COMMENTARY

It's Time for Physicians to Organize -- For Our Patients' Sake

; Abraham Verghese, MD

Disclosures

October 04, 2019

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol. Welcome to a new episode of the podcast "Medicine and the Machine." I'm with Abraham Verghese, and today we're going to delve into my recent New Yorker essay, "Why Doctors Should Organize." So, Abraham, what was your take on the whole thing?

Abraham Verghese, MD: First, I was thrilled for you because as a writer, to break into The New Yorker is still a beautiful thing. I very much remember that moment, so I hope you were pleased to have cracked that nut because I think it portends well.

I'd love to talk with you about two different aspects of this, if you don't mind.

Topol: Of course. Thank you.

Verghese: First, I'd like to talk about the writing process and the mechanics of working with The New Yorker. My memory is that it's a wonderful experience to be working with people who take so much trouble with the written word and every sentence—and the fact-checking. Tell us what that was like for you.

Topol: It will be fun to get into it because I haven't discussed it with anyone. In all my years of writing—more than three decades—I have never had fact-checking like this. Every word was fact-checked. There was a fellow named Melvin who was assigned to fact-check me, and this was beyond the beyond.

I had cited articles from The Washington Post, for example, and he said that it wasn't good enough; I need to go to the source and get the PDF of The Washington Post article and what it said. As you may recall, in the article, I reviewed the experience I had while at UC San Francisco as a resident when I was picketing as part of an organized protest about the nursing shortage. And Melvin wanted to know who some of the other residents were, to verify that this had occurred. I gave him the name of one of them and Melvin contacted him. Turns out, he remembered the protest but he wasn't at the San Francisco General Hospital, so he had to give the names of two others, who Melvin contacted to confirm that the protest occurred.

Then I had written that I had long been a member of the American College of Cardiology (ACC). Melvin called the ACC to find out whether I was a member, and the ACC president spoke to him and said, "I have to get back to you on that." The ACC president sent me an email telling me to call him right away. So I call and—I can't believe this—he says, "You have to pay your dues or I can't say you're a member."

This fact-checking went to the extent of contacting Medicare and the Bureau of Labor Statistics directly about the ratio of administrators to physicians. So this was a grueling experience that took many hours—not just of verbal communication but back-and-forth email with sources and getting PDFs sent. It gave me a deep respect for this medium. I've never seen anything like it. I wish everything could be fact-checked like that. It takes longer. It's a process, for sure; you don't see this kind of fact-checking to this extent.

Verghese: Especially in this day and age when facts are flying so loosely on the national level, it is so refreshing to encounter this. I've written both fiction and nonfiction for them, and I've been struck by the worry they would take over a punctuation mark and a particular word choice. It was beautiful. It was a reminder of how seriously you can and should take writing.

It makes me wonder also about our medical journals and our peer review. I think we don't have that kind of fact-checking but we count on readers to quickly respond with letters to the editor if we're way off base. But we never have that kind of fact-checking. Not even reference checking.

Topol: You're absolutely right. We don't. I spent an evening recently with Carl Zimmer, a science journalist for The New York Times, and he told me that during his career, the type of legendary fact-checking that was at The New Yorker was replicated by many other magazines and media. But over time, because of the constraints of funding, they just couldn't support the human resources to continue to do it. It's a shame because, as you say, there's so much difficulty right now in differentiating the truth—the gray zone and the actual fact. It's good to see that someone still puts some emphasis on that.

Verghese: Yes, that's wonderful. Now let's get into your piece. I love the way you launched into it because it was about a topic that's very dear to my heart: the issue of gun-related violence and what role medical personnel—students, physicians—have in this. We have a very active organization of physicians addressing gun violence here at Stanford. It was started by our students and championed by our faculty, especially Dean Winslow, who is a former distinguished military officer as well as a wonderful infectious disease physician. I think he was appearing at a congressional hearing to be undersecretary for defense under General [James] Mattis, with whom he had served, and he was asked about guns. He candidly said that he didn't see why assault-type weapons should have any business in civilian life. Well, that was the end of his hearing. That was the end of it.

Anyway, you led the article with an account of doctors getting involved in the gun violence issue. Tell us about that, because that's what led you to this argument in favor of organizing, it would seem.

Topol: You're absolutely right. To me, that was a turning point—watching physicians come together against the NRA. When the Annals of Internal Medicine and the American College of Physicians published the position paper[1] about the way doctors should tackle gun practices and specifically be concerned about guns in patients' homes, and advocated for assault rifles being banned, of course the NRA responded negatively. "These doctors should stay in their lane," the NRA said. And then you saw the extraordinary response from physicians—the solidarity, the likes of which I've never seen. And it was not just social media. It was on television and in magazines and newspapers. It was everywhere.

That gave me a sense that we're at a different time in medicine. So many prominent physicians then posted pictures of themselves splattered with blood. All of these things brought out the emotional side of what it's like to be a doctor who cares for patients who have suffered gunshots.

At the same time, I was thinking about the Parkland, Florida, high school students. Look what they've done. Not that we've gotten the laws changed, even though, you know, 90% or more of Americans want them to be changed. But it got me to wondering: Why aren't we having more activism? I tried to think back over my many years in medicine, and the only other time I could remember was the strike in front of the San Francisco General Hospital.

Verghese: Tell us about that. It sounds like the year that I was also a house officer, in 1981.

Topol: Right. It brought all of that back to mind. The New Yorker was thinking about publishing pictures of the residents picketing, but then they'd have to get permission, and a lot of them look like hippie freaks, with their hair down.

Verghese: They're all distinguished professors now with much less hair, I assure you.

Topol: There you go. The strike was over a number of things. The nursing shortage was one. Also on the list was childcare, better meals, and a ping pong table in the lounge. You know, silly things. The chief of medicine at the time was Merle Sande, and he was enraged. He came out with a bullhorn and told everybody to get back to work, and they refused. It led to some pretty serious confrontations that extended even beyond the strike.

I've heard now from many other people that they've had small gatherings like this in their experiences, whether during training or subsequently. But it's unusual, because most times, as you know, doctors are busy. They're taking care of their patients and their other activities, such as data clerk work, as we've discussed in previous episodes, so they just don't come together for many purposes.

Verghese: I think the trouble is that doctors are perceived as having great lifestyles, and unions are seen as the bread and butter of the blue-collar worker. Over the years, as doctors have lost more and more autonomy and have wanted to organize, perhaps they've come up against obstacles. There's no support for doctors going on strike. I mean, immediately there's a sense of alarm. Are their patients going to be affected, and so on. So it's been a curious phenomenon to observe. Whereas everyone else in the hospital is very well organized. The nurses are incredibly organized, and that union is gaining in numbers every year and bringing about concessions that are important to them. But not so with [physicians].

Not thinking about what an organization could do today in terms of prioritizing time with patients is representative of the problem.

Topol: It's true. And when you look at the landscape, the fact that we have no entity that represents even half of doctors, much less all, is a big shortcoming. Think of the gravitas of having most doctors unified for purposes that are different from most professional organizations as they exist today. Our professional organizations are largely concerned with the interests of the doctors rather than the patients and that relationship. I believe there is a potential here.

I got some tough responses to the article from the ACC. They wrote a letter to The New Yorker and they called me. They tried to list all of the patient-centered activities that they're involved in. But I still haven't found any, despite their list. Not thinking about what an organization could do today in terms of prioritizing time with patients is representative of the problem. It's the essence—as you say, the "presence"—the human element that has largely been compromised. I don't know any organization yet that has stood up for that among doctors.

Verghese: The trouble is that so many of our professional organizations (and I think this is true of almost all of them) were supported by a membership that really wanted them to be at the table in Washington and make sure that the interests of the membership were not being hurt. It was all about the bottom line; it was all about each specialty making sure that it was not being hurt by whatever was coming down the pike. So Congress is used to us lobbying for money; when you turn the argument away from money to something else, we've already lost credibility. I don't think they're listening very well. When we talk about gun violence, they should be listening. No one else sees it quite the way we at the frontline see it.

Topol: Right. And the other thing that brought to mind is how vital this is at this juncture. We haven't ever gotten the gun thing right. It's such a remarkable void of action for decades now. We keep seeing the mass shootings and deaths, and we're such an outlier in the world. But at the same time, we have this ability to potentially get medicine on track. As we've discussed, we have the ability to lean on machines, to decompress the work of doctors, to organize things better for doctors, and also to outsource more to the patients who want to take this stuff on. But if we don't do something different, the squeeze will continue, don't you agree?

Verghese: Absolutely. The trope for 10 years at least is how many of us are miserable about the electronic medical record (EMR) and how many of us are leaving medicine. The fact is, you and I have very good jobs and very satisfying organizations to be working for, but universally everyone is struggling with the EMR. What if the hundreds of thousands, almost a million, physicians out there got together and said, "You know what? Today is a paper day; we're only going to write things on paper today"? I think we'd get some attention because it has felt as though "you've got to do this; this is the way it is." I think the misery it's caused over the past decade or more could perhaps have been avoided if we'd had a stronger say in what was being brought down and given to physicians to use.

Topol: There was an interesting essay in the Annals of Internal Medicine by a physician named Diana Pi.[2] I don't know her. She works in Ohio. She wrote about how she was working and then the administrators she was working for said that her new-patient slots would be reduced to 20 minutes. So she quit. And she realized that when she didn't have to deal with the reality of not providing the care she wanted to provide, things got better for her. But then she yearned to care for patients again and she went to a free clinic. And there the people said, "Just take your time, however long it takes." And she's completely recharged, rejuvenated, and enjoying the practice of medicine again. It was extraordinary to read that. That's the sense—that there's not enough time. It is the disenchantment factor that current professional organizations aren't talking about.

Verghese: Exactly.

Topol: There's none of that concern. They are folding into the business of medicine and being a party to it. This is disenchanting. Another noteworthy aspect of this is the abuse of the term "patient centric." That term is used for so many things that aren't patient centric. The question is, how do we get back to this better state of real medicine?

Verghese: Part of the challenge is that this is not one discrete entity. We're not talking about truckers. Physicians play so many different roles, and each hospital and medical organization is so different that, even though we are a million strong, trying to make that million work around one issue will be incredibly difficult. This is especially true if it's a local issue, such as your EMR, which may be very different from mine.

I think I read that in 1999, the American Medical Association actually created a physicians' union that was called Physicians for Responsible Negotiation. This union vowed never to strike because that went against the norm of our vow to the patient. (I must add, in all the strikes that I've read about, no patient care was ever seriously jeopardized; critical care was maintained.) But at a certain point, I believe that the patient discomfort and the pushback that comes has always weakened physicians' ability to form unions.

Topol: I avoided the term "unions" because they have a negative connotation. The other question is, how do we go forward with this? I didn't know that this could take shape. But what has been fascinating to me is that so many physicians have contacted me who would like to actively support this movement. Already a few are getting organized to take the lead. We've talked about whether the membership fee should be one dollar or five dollars, just to say that you're in it. There will be some costs to the formation, charters and legal fees, registration for a nonprofit entity, and so on. So there has to be at least a small amount of monetary support.

The goal would be to get as many of the million physicians as possible to take on this initiative, to stand up for the patient-doctor relationship, to get behind the things that really matter—kind of, back to the future of medicine. But another potential role is to counter all the misinformation that's around—for example, about vaccines or nutritional supplements, or standing up together for gun safety. This organization could stay narrow in its focus, but by standing up for patients we can address other matters that have been left untouched.

Verghese: In your article you mentioned a Union of American Physicians and Dentists. It does not have a large membership. From your understanding, what would be the limitation of using that existing organization?

Topol: Lots of these small unions and organizations exist. Some of them even had a mission that wasn't so different from what I've articulated. But they're very small. Many have been around for a long time. They've never developed momentum. One thousand, 10,000, or 100,000 is not going to do it. It has to involve as close to the majority or complete presence of the physician community as possible. One of the problems we've had is that even though there have been many of these entities over the years, most have not been in alignment with this goal. Many have disbanded along the way; none have developed any momentum over time.

Also, the last thing we want is to create another financial hit to doctors. So, if not free, this needs to be close to that so there's no burden attached to it. I believe that this is important.

Verghese: I love the fact that this is really about the primacy of the patient-physician relationship and the time with the patient. I believe that as long as that's front and center and you get the numbers, then you can have an impact on some other issues that are perhaps of less concern to the patient but are critically important to the health and well-being of the people caring for them. It's a great idea.

Topol: Thanks. The patient-physician relationship must be the center, the principal objective. In the medical world, we are largely beholden to our overlord, the administrator, whereas in the rest of the professions, that's not the case. Now, many organizations and health systems in the United States do have a physician at the helm, but those are the exceptions. Most of the time, the bean counters are not physicians. The performance metrics of those with physician leadership show that to be an advantage. Nonetheless, we're in a peculiar situation where doctors have become essentially subservient to administrators whose principal interest is to deliver the financial goods, and that's a problem.

We have to somehow come up with a counter to that. Whether artificial intelligence could replace a lot of the administrators, I don't know. But that is the creep that's occurred. We've seen a 3200% increase in administrators, which was verified directly by the fact-checker, versus the 150% increase in physicians. So we're talking about two orders of magnitude more of administrators, and they are not involved at all with patient care. Yet we physicians are lacking time with patients. Isn't something wrong with that picture?

Verghese: It's amazing. Way back when managed care started out, physicians feared that it would put people in charge who would create an efficient organization at the expense of the very things we care about, not just income. We lost that battle because there was no union at that time. There was no organization. And that's why we're in this situation where we're not autonomous by any means, even though we like to think we are.

Topol: You're absolutely right. That was a big hit and it didn't have much pushback. Then there was the relative value unit (RVU), which organizations like the AMA participated in but which further devalued and basically bar-coded visits and prioritized procedures for better financial remuneration. And then, of course, the latest issue, which we've talked about in a previous podcast, has been the EMR and the keyboard. We have weathered through, although I wouldn't say favorably. We've seen many profound hits to medical practice. Perhaps this is the moment we can begin to turn things around. I know many think that's overly optimistic, but it's better not to lose hope.

Verghese: I like the way your piece started, which is the way we might bring this to a conclusion. Being told to stay in their lane just rankled so many physicians that it brought them together organically around the hashtag #ThisIsMyLane. Capitalizing on that, Eric, with your article and the ensuing discussion to create a unified voice around the best values of being a physician, this is truly a powerful thing we could do.

Topol: I completely agree. One other thing I'd add before we close is that many of the leaders of that NRA pushback, #ThisIsMyLane, were women. Some of them were men, such as Joe Sakran at Johns Hopkins in Baltimore, but many were women. And many of the women have become the leading activists on social media about medical matters.

I wonder whether, because women have in many ways not had the voice that they should have had in medicine over the years, that's why you're seeing them shine through on this. The other demographic is younger people, younger than you and me. They are savvy on social media. These are favorable trends that may well serve the idea of standing up for the patient-doctor relationship. All of us know how precious it is and how, when we have a chance to bond and have the time, it's rejuvenating.

I hope we're seeing some of the seeds with respect to that. For other matters, some are already willing to get engaged and put their time and energy into organizing. I'm hoping it will come together.

Verghese: I'm sure it will, Eric. What is the next piece you have in mind for The New Yorker?

Topol: We've talked about the 7-Eleven or McDonald's syndrome of American medicine, where you have such profound decentralization. I've experienced it when choosing where to have a medical procedure or encounter, as have my wife and family. We have these medical facilities in every strip mall. I think that is a part of the business of medicine that's led to another big compromise and hasn't been reviewed adequately. We'll see how it comes together. It's in the early stages.

Verghese: Wonderful. Again, congratulations. It's a lovely, thought-provoking piece. I can tell you from the [experience] at Stanford that I'm struck by how much discussion this particular piece has generated, so it is quite gratifying to be having this conversation with you.

Topol: That's very kind of you. We'll look forward to our next discussion on "Medicine and the Machine." Thanks, Abraham.

Verghese: Thank you, Eric.

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