Just Like Someone Without Mental Illness Only More So (23 page)

Interviewees invariably talked about how much they wanted to contribute to society, help people, push medical science forward. When I asked them what being a doctor was going to do for them, often they looked at me like was a trick question.

We rate applicants on a scale of 1 to 10, but you quickly learn that a 9.0 is the kiss of death. I mentioned this to one of my fellow committee members, who said, “Yes, and 9.5 is no kiss at all.” If you didn’t have all or mostly 10s, you probably weren’t going to get in.

The process whereby one gets to be a doctor is one where you pretty much have to be a grade-and-approval junky. This eventually has unfortunate consequences—all a hospital or insurer or pharmaceutical company has to do to get doctors to jump through hoops is set up a grading system and put some doctors in tier one and others in tier two or three or four. The courage to do the right thing in the face of disapproval is often lacking.

There is a dangerous point in the deliberation process of the admissions committee where the application has been formally presented and one of the people who interviewed the candidate briefly defends why he gave the candidate a 9.5 or 10.0. There’s a pause where anyone on the committee can say anything. If the next thing that’s said is strongly positive, the application will sail
on to the next level, but if someone says, “A bit thin on the extras,” or “Were they involved in the community?” or, worst of all, “It’s a strong application, but is this applicant really right for
here?”
the fate of the otherwise strong applicant twists in the wind. Trying to defend someone at this point almost seems to make it worse. If the application needs your help, how good could it be?

People don’t apply to Harvard Medical School lightly. They are all standing on a lot of shoulders. We were passing judgment on some of the most absurdly intelligent, accomplished, highly motivated men and women the world had ever produced.

The curse of having to be important dooms a lot of us. Living up to all that white marble and the tree Hippocrates taught under and the admissions process is not easy. If you become a doctor to make a difference, it turns out that no difference you can make is enough. Unambitious people aren’t going to be applying to or getting into medical school, but once an ambitious person gets in, she has to either win a Nobel Prize or learn how to be of service to ordinary people with unglamorous problems.

If it wasn’t for questions like “How high’s the fever?” “How many days has he been sick?” or “Diarrhea?” I wouldn’t know what to say to people. Whether or not children eat vegetables has consumed a significant part of my professional life. Nobody I’ve interviewed for medical school has said they want to get really good at treating diaper rashes and quieting crying babies and frightened children. Life-or-death comes up less often than you might imagine and when it does the doctor’s power to change the outcome is limited. If you’re saving your energy for the big important moments, you’re going to be saving a lot of energy. People who are trying to die are trying to tell us something.

——

“What problems are young people having today?” I was asked at a harmless social get-together at the home of the dean of admissions.

The problem for young people today
is
the Harvard Medical School admissions committee. People this bright and accomplished shouldn’t have to be begging for a job in medicine. It shouldn’t be so hard. There should be more clearly defined, simple paths for people to be of use. That so many young people want to be doctors speaks well for the families producing intact applicants and for medicine for attracting them, but I can’t help feeling that there should be a broader array of choices. People that intelligent who have worked that hard should be able to be doctors if they want to. What exactly is the point of producing an abundance of amazingly capable people if we don’t have more things for them to do? Two hundred years ago being able to read and write a little, being healthy and having a work ethic, meant you could do well at just about anything.

It shouldn’t be so hard for people to figure out what to do with their lives.

“What the hell are we going to do with Timmy?”

“I don’t know. Do you think we could get him into med school?”

Every Nobel laureate was once a goofy sixteen- or twenty-two-year-old whose family worried about what the hell he or she was going to end up doing.

I have had heartbreakingly accomplished patients kill themselves or become heroin addicts. It’s not enough to play an instrument perfectly or to get a full scholarship.

As soon as a new hurdle is set on the path to getting into
medical school (organic chemistry, higher and higher GPAs, higher and higher board scores, extracurriculars, community service, moving personal stories, et cetera), the ability to clear that hurdle spreads through the applicant pool like the ability to resist penicillin spreads through a petri dish. Everybody is throwing a lot of pasta up against the wall hoping that it will stick. Any essay that works will be reworked and reworked and reworked some more.

Some applicants were accused of trophy collecting. It wasn’t enough to be a concert pianist, work in a first-rate research lab, or save a small South American village. It had to come from the heart.

After watching so many candidates I liked go up in flames I suggested to the dean that each committee member be allowed to advance one applicant a year to the final pool without the usual debate. He thought it was a good idea and would bring it up to the committee.

Is a doctor really that special a thing to be, or are we making too big a deal of this? It’s like we’re all scrambling to get to a place a little higher up on some slippery pyramid because we don’t know how high the water will be when the tide comes back in.

Sometimes my father would call me out of the blue. “Is this the doctor on call?”

“Yes, it is, Dad.”

“Sorry about your profession. I wouldn’t be a doctor for anything. That’s got to be the worst job in the world.”

When I became a pediatrician, a short visit cost ten dollars, a checkup was twenty. People paid cash. Our overhead was 27 percent. Our books were kept on a yellow pad. We were free to determine the content of the visit, which mostly consisted of asking patients or parents what we could do for them and taking it from there. When medical insurance came into pediatrics, it seemed like a good deal because we would suddenly be paid twice as much for visits and procedures and our patients wouldn’t be paying anything out of pocket, since it would all come out of the insurance that was taken out of their paychecks. We also realized we had no choice, since no matter how much they loved us, most families would take their kids where the care was covered by their insurance. We also had to get computers and hire people to track whether or not we got paid and do a bunch of other stuff. There goes the overhead.

In the fine print it became illegal for us to charge the uninsured or anyone else less than we charged our insured patients and it also stipulated that the insurer would pay us at a discounted rate for our charges. The net effect was that my professional services went from something my patients could easily afford to something that, without insurance, they couldn’t.

When I ask pharmaceutical salespeople what a new drug costs, they hasten to reassure me that it’s covered by insurance and will only cost the patient a ten- or twenty-dollar co-pay. Co-pays are the tip of the iceberg. Without insurance all these new, absurdly expensive medications could not exist. With insurance it becomes suddenly worthwhile for pharmaceutical companies to spend millions and billions pushing less-than-necessary medications to providers and patients. These costs push up the cost of other medications and insurance and care in general. If you believe that the dollars made by the pharmaceutical
industry are plowed back into research that leads to better and better medications, you probably believe in the tooth fairy as well.

A dispassionate look at all the many innovations of the insurance industry, from HMOs and managed care to co-pays and prior authorizations, would show that each innovation was a way for insurers to make money at the expense of the public good. If these innovations were studied like a new drug or medical device, they would be taken off the market.

What doctors should be doing as advocates for their patients—as advocates for change—is grading and reviewing the hospitals and insurers, but instead they cower in fear. Doctors get to be doctors by knuckling under, but at some point, for the good of their patients, they should wake up and insist on being in charge.

Both the medical insurers and drug companies make and hold on to as much of the money as they can. They have, to a large extent, subverted the efforts of hospitals and other providers to care for the sick. The sick have been converted into financial instruments whereby large amounts of money are transferred from one corporation to another. The business opportunities presented by sickness and the threat of sickness have cast into outer darkness the opportunity for medical practioners to be of help and service.

A hundred years ago the Flexner Report revolutionized medical education and medical care by emphasizing science and paying attention to what happened to patients. It’s always possible that history will repeat itself. Maybe today’s medical students or the next generation or the next will say, “No. This is how it should be done. First, do no harm, care about what happens to patients, and settle arguments with good science.”

You Can’t Ignore Gravity
, 2008

(Painting by Mark Vonnegut)

Three years and two more marriage counselors after Honduras, I hadn’t had a drink in five years. I smashed a glass at my wife’s feet and broke an expensive tile. The next day I pushed a chair she was in.

I had to leave.

Whatever peace we had managed to work out couldn’t survive my not drinking.