The great paradox of modern medicine is that even as doctors find themselves empowered by science to extend human life and battle diseases they hitherto couldn't, the health-care system within which they perform is perceived as increasingly impersonal and even, at times, inhumane. Caught between rising treatment costs and the often unwelcome dictates of the managed care apparatus that was created to control them, doctors have sensed a critical loss of freedom in dealing with patients. Most try to do their best within the system, wrestling with HMO bookkeepers over issues of treatment and expense and doing what they can to help patients outside the system—the 43 million Americans who have no health insurance at all. Across the country, though, more and more doctors have taken steps to free themselves from an increasingly intrusive bureaucracy in order to practice medicine simply as healers, rather than as cogs in a system not of their making. On the following pages are some of their stories.
Free Hugs, Low Fees
Perhaps no one has a better perspective on doctors than the drug-company representatives who go from one physician to another touting their wares. Day in and day out they see the good, the bad and the indifferent. And in the opinion of Bryan Canterbury, who represents Pfizer in suburban Silver Spring, Md., there aren't many doctors better than family practitioner Margaret Snow. "She has to be one of the best physicians out of the 300 to 350 I see," he says. "She takes time with her patients, really slows down and treats them. She's a true caregiver."
Snow, a divorced mother of seven who has offices in Silver Spring and rural Damascus, has been dispensing her wisdom and comfort for 53 years. Rather than feeling behind the times, Snow, who guards her age as carefully as her stethoscope, firmly believes that fidelity to the old-fashioned values—above all, putting the patient's interests first—has never been more urgently needed. Indeed, about the only thing that riles the preternaturally soothing Snow is a discussion of managed care. "HMOs are the worst thing ever to happen to medicine," exclaims Snow, who has never belonged to one. "Patients are treated like sheep in a pen."
In her practice, patients are made to feel more like newborn lambs. All get a hug from Snow and as much time as they need. She keeps her basic office-visit fee at $40—about half the going rate—but treats people even if they can't pay anything at all. She sees fewer patients these days, around 25 to 30 a day, as opposed to the 40 she used to treat, but she has no plans to retire. "I'm busy, happy and active," she says. "I'm gonna die with my boots on."
Care for the Neediest
As a young resident 15 years ago, Andrew Bindman fell in love with San Francisco General Hospital, a public institution committed to treating destitute patients. A graduate of Harvard and the Mount Sinai School of Medicine in New York City, he could have worked just about anywhere, but eagerly joined the hospital's department of medicine. "I've loved every moment of being able to do what I do," he says.
As a professor of internal medicine at the University of California at San Francisco, which is affiliated with San Francisco General, Bindman, 41, researched access to medical care and found that physicians in private practice accept very few patients who don't have insurance. "There had been this tradition within medicine of charity care," he says. "Before, it wasn't an enormous hardship to make that available." The more time doctors spend with managed-care patients, the less time and financial resources they have to provide to charity cases. For his part, Bindman believes that $100,000 is "a perfectly fine salary" for a doctor, though well below the $145,000 national average.
Bindman will even go to patients' homes to bring them in for treatment. His wife, radiologist Rebecca Smith-Bindman, 36, mother of their three young children, remembers being smitten by his dedication when they first met. "I was enraptured," she says. Bindman tries to convey his enthusiasm to medical students who visit San Francisco General, but he knows it's a tough sell. "Clearly," he says, "there are a relative minority of physicians who would work in this sort of environment."
Curing the HMO Blues
Lisa Underwood gathered her staff and some other doctors at a home in suburban Phoenix a couple of years ago. As a fire crackled in the backyard, her colleagues took turns throwing insurance company contracts into the flames. Underwood, now 44, had decided to walk away from HMOs out of frustration over what she saw as their willingness to hold back on medical treatment for profit's sake. "I finally said, That's it,' " says Underwood, a gynecologist and surgeon.
Now relocated to a new practice in suburban Las Vegas, Underwood readily acknowledges that her decision has driven away some patients who would prefer to pay a straight $10 to $20 fee for a doctor's visit. But she points out that she is almost always willing to reduce her charges to what a patient can afford. More important, she argues that having the freedom to do what she deems medically necessary without having an HMO looking over her shoulder is better for her and her patients.
As her own boss, the twice-divorced Underwood, who has two college-age children, runs her practice exactly as she wants. For instance, she has a rule that she never reaches for the office doorknob when a patient has a question. Such consideration has earned her fierce loyalty. "I have never been so impressed with a doctor," says Juanita Taskushi, 58, a retired phone-company worker. "I felt so secure with her, I didn't want to leave."
Though she has liberated herself from the frustrations of managed care, Underwood is sympathetic to doctors who haven't. "Many of them feel enslaved by the process—and angry," she says. "Sometimes they take it out on their patients."
Going the Extra Mile
Two years ago, Judith Bromley suffered a concussion when she fell off her bicycle in Chicago and was taken to an emergency room for treatment. Her husband, Dr. Serafino Garella, now 61, was concerned, but not so preoccupied that he didn't take time to encourage the young resident who was treating his wife to volunteer at a free clinic he had started. Opened in 1993, Garella's Community Health clinic now logs 10,000 patient visits a year, all at no charge. "He is obsessed with the clinic," says Bromley, 54, of her husband, a kidney specialist and head of the department of medicine at Lutheran General Hospital in Park Ridge, Ill. "It is a great passion for him."
The clinic, on the west side of Chicago, is a vital resource for the working-class, mainly Hispanic residents of the area. Garella, who was born in Italy and earned his medical degree there, could never fathom how a country as prosperous as the United States could not have universal health coverage. So with a little grant money and a lot of moxie, he started the clinic. He relentlessly enlists residents and medical students to pitch in, and he never hesitates to ask doctors to donate their services when a patient needs special care—such as repair of a cleft palate. "Not once have I had anyone turn a patient down," he says proudly. Says Sheila Lyne, Chicago's commissioner of public health: "He is the kind of person who doesn't look for anything in return. That is why people are so willing to come in with the spirit to volunteer."
Garella, who lives with Judith, a freelance architectural photographer, in a dramatic Frank Lloyd Wright house in Chicago's Hyde Park, can be found every Saturday at the clinic. "I don't think I'd rather be playing golf," he says. "I don't view it as a job." In fact, according to Judith, the clinic is what makes him happiest. "He has never felt comfortable," she says, "making a living out of other people's illness."
She Does House Calls
More than anything, growing up in poverty has shaped the way Margaret Kaiser practices medicine. Her experiences in Portland, Ore., as one of four children of a single mother, left her with a personal understanding of what the poor must endure to get the treatment others take for granted. "I still remember the clinic at the University of Oregon Health Sciences Center," says Kaiser, 46, who practices internal medicine out of her private office in the rural town of Oakland, Md., in the Appalachian Mountains. "It had hard wooden benches, and you waited for hours and hours."
Going about her rounds in Garrett County, 140 miles northwest of Washington, D.C., near the West Virginia border, Kaiser, who specializes in geriatrics, is often the only source of health care her patients can count on. Not only does she make house calls for those too ill to get to her office, sometimes driving 45 minutes to see a single patient, but she also goes out of her way to do the paperwork they may need to enroll in programs allowing them to receive free medicine from drug companies.
In general, Kaiser lets patients pay what they can, though she still grosses about $130,000, which she considers more than adequate. "I grew up on welfare, so for me to have anything is enough," says Kaiser, whose husband, respiratory therapist Eric Tribbey, 47, heads the cardiopulmonary department at Garrett County Memorial Hospital.
Kaiser tries not to be too critical of doctors who don't share her approach. "Most people go into the field because they want to help people, but that's very easy to lose during your training," she says sadly. "You don't get a lot of rewards for being a caring, feeling person."
Bill Hewitt
Giovanna Breu in Chicago, Amanda Crawford in Oakland, Todd Foster in Silver Spring, Jerry Kammer in Las Vegas and Penelope Rowlands in San Francisco
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