HANS DUVEFELT, MD

I am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

In many of today’s medical practices, the doctors’ names aren’t on the front door, office letterhead or company advertisements; they’re often not even in the phone book. A group of employed doctors these days can consist of multiple personality types with disparate treatment philosophies and clinical styles. I once worked with a doctor who would give patients with upper respiratory infections half a dozen prescriptions while I would say “go home and get some rest; it’ll go away”. Not knowing what the two of us were like, patients could end up choosing the doctor whose style didn’t meet their needs.

I have worked with colleagues who view every laboratory abnormality as an ominous threat and pursue each one to the ultimate degree, making even the healthiest patients uncertain about their chances of survival. Some of the same doctors also insisted on seeing even patients with mundane medical conditions on a tight schedule in order to monitor them for unforeseen medical disasters. In today’s generic clinics, patients may not know if their new or covering doctor is a reassuring pragmatist or a consummate worrywart. Worse yet, they may be shuffled back and forth between doctors with opposite styles.

2) Training Differs

In Primary Care, we have MD’s and DO’s, Family Physicians, Internists and “Med-Peds” physicians.  Each training is inherently different, further complicated by differences between schools, regions and countries.

Internists, trained to treat diseases of adults, are sometimes asked to treat children in the government-sponsored type of clinic I have spent most of my career in. They are also oftentimes faced with treating conditions in ophthalmology, otorhinolaryngology, gynecology and orthopedics – areas where they may have little experience. Their residency training may have been entirely urban and hospital based, but in today’s American job market, the demand and opportunities tend to be in more rural areas, particularly for visa applicant physicians from third world countries, where academic hospital medicine may be fairly similar to US healthcare, but where small town and rural medicine can be very different.

3) Culture Matters

As an immigrant physician with English as my second language, I had to work at speaking comfortably with rural American patients, many of whom were of French-Canadian origin. It must be a bigger challenge for physicians from further away than Sweden. Language is only the beginning. How different cultures view life events and medical conditions can vary greatly. I am told that the Japanese don’t have a word for hot flashes and that in Tibet, most people aren’t familiar with the notion of depression.

People in this country often talk about how doctors need to be sensitive to minority patients’ culture. Less is said about minority physicians’ familiarity with the American majority of patients; whether we are from Sweden, Japan, Tibet or India, we each have a learning curve for understanding those we are here to serve as personal physicians.

I remember one internal medicine physician from a Muslim country who found out that his American employer expected him to perform routine gynecological exams including Pap smears on his female patients. Not only had he never been trained to do any of it, he also had to wrestle with overcoming what his his entire upbringing had told him was improper.

4) What is a Good Doctor?

The industrial view of healthcare imagines that it consists of standardized processes that are easily measured: What is the average blood sugar, or glycohemoglobin, of Dr Andersson’s and Dr Singh’s patients? Their pneumonia immunization rate? How many of their heart failure patients are on a beta blocker? How many seniors have had a fall risk assessment? How many obese patients have an obesity action plan documented in their medical record?

Nobody talks about this, but all those quality indicators make less difference for individual patients’ longevity and for entire populations’ health than healthy lifestyles do. For individual patients’ health as it relates to healthcare, accurate diagnosis of new symptoms can amount to an all-or-nothing disparity between health and disease, even between life and death.

Some of the most basic measurements of physician quality are surprisingly irrelevant: Beta blocker therapy in heart failure patients only increases average survival 6-12 months, it takes 50,000 pneumonia vaccinations to prevent one pneumonia death, and prostate cancer screening, once a basic minimum requirement for men’s health care, is no longer even recommended.

My uncle had waxing and waning paralysis of his left arm, but his doctors never checked his carotid arteries, and soon thereafter he had a stroke. My aunt had a cough for well over a year, but because she never smoked, her doctor didn’t order a chest x-ray until it was too late and her lung cancer was inoperable. This happened in Sweden, where the average life expectancy is the 6th highest in the world, 3 years more than 32nd ranking USA. It could have happened anywhere, because doctors are people, each one different, and the real quality of their work cannot be measured, let alone regulated.

Employers and bureaucrats may think a doctor is a doctor is a doctor. My aunt, for one, doesn’t think so anymore.