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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.