“It is our obligation to remove the biases that stand in the way of good medicine. We need to assure no consideration of economic self-interest will prevent us from giving our patients the safest, most effective and most economically responsible health care possible.” So spoke the president of the American College of Cardiology to a group of inductees in 2005.
In the audience sat many young doctors, including Dr. Sandeep Jauhar, a New York cardiologist struggling with many aspects of the American health care system. The convocation speech is filled with platitudes such as this one, and virtually no doctor, especially at the outset of his or her training, would disagree with these sentiments. The struggle, writes Jauhar, is to actually make convocation speeches come to life. How do we keep these sentiments from just being banal and clichéd statements and instead enact them, creating a real impact in the way we practice medicine? This question and the effects of our failure to answer form a central theme in Jauhar’s memoir Doctored.
Doctored: The Disillusionment of an American Physician is Dr. Sandeep Jauhar’s second book. In keeping with good narrative nonfiction, Jauhar offers a mix of personal stories, thoughtful interludes and an obvious effort to back up claims with facts and statistics. He offers compelling anecdotes, which allow the reader to situate him or herself into the context of health care in New York City. These personal vignettes are especially helpful for highlighting concepts difficult to discuss; an ethical dilemma or complex criticism of the health care system becomes much easier to understand when tied to a tangible person or place. His writing style is casual and conversational, making the book an easy read; even so, there is a wealth of truth and meaning to be found within its pages.
The book covers a wide variety of subject matter: the American health care system, the physician burnout epidemic, medical education, ethical issues, familial struggles, being a husband and father, even religion and faith. Jauhar writes honestly and candidly about his personal experiences with American health care. He doesn’t seem to be casting himself as the “good guy” or “bad guy,” but instead tries to give the reader an authentic look into the system in which he works. He does not shy away from his own moral quandaries, doubts, failures or weaknesses, which makes him relatable. He is also unafraid to openly criticize the system in which he works — a system that is, at least from his perspective, replete with problems.
The sheer amount of problems Jauhar identifies, along with how he tries (and often fails) to handle them, is mind-boggling and quite depressing. In fact, my main and only criticism with the book is that it is at times overwhelmingly distressing (just reading his lists of duties and responsibilities was enough to induce a bit of anxiety in me). The introduction paints a bleak picture of the system, using data and stories about burnout that are disheartening. Although it ended with some slightly more optimistic stories (for the author, at least) there is no “happy ending” — he does not offer a comprehensive solution or even demonstrate that most of these problems are fixable. Although this is in itself depressing, it is raw and honest, too. The point of the memoir isn’t to solve the problem; if he could do that, he would be doing it. Instead, I felt the purpose was to shed light on the previously dark, hidden parts of American health care from a doctor’s perspective, to offer a few ideas about why we have such problems and to inspire the reader to change for the better.
Unsurprisingly, many of Jauhar’s thoughts regarding the broken health care system revolve around money. He presents a dizzying amount of information on finances, revenue, bureaucracy and the like (though he generally presents it in an understandable and relatively manageable way). He reports on many conversations heard over a four-year period — at the hospital, at home, at dinner parties — and all the gossip seems to be about money: doctors aren’t paid enough, doctors are paid the wrong way, hospitals get rich while doctors get poorer, overtesting is a problem but it’s the only way to get paid, etc. The anecdotes regarding fraud and ‘bending the rules’ for personal gain are sickening, both to the reader and to the author; even so, Jauhar confronts many of the issues in himself. It is clear he has made some hard decisions, some of them ethically questionable, but he does not try to portray himself as better than “those other guys.” Instead, he confronts his own struggle with thinking he would never succumb to that way of life vs. feeling like he had no other choice. It seems easy to hate the selfish, greedy doctors, but I think he is trying to show it is more the system’s fault than any individual’s. I liked this line: “Most people think of doctors as either consumedly avaricious or impossibly altruistic.” Through the course of the story, it becomes clear to the author and the reader that almost everyone is somewhere in between.
As a medical student, I admit this was hard for me to read — no one wants to hear that the career they are pursuing is broken, maybe hopelessly, and that it’s filled with self-centered professionals who care more about money than serving others. The author addresses this, too — he talks about the genuine desire to help people that motivates nearly all doctors at the beginning of their training. He seemed to be simultaneously yearning for a big change in the culture of medicine while feeling like the problems are so immense the system can’t be changed. He explores this mindset briefly, noting that it has caused many (including himself) to become jaded to medicine. This is unfortunate, but he does conclude somewhat hopefully with the idea that medical students might be best equipped to handle the issues because they aren’t so weighed down by expectations. I believe that’s why books like this are so important — Doctored gives us a candid look into a modern physician’s life in a way that wasn’t available to doctors of Dr. Jauhar’s generation. Even though I struggled with a sense of self-righteousness and justice (“I would never choose to do X to a patient just to make more money!”), I realize this is exactly the point he was trying to make — the system is so broken that it makes the best of us compromise our own values sometimes.
Despite much focus on bad doctors and a confusing, injured health care system, there were many spots of joy in the book, too — most of them centered around patient care. This isn’t surprising, really; Dr. Jauhar himself claims that even the most disillusioned and dispirited doctors still get more joy from their patients than anything else. He discusses the values of thinking critically to solve a problem, laying hands on a patient and performing a thorough physical exam. One of my clinical medicine professors loves to tell us, “never miss an opportunity to touch a patient;” not only does this go a long way towards making the right diagnosis, it makes patients feel better about the care they are receiving. Many of the anecdotes seem to make this exact point. He recounts one relevant story involving his own father; in the case, a long, expensive workup was unable to make a diagnosis eventually made by a simple physical exam maneuver. He also writes about the value of admitting mistakes. Though malpractice lawsuits have made physicians wary of admitting fault, doing so actually goes a long way to providing better care (in addition, of course, it’s ethical to tell patients the truth).
The most valuable feature of this book was, to me, the author’s labors to make it educational — to teach the reader about everything he is writing. At heart, Dr. Jauhar seems to be a teacher. He writes much about his internal struggles with choosing academic medicine or private practice; for him, the decision seems to hinge on his unwillingness to give up the title of assistant clinical professor. Throughout the book, he takes brief asides from his points to make sure the reader understands exactly what he is writing about, whether it is a procedure, a medication, the difference between private practice and an employee hospital or an insurance plan. This makes it an even more enjoyable read, as well as accessible to a broader audience.
The struggle to be an ethical physician driven only by internal purpose and altruistic motives is central to this book. Indeed, Doctored goes beyond the typical memoir by striving to answer what it means to be a doctor in the modern health care system. The cynicism of the modern physicians seen throughout the book is more than understandable when read through the lens of these doctors: they struggle to be ethical, but feel there are too many gray areas; they strive to provide the best patient care, but need to pay their bills; they desire to work from altruistic motives only, but find that American health care is largely based on the bottom line. These issues are serious and run deep, and the burnout that plagues Dr. Jauhar seemed to me a reasonable response to the brokenness in which he works. It is tempting to judge doctors from a distance and to blame them for causing their own problems. As with anyone, though, it is unfair to judge until we have put ourselves in the other person’s shoes. Doctored offers us the opportunity to do just that. When we step into the shoes of Sandeep Jauhar, we are fortunate to find that even in the midst of the brokenness, there is still hope.
Editor’s note: A version of this article was previously published on Student Doctor Network.
Prints, Pages and Pagers aims to look closely at the lives of medical students and doctors, real or fiction, whose lives and experiences are told in novels, short stories, poetry or any kind of writing. These book reviews are an opportunity for medical students to learn from the many fascinating stories produced by the field of medicine, and maybe to read something other than a textbook.