Be­tween a doc

Pasatiempo - - In Other Words - Casey Sanchez The New Mex­i­can

Pasatiempo: Read­ing The Kitchen Shrink, I was struck by the amount of sweet-talk­ing and schmooz­ing that doc­tors do be­hind the scenes to get health-in­surance agen­cies to cover their pa­tients. Dora Calott Wang: Doc­tors spend a lot of their time with bu­reau­cracy. One in three med­i­cal dol­lars goes to ad­min­is­tra­tion. This is where our money is go­ing. In my prac­tice right now, my clinic has a staff of four just to deal with this. Pa­tients don’t see this, and doc­tors’ of­fices don’t let pa­tients know. Paul Krug­man calls it the world’s most costly sys­tem, and it’s aimed at not pro­vid­ing care. Pasa: You men­tion a Yale med­i­cal-school pro­fes­sor and doc­tor who car­ries a lam­i­nated card with key phrases that help him win cov­er­age for his pa­tients. What were these phrases? Wang: They were phrases such as, “I have seen and eval­u­ated the pa­tient and agree with the res­i­dent’s as­sess­ment.” It’s like a lit­eral script. In my clinic we have a form — it doesn’t ask for my name, just my provider code. We had to list what time I saw the pa­tient, how many min­utes I spent with the pa­tient, sleep and thought con­tent. The space for thought con­tent, it’s enough for about five words. But if I want to do ther­apy, I have to spend 20 min­utes on the phone seek­ing per­mis­sion to do ther­apy. It’s a de­ter­rent against do­ing ther­apy. In any case, this is why it’s got­ten so dif­fi­cult for psy­chi­a­trists to do psy­chother­apy.

They will ask me, “How long is it go­ing to take to make this pa­tient bet­ter?” The an­swer is, I don’t know. Each pa­tient is dif­fer­ent. The physi­cians who are busi­ness­men sur­vive. The physi­cians who are pri­mar­ily in­ter­ested in pa­tient care be­yond the bot­tom line are find­ing it dif­fi­cult to sur­vive — al­most im­pos­si­ble ac­tu­ally. Pasa: In the not-too-dis­tant past, pa­tients paid for med­i­cal ser­vices not through in­surance but with cash, trade for other ser­vices, food, or even live­stock. Why is some ver­sion of this no longer pos­si­ble? Wang: If a physi­cian takes Medi­care, then a physi­cian has to charge the same for all pa­tients. They can’t ac­cept chicken and let­tuce. Psy­chi­a­trist Dora Calott Wang says that, like most physi­cians these days, she prac­tices “a strange new kind of doc­tor­ing.” It’s the kind of doc­tor­ing in which life-and-death de­ci­sions are made less of­ten by doc­tors and pa­tients and more fre­quently by the man­aged-health­care in­dus­try. Wang’s re­cently pub­lished book, The Kitchen Shrink: A Psy­chi­a­trist’s Re­flec­tions on Heal­ing in a Chang­ing World, opens with a dark chap­ter about teenage “Se­lena,” one of her for­mer pa­tients, who died of liver fail­ure de­spite hav­ing in­surance that would cover a liver trans­plant. The devil was in the cost-cut­ting, bureau­cratic de­tails — the in­surance com­pany re­fused pleas by Wang and other doc­tors to eval­u­ate Se­lena, thereby block­ing her trans­plant. The in­ci­dent is the most ex­treme ex­am­ple of what Wang has wit­nessed in her three decades in medicine, namely that “the in­surance com­pany has re­placed the doc­tor as a pa­tient’s pri­mary med­i­cal re­la­tion­ship.”

Wang is a Yale-ed­u­cated psy­chi­a­trist who has worked in­side hos­pi­tals as a li­ai­son be­tween doc­tors, pa­tients, and their fam­i­lies. Cur­rently, she teaches at The Uni­ver­sity of New Mex­ico’s school of medicine and runs her own pri­vate psy­chi­atric prac­tice. Wang sat down with Pasatiempo to talk about the book.

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