I’VE BEEN SEEING this guy since I was a little kid,” said Cameron Ryan in amazement, sitting on the tan leatherette examining table. “Since I was 18 months old!”
He’s now a very big kid: six-five and close to 300 pounds, a high school senior with a smooth precocious basso and a passing resemblance to Magic Johnson. When Ryan first sat on this examining table, “this guy,” Dr. Martin Cahn, was a young MD struggling to establish his practice. He had a bushy beard and a halo of reddish hair and he wore a tie because doctors were supposed to. Today ties are a distant memory, and Cahn wears sneakers at the office. His hair and beard are salt-and-cinnamon. He has a middle-aged spread and an expression that flits between solicitude, exasperation, and, at the moment, glowing pride.
This visit, a routine checkup, was also a personal milestone for Ryan, and an example of the difference an old-fashioned family doctor can make in one patient’s life, above and beyond what’s commonly labeled “medicine.” Ryan is as ebullient as the toddler he was when he first saw Cahn. “I’ve lost weight,” he said proudly. “I want to get down to 280. But I assume my blood pressure is high….” Cahn checked it, frowned darkly, but said nothing; he didn’t want to kill his patient’s buzz.
Ryan had big news. Next year he’ll be attending a top-flight school, Purdue University. “And it was this guy who got me to do it,” he beamed, pointing to his doctor. “He was the one who told me, ‘Apply to colleges!’ even when I didn’t think I could do it.”
A year ago it was by no means obvious Ryan could do it. “You’ve always been an extraordinarily smart guy, Cameron,” Cahn told him. “You just needed to focus.” In junior year Ryan was flailing. Then a belated diagnosis of attention deficit hyperactivity disorder and the resultant drug regimen turned him around. His grades and SAT scores soared.
“Any idea what you’re going to major in?” Cahn asked.
“I don’t know, probably psychology. I’m also interested in business, but I don’t know if there will be any jobs in it when I come out. I figure there will always be work helping messed-up people.”
“My advice is to have a great time at college and try as many things as you can,” said Cahn, and for the second time that day he segued into The Story, the one he likes to tell patients trying to figure out how to live their lives…
Martin Cahn grew up in Chicago, Lexington (Massachusetts), and Schenectady. His father, John Cahn, is a celebrated metallurgist; he received the National Medal of Science and was bruited as a Nobel candidate. Young Marty set out in his father’s traces. He attended MIT, where his father once taught, and majored in biology.
One day in junior year Cahn was walking through Boston’s Fenway neighborhood when he noticed an open door in an empty basement storefront. Curious, he ambled in and asked a guy working on the place what sort of store it would be. “This isn’t a store, man,” the guy said. “We’re putting in a free clinic.”
“I said, ‘Oh, cool.’ He said, ‘Can you use a hammer and saw?’ I said sure.”
When the clinic opened, it needed someone to “room” patients—to show them in, weigh them, and take their blood pressure. Cahn said he didn’t know how. “They said, ‘It’s easy.’” He moved on to other tasks, becoming a learn-on-the-job lab technician. And he found his calling. Forget lofty science; he wanted to be a doctor, to help people and unravel the mysteries of their ailments. Not just a doctor but a frontline doc, a family physician, the primary watchdog over his patients’ health, contending with everything nature and fortune might throw their way, from cradle to twilight years: “I wanted to do it all.”
Cahn admits his father was “a little disappointed” at his choice—a choice he himself had never considered until he wandered into that empty storefront. “That’s why I always tell my young patients—open every door. Try everything you can, while you have the chance. Something will be right for you.”
Cahn walked Cameron Ryan and his mother out, past the magazine racks, the toys, and the bulletin board covered with snapshots of babies he’s delivered. He took Mom aside and said quietly, “His blood pressure is still up. I’m going to put him on two medications.”
The visit was notable for how long it took—24 minutes—relative to the amount of medicine practiced, as measured by insurance schedules and diagnostic manuals. It’s easier for Cahn to take the time when the economy’s bad. Ordinarily he sees 25 patients a day; today only about half that many had made appointments. “I’m not getting any more requests to forward records,” said Cahn, “which means they’re not going to new doctors. They’re just not going to the doctor.”
Cahn seems to remember every patient though he has 7,356 in his database, almost half of them active patients. Having data handy helps; he carries his laptop into exams like a waiter balancing a tray, checking records and firing off prescriptions while he chats. He’s also devised a mnemonic trick: “I try to remember one interesting fact about each patient, and that fixes them in my mind.” I wonder what fact he fixed me with; I’ve been Cahn’s patient, with interruptions depending on the vagaries of insurance, for nearly two decades.
By choosing general practice, Cahn and others like him are bucking the trend and their own pecuniary interest. About 30 percent of American doctors work in primary care—pediatrics, general internal medicine for adults, and family practice for all ages. (Cahn’s current patients range from two days to 99 years old.) But the number entering primary care has fallen by more than half since 1997, to just 13 percent of medical graduates.
Next: Why America’s primary-care corps hasn’t yet collapsed—yet—and why primary care means lower death rates.
That’s far fewer than in other industrialized nations, where half or more of doctors work in primary care. But despite dire predictions, America’s primary-care corps hasn’t yet collapsed, for one reason: immigration. We import doctors to perform the work American docs don’t want to do, just as we import farmworkers, dishwashers, and housekeepers. And we do so for the same reason: We pay them less than Americans want to work for.
In 2007 the median pay for primary care doctors was $182,000, much less than the median $460,000 for orthopedic surgeons, $464,000 for radiologists, and $332,000 for specialists overall. Physicians often cite the years and money they spend to become doctors to justify their incomes. Many come out of med school with forbidding debts—$150,000, $200,000, sometimes $300,000. They can easily spend as much again to establish a practice. “If I’d come out of school owing a quarter million dollars, I might feel differently myself,” Cahn admits.
“I always tell my young patients—open every door. Try everything you can, while you have the chance. Something will be right for you.”
Importing doctors has its side effects. Immigrant doctors tend to settle in cities rather than the rural areas where they’re most needed. Many arrive with excellent training but limited English skills, unfamiliar with American ways. That matters less for elite specialists; a bypass is a bypass, whatever you call it. But general practitioners must attend to fine nuances. And importing our docs causes brain drains and treatment shortages in poor countries that can ill afford to lose theirs.
A ream of studies shows that more primary docs relative to population means lower death rates, in particular from heart disease and cancer. Primary physicians monitor the entire patient, not just particular organs. They catch ailments early, before they become crises and require costly tests, treatments, and hospitalization, all of which carry risks. “I tell patients I’m available anytime,” said Cahn. “I’d rather hear about a problem at 2am than an emergency at 6.” He still remembers the patient who didn’t call the night he felt chest pains “because he didn’t want to wake anyone up” and by morning had a massive heart attack.
Specialists don’t just charge more than primary docs. Other studies have found that the more competitive the market—the more populated with specialists—the more unnecessary procedures get performed. To a surgeon with a scalpel, every organ is a potential operation. Treatment expands to fill the needs of those providing it, not of those receiving it.
One result: In 2000 the World Health Organization rated America’s health care system 37th-best in the world—barely ahead of Cuba’s, well below Colombia’s and Morocco’s—and 72nd in performance, below Iran’s and Albania’s. The United States ranks 50th in life expectancy. It is number one, by a mile, in just one indicator: medical expenditures per capita.
President Obama seems to get all this. In a landmark speech to the American Medical Association in mid-June, he called for more investment in preventive care and more affordable training, plus more rewards, for “students who choose a career as primary care physicians and who choose to work in underserved areas instead of a more lucrative path.”
After graduating from MIT, Cahn attended Tufts University’s med school, near Boston, one of the world’s great health-science meccas. But while Boston was chockablock with elite specialists, primary care got no respect there; the Fenway Community Clinic, where Cahn got his medical baptism, was in a neighborhood packed with world-class hospitals but bereft of available care. One of those hospitals, Brigham, trained family practitioners but didn’t admit its own graduates to practice on its wards.
So Cahn left Boston, performed his residency in Buffalo, and then continued west on I-90 to a city where primary care did get respect. Seattle is a relative bright spot in the health care picture, with better-than-average care, better general health, and lower costs. Mild weather, high median income and education, and all that jogging may have something to do with it. But credit also goes to a tradition of innovation in preventive care dating back at least to the 1947 founding of Group Health Cooperative, an HMO pioneer. The UW med school’s primary care training has long been among the nation’s best. Cahn felt at home.
He went to work for Group Health: “I replaced a really popular doctor, so I was seeing 35 patients a day. I was young and I thought I could do anything.” But he burned out and grew disillusioned with the co-op model’s built-in incentives to deny care, whatever its good intentions. “Group Health was a closed system. The less care they provided, the more money they made.”
In 1988 Cahn set up a solo practice in a Queen Anne storefront; eight years later he moved to Fremont, a neighborhood as short on doctors as Boston’s Fenway had been. Going solo seemed a natural extension of family practice: He would decide for himself how much time to spend with patients and what kind of treatment to provide.
Cahn had a lunchtime appointment, with pharmaceutical sales reps rather than patients. He grimaced. “Thirty years ago the drug reps were mostly retired pharmacists,” he said. “They knew their stuff, and you could pretty much take what they said. Now they’re pretty young things who wanted to be models.”
One of the two reps was a tall young woman who could almost be a model. The other was a short young man dressed like one, in a sleek black suit, killer tie, and hipster goatee. He sustained a salesman’s grin; she looked faintly embarrassed. They delivered coffees and pastries from the staff’s favorite espresso stand. “They know I can be bought cheap,” Cahn joked. He stood stony-faced, and they didn’t even bother with a spiel. (“They already know I hate them,” he said afterward. “And they know exactly what I prescribe and how much. Pharmacies sell that information.”) The reps delivered their samples and made their escape.
“These are nearly the only reason I see the reps,” Cahn explained, depositing the samples in a cabinet packed with pharma swag. He gives them to patients who don’t have coverage for meds; for some they’re a lifesaver.
That afternoon Edge Newcomb, a restaurant worker–turned–independent filmmaker, stopped by for the inhalers that control his allergies and chronic bronchitis. “I’ve always liked coming here,” he said. “Dr. Cahn is like an old-fashioned doctor. I’ve gone to others, but it seemed like cattle farming. You feel like they’re hosing down the seats between patients.”
Cahn handed him a bag of inhalers. “These would cost a couple hundred dollars a month. I can’t afford that,” said Newcomb.
“Thank you again!’ he called on his way out. “You’re very welcome,” Cahn replied without looking up. “I wish I could give you more.”
Martin Cahn is the last primary care doc left in lower Fremont. He knows he’s an industry anachronism, but he’s worked in large organizations and doesn’t see the point: “I like to say I’m just as inefficient as other doctors.” Maybe more efficient, thanks to one great, disruptive force: automation.
Technology has leveled the field. Practitioners who undergo the ordeal of automating their patient records, billing, and other office functions achieve efficiencies hospitals are still struggling to match. But it is an ordeal, even for an MIT geek married (as Cahn is) to a former Hewlett Packard librarian. “For my wife and me it was six months of hell. The only days we had off for two months were Christmas and New Year’s Day.”
The switch was worth it, foremost for patient safety. “When Vioxx [an arthritis drug implicated in heart attacks] was discontinued, I was sitting here trying to go through every chart—Was Mr. Smith on Vioxx or was it Mrs. Smith?” Now he’d conduct an instant search and send out a letter, customized and mail-merged, to every affected patient.
“I’m available anytime. I’d rather hear about a problem at 2am than an emergency at 6.”
Cahn just wishes all the new medical software programs could talk to each other. “We’re back in the days of Amigas, IBM mainframes, Apples, and PCs. It’s a role for the federal government, to set up a common standard. I would love to give you a little thumb drive and say, Here’s your medical history, all encrypted. You could walk into any doctor’s office in the country and plug it in.”
Just having Google in the examining room makes for efficiency. One new patient, a 43-year-old salesman, had been constipated for a year, ever since he ate “a whole bunch of cheese pizza.” “Are you taking anything for it?” Cahn asked. “I’m taking Almighty Cleanse, once a day.” Cahn tapped a few keys: “Almighty Cleanse… ‘All natural ingredients.’ That’s always suspicious…. Aha! The major ingredient is senna. It’s an irritant to the bowel. Eventually your body becomes used to it and you need more.”
After prescribing a bulk laxative and a couple weeks without milk or cheese pizzas to test for lactose intolerance, Cahn asked how his new patient learned of Almighty Cleanse. “Oprah,” the man replied.
“I should have realized it was Oprah,” Cahn fumed afterward. “There’s a distrust of doctors, so people get all this misinformation from her.”
I love medicine,” Cahn mused during a lull. “I like helping people. I’ve enjoyed every part of it—except dealing with the insurance companies.” He scowled. “It’s an incredible source of friction in the system.”
Insurance profits, overhead, and red tape eat up 30 to 40 percent of health outlays. Cahn figures it takes the equivalent of one full-time worker to handle his claims and appeals. “The thing that hurts me is when patients I’ve been seeing for years lose their jobs, lose their insurance, and say, ‘Dr. Cahn, I’m not sure how I’m going to see you again’—realizing their health is going to suffer.” In the 1990s he referred one patient with abdominal pains for an endoscopy—a simple stomach probe that cost a few hundred dollars then. But the patient had no insurance; months later, when he finally got the endoscopy, his stomach cancer was inoperable.
Uninsured patients get caught in the middle of a never-ending price tango. Insurance companies and, especially, Medicare and Medicaid force deep discounts on doctors, who respond by raising their fees. And the uninsured pay full freight.
Cahn cuts deals and gives terms; one mother paid off her delivery in $25 monthly payments. And he’s made his own painful decisions. Two years ago he stopped taking new Medicare and new Medicaid patients, save the odd elderly neighbor who can’t get anywhere else. This year, after more than 500 deliveries, he sadly swore them off. His patients are aging; in the second half of 2008 he delivered just one baby, and obstetric insurance costs $12,000 a year.
Cahn’s not the only one feeling the squeeze. Some physicians are “going bare,” dispensing with malpractice insurance. Others shake off the shackles of medical insurance, taking only cash—usually affluent—patients. Seattle is a hotbed of this “direct practice” rebellion; high-end “concierge care”—your personal doctor holds your hand even when you visit specialists, like a lawyer accompanying you to court—started here in 1996. It can cost $1,000 a month or more.
A minority of direct practices offer unlimited primary care for monthly fees ordinary workers can afford. One, sponsored by Swedish Medical Center, charges just $45. Now a brash Seattle start-up, backed by early Amazon investor Nick Hanauer, proposes to do for direct practice what Starbucks did for espresso.
“I should have realized it was Oprah. People get all this misinformation from her.”
Qliance’s founders include two physician cousins, Garrison and Erika Bliss, who like Cahn were fed up with what their CEO, Norm Wu, calls the “hamster-wheel -model” of insurance-driven medicine. Qliance’s downtown Seattle prototype offers a “medical home”—primary, urgent, wellness, and preventive care, open seven days a week—for $39 to $79 a month depending on age, more if you want to make hospital visits. Its doctors (for now, anyway) have about 800 patients each, versus the usual 2,000 to 3,000. They gladly answer questions by phone. So does Cahn, but it costs him. Insurance doesn’t pay for phone calls, only office visits, one reason receptionists typically ask you to just make an appointment.
Meanwhile the battle rages over whether to salvage or rebuild America’s health care delivery system. Cahn admits he’s as unsure of the answer as the next citizen, save that “whatever system you get, it’s got to include universal coverage.
“There’s a saying—if you want good-quality care, cheap care, and easy access to that care, pick two out of three. How do you help people in a cost-effective way?” Perhaps with the new “medical home” models? “I’m looking at them,” he said. He knows business as usual isn’t working. “Something’s got to give.”