you?" In your case, it sounds as though the interaction with trainees and the teaching aspect of academia is what made you want to get up in the morning. I tell people that you want to be doing what it is that you love and then, we all have to think about the financial realities of compensation, etc, but you really want to think: what do I love to do? What really makes me say, "Hey, this is why I'm here"? In your case, the teaching aspect of it is so critical.

Disillusionment and the Stress-Test Mill

Dr Harrington: As we talk about the book, we are weaving in the themes that you bring out, the book is a lot about your disillusionment. You realize that medicine is a business, and you realize in some ways that it is a very cold, calculating business, at least in the environment that you are in.

I am not a naive person, but some of the descriptions of the business practices shocked me. Am I naive enough to think that people don't run tests because there is money involved? Of course not, but the almost-laser focus on that mercenary behavior was shocking, and I imagine that is what led to your book.

Dr Jauhar: I started in academic practice. I felt good about it, but for a number of reasons there was a shortfall in my income, with a lot of debt to pay and a new family. I found myself in a position where I had to moonlight to make up for that shortfall. I found a private practice in Queens where I was offered the opportunity to work on weekends to supervise stress tests and also see patients, and as you probably know a lot of academic physicians do moonlight to make ends meet.

Dr Harrington: It's a common issue across the country.

Dr Jauhar: I found myself in a position where I had to do that. There was a huge focus on running a mill of patients who were almost lined up through the door waiting for their echoes and their stress test and their Holter monitors, and in many cases they were unnecessary. There is no question about it, and even though I wasn't ordering the tests (I had been hired, basically, to supervise them), I would talk to the patients and ask them about symptoms they were having, and in many cases it turned out they weren't having too many symptoms, and the stress tests were really unwarranted.

I just started to feel dirty about the whole thing. At the same time, I was under financial pressures, and I am not going to say that doctors don't make a lot of money, they do, but in my particular circumstance with the debts and having to make up for the deficit somehow, I continued to supervise these stress tests and read these echocardiograms. I didn't order them. I tried to dissuade some of the testing as much as I could, but in the end I felt that I was complicit in this financial machine. The doctors I was dealing with knew exactly what they were doing, and they were very focused on doing procedures and generating revenue.

I am certainly not saying that all private practitioners are like that, but the doctors I dealt with in this part of the country were very focused on that.

Dr Harrington: As you have had a chance with your book to travel the country and be interviewed. Is this a New York, or a Northeast, or a country phenomenon? I have to say that some of the descriptions not only were distasteful, but they were shocking in terms of the complicity, not your complicity, but in terms of everybody with a wink and a nod saying, oh, we know this is going on but this is okay.

Dr Jauhar: There is a scene in the book where I spoke to another physician, who was also moonlighting at this practice, and I tell him that I am going to quit. This is just a few weeks after I started and he said, "I know you are unhappy, but you will get used to it." That was essentially what he was saying.

Dr Harrington: I remember this.

Dr Jauhar: And he said, "You think this is only happening in New York? This is New York, New Jersey, Northeast, California, this is happening everywhere." And he correctly said, "If you quit, the guy is just going to hire someone else."

Dr Harrington: And, as they say, and so it continues.

Dr Jauhar: Exactly. I continued for about a year or so and then made some changes and got out of it, but it was an eye-opening experience.

Dr Harrington: And it clearly tortured you, and that comes across in your writing. You are a physics undergraduate major; I was an English major as an undergraduate, and in many ways the book struck me as the fall-and-redemption story of the innocent wandering into this world of this bad behavior and the proverbial fall from grace, and then there is the recognition of the wrong and the redemption.

And your redemption seemed to be getting a better hold on your work/life balance, not having to travel, not living in the excitement of New York, but moving to the suburbs for a bit of a quieter life, and by the end of the book, I feel a sense of almost relief coming from your writing.

Dr Jauhar: Absolutely. It was a tough few years, and when I started writing the book I had this "I-don't-give-a-shit" attitude, I am going to write this book, and I don't care what the consequences are. This is something that I needed to get off my chest. With that motivation it was as truthful a book as I could write. It is very unadorned. It is warts and all, and for the most part people responded fairly positively.

Physician Reaction and Fixing the System

Dr Harrington: I could talk to you all morning, but we want to be respectful of both your time and our listeners' time, so let me ask you two questions. For the first: What has been the general response, and I am particularly interested in physicians, since our listeners are mostly physicians? And then the second question: Is American medicine doomed as currently configured, or is there redemption for us? What do you see as the path forward?

So let's take the first one. How are physicians reacting?

Dr Jauhar: Generally very positively. I walked out of the Au Bon Pain at my hospital a week or two after the book came out, and there were three physicians there and they actually applauded. They applauded me in the hallway, which was a wonderful feeling. But there were certainly a vocal minority of physicians who were unhappy.

Dr Harrington: Oh, I suspect there were.

Dr Jauhar: They were unhappy with how I have characterized the profession and private practice, and it wasn't my intention to paint things in such broad strokes. I made it very clear that this was my experience, and I state very clearly that the vast, vast majority of doctors, are good, honest people, but the system is so diseased that it forces behavior in people, including myself, that is just distasteful.

Dr Harrington: Let's talk about that, the system issues. Certainly, as we move more and more toward physicians as employees, physicians or health systems taking care of populations instead of the traditional fee-for-service mechanism, is that the right way that the system is going to be reformed, or do you see that more fundamental, bigger changes have to be made?

Dr Jauhar: I personally feel that the fee-for-service system has created very perverse incentives that are largely responsible for the hole that we are in. The fee-for-service system is why this doctor was able to get away with this nuclear-stress-test mill, and we have to do something about that at a fundamental level.

I made my choice to be a faculty physician, to draw the salary. I personally think it is the right choice for me and quite possibly is a good choice for a lot of physicians, removing the incentive to do a lot of testing and having to think about the commercial aspects, which I think most physicians are uncomfortable with and has led to a deepening disillusionment.

Exactly how the system should be reformed I am not sure. One way of thinking is something that Steven Brill talks about in his new book ( America's Bitter Pill ), which is integrated-care systems where hospitals have their own insurance product, and that takes away a lot of the incentive for their doctors to overtest, overtreat patients and it also takes away that "beholdenness" to insurance companies. That may be one way out of the mess, but I have no doubt that there will be a way out of the mess, because American medicine was always the best in the world and today there is a lot of dysfunction in this system. But there is a lot of good in the system, also, and I think we are at a tipping point. When physicians are unhappy, patients are apt to be unhappy, and right now no one is happy about the system, and I think that creates the right mix to conduct large-scale reform.

Dr Harrington: This has been an enjoyable and enlightening conversation, Dr Jauhar. I'd love to get you back some time to talk about some of the topics I've perused on your New York Times blogs and hear what you are thinking. We are glad that you are in cardiology, and we appreciate your willingness to be so raw in your descriptions, to be so open and transparent.

I want to thank, then, my guest, Dr Sandeep Jauhar, who is the director of the heart-failure program at Long Island Jewish Medical Center. He is a frequent contributor to the New York Times and for the purposes of this discussion is the author of Doctored: The Disillusionment of an American Physician. Thank you for listening and, Dr Jauhar, thank you very much for joining us here today on Medscape Cardiology.

Dr Jauhar: It was my pleasure. Thank you.

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