Being busy with other things, we had no idea that the book you’ll read about today was making a splash until we heard it about it from today’s contributor, Phil Kuehnert. For a sample of the attention that Doctored is getting elsewhere, see the recent reviews in the New York Times and the Boston Globe, both of which will set you up to appreciate the greater depth that Phil brings to his discussion of it. That he does so will surprise no one who heard his presentation at the Crossing conference last January. The topic then was The Christian Chaplain in a Pluralistic Society. You’ll find him bringing a similar sharpness of sympathy and analysis to the matters at issue here.
Phil’s personal physician, who also names Christ as Lord, has written his own review of this book. We’ll send you that next week on the safe assumption that you’ll find it equally intriguing.
Peace and Joy,
Jerry Burce, for the editorial team
The Disillusionment of an American Physician
By Sandeep Jauhar
268 pages. Farrar, Straus and Giroux. $26.
Reviewed by Philip Kuehnert
When I read Ivan Illich’s Medical Nemesis in the early 1980’s, I was under the influence of a young cardiologist and his wife, a pulmonologist, who with their two young children had joined the congregation that I was serving in Atlanta. In their effort to bring me into the world of culture―music, literature, and even theology, through books like Joachim Jeremias’ classic The Parables of Jesus―their recommendation of Illich’s book was not a surprise, but what was stunning was its prophetic note. Jauhar Sandeep’s new memoir, Doctored: The Disillusionment of an American Physician, is no less prophetic in a way that Illich’s book eerily predicted.
I have long been under the influence of physicians, from time to time under their direct care. In at least one instance, my death was postponed significantly (42 years, six months, five days and counting) because of a surgical team at Charity Hospital in New Orleans. I have worshipped and adored physicians.
Possibly because I was a celebration baby, the live birth that followed my sister Paula Hope’s still birth, I was given a special place in the family. Paula Hope’s tombstone in the church cemetery was always visible from the living room of the parsonage where the family gathered twice a day for devotions. Even when we moved to another congregation, the story of Paula Hope’s death was always just a page turn or two away: “prefect pregnancy….the Sister came in and said ‘Come and baptize your baby’….she was perfectly formed……blue…..lying face down with two large hypodermic needles stuck in her back….I told the sister, ‘she’s dead’….the sister insisted saying ‘there is still life in the body.’” Then later I heard that “the cord was around the neck” and the nurse on duty was not experienced. It was decades later that I heard that our family physician, an alcoholic, was too drunk that night to come to the hospital.
Now, more than half a century later, I look back on decades of doctoring, from my sister’s nine-month hospitalization for anorexia complicated by a psychotic breakdown, to my father’s open-heart surgery—at age 89—to implant a pig’s valve to replace his aortic valve, to my brother’s successful experimental treatment for hairy cell leukemia, to my oldest brother’s last three years of life as a patient of the Heart Failure Clinic of Touro Infirmary in New Orleans, to my wife’s womanly surgeries nine years apart, to my own cardiac catheterization resulting in four ablations three months ago, to the weekly monitoring of my defibrillator/pacemaker. But few that I know in my age category are doctored any less. I don’t know of anyone who is not taking medicine, who does not have at least one specialist, and most have several. Those who work and serve in close communities of education, chaplaincy, or ministry have first-hand knowledge of how doctored we are. All my age (b. 1944) have their Medicare and supplemental insurance.
And most have some first-hand knowledge, not just about being a patient, but also about the delivery of health services. My wife ended her 43-year nursing career as a nurse practitioner, being the only mid-level provider on the staff of seven pediatricians at a large private clinic in Alaska. More than likely, someone in your family, an uncle or aunt, sibling, child, niece, or nephew, has a career in health care.
We can forgive Sandeep Jauhar’s whiney prose, because we have read enough and have listened to enough first-hand accounts to know that when he writes about the challenges of providing health care in the “mid-life of American health care” he is not exaggerating. The Affordable Health Care Act and the polemics that it has spawned lie at the center of the current debate about how best to provide health care to the entire population. Rarely a week goes by without yet another issue being raised about the adequacies or the inadequacies of the Act. We “know” that everybody is unhappy, and Jauhar tells us in great detail why he is unhappy. And perhaps that is why this book has such a dark cloud hanging over it. In mid-book, in an angry confrontation with his father after antidepressants have been recommended for his mother, his father says: “Antidepressants make you happy?….You think a medication will change her basic nature? Like you, she is not a happy person.” Mmm…father knows best? Maybe “without joy” is a better way to describe Dr. Jauhar’s life.
What Doctored provides is a well-written, finely-edited memoir that places the author’s experience in the context of the general milieu of cardiac medical practice. In addition to breathtaking personal accounts of his own struggles as an attending physician at a large teaching hospital in metropolitan New York City, Long Island Jewish Medical Center, the author provides the results of extensive research to document the demise of physician pay, morale, satisfaction, and respect. It is the last which in his own experience stands in such contrast to his grandfather’s esteemed place as a physician in India. His parents (his father is a frustrated plant geneticist) insisted that both he and his older brother become physicians because of their perceived exalted status of physicians. Hence, the word “disillusioned” in the subtitle of the book.
But who isn’t disillusioned about one’s health? Who isn’t “doctored?” And there are few people who could not repeat at least one horror story about medical treatment that went wrong. Hip replacements are bad enough, but when people outlive the life expectancy of the artificial hip, or when a patient is reactive to the titanium in the implant, or when a hospital-hosted infection requires weeks of infusion of antibiotics, just this one procedure carries with it great risk. Yet, for orthopedic surgeons and for physical therapists, and for the manufacturers of artificial hips, and for the pharmaceutical companies that make the drugs, living longer drives their market! And who, honestly, is not disillusioned that this sack of worms to which we were consigned inexorably gets weaker and sicker?
Living longer and living poorly is the where Crossings’ Level One diagnosis congeals into a “yes, that’s it.” Living longer and living poorly are defined primarily socially and economically. And so we are “doctored.” In fact doctoring is demanded. And in many developed countries, doctoring is provided for all. It has been long established, even before Michael Moore’s movie Sicko, that there was something wrong with health care delivery in the United States. Dr. Jauhar feels that the golden age of American medicine—from the end of World War II to sometime in the sixties—ended with the proliferation of HMO’s in response to the greed of physicians. Paralleling his own midlife process/crisis is the midlife process/crisis of American medicine, and that puts him in the middle of Crossings’ Level Two diagnosis.
Internally, the almost parochial world of this first-generation Indian immigrant becomes the center of his malady. An almost “Cain-like” relationship with his successful older brother (also a cardiologist), the incessant attempt of his pulmonologist father-in-law (also an immigrant from India) to help his daughter and son-in-law both financially and spiritually, Jauhar’s realization of how deeply he has disappointed his parents, and the never-ending carousel of colleagues, mostly foreign nationals, create a vortex of avarice, manipulation, despair, betrayal, and hopelessness. And if all this were not enough, primary in his memoir are his very sick heart-failure patients. He writes, “heart failure is the common final pathway for a host of cardiac diseases.” Heart failure leads to death usually within two years of diagnosis. His metrics for success with his patients were noble, initially; to wit, “I wanted to develop close relationships with critically ill patients and provide long-term care.” But as he described his interview for his first job as an attending physician—creating a heart failure unit for Long Island Jewish Medical center—those noble aims were already being overshadowed by his promise to “decrease lengths of stay, improve hospital performance measures, improve the discharge process, decrease readmissions, install a computerized database, enroll patients in clinical trials, write emergency room protocols, and start an intravenous infusion.”
And on the most personal level, as he discloses his innermost doubts and struggles, this is a man who lives under perpetual judgment, not only by his preening older brother, his parents and in-laws, but most damningly by his wife who insists on a lifestyle whose financing demands $2,000 more than his monthly income. The “disillusionment” in the subtitle is a theme that runs strongly not only with his chosen profession, but also with himself.
The distance from this book to the cross is at the same time immeasurable and immediate. If the judgment of God would be unleashed on this system and on this doctor, nothing less than an Old Testament rant would be acceptable. Greed, hubris, and envy in the most egregious forms surface personally in Dr. Jauhar and in the medical professionals he relates to. And while I hope it is not just because of my self-righteous nature, I have described this book to others variously as empty, sick, disgusted, disturbed and hopeless. And bordering on the sacrilegious is the hubris of this line in the closing chapter: “But medicine holds the key to its own redemption.” His basis for this hope? He tells story of an intern who returns to medicine as a second career at the age of 46, in spite of significant health problems. Then this: “What redeems the effort? It’s the tender moments helping people in need. In the end, medicine is about taking care of people in their most vulnerable state and making yourself a bit of the same in the process.”
So who will speak the Word of promise to Dr. Jauhar and his colleagues? Surely there must be confessing Christians who intersect with his world. There was no indication that the Christian message has touched him in any meaningful way—no references to chaplains, pastors, priests. He and his physician assistant did attend a funeral of one of their patients, but there was no indication that it was in any way Christian. His father-in-law, a devotee of various gurus, invited Jauhar and his wife to his home when they hosted Guruji and his followers with the hope that Jauhar would find peace. Rather, he found the whole ordeal to be exhausting and “a wash.” But then, as he was leaving, a disciple of the Guruji gave him this piece of advice: “Once you know and accept you are going to die, the future will not haunt you.”
In contrast are writers and theologians like David Novak (Jewish) and Stanley Hauerwas (sectarian Christian) who have written extensively and at times prophetically about medicine, the health delivery system and the role that theology, synagogue, and church play in health. Their perspectives would provide a most interesting counterpoint to Jauhar’s book.
Having been “doctored enough” and having been, at times, on both ends of Dr. Jauhar’s assertion that “most people think of doctors as either consumedly avaricious or impossibly altruistic,” my experience with doctors has been for the most part quite different from Sandeep Jauhar’s picture of the medical profession. All three of my primary care physicians, beginning in 1994 in Alaska, were men who genuinely cared about their profession and their patients. Yet all three of them have changed their mode and place of practice. My first, an internist, left the clinic where he was doing primary care and became a hospitalist. The second, also in Alaska, had done a tour as a doctor in Cameroon, then worked for years in Barrow, Alaska (find that on the map!) before moving to Fairbanks. The third, my present physician, began in the Navy, then for several years was in a private practice with other physicians in North Carolina before moving to Williamsburg, where he is part of a large hospital and clinic system. I have had the privilege of being part of the same worshiping community with the last two. All three did extensive first-visit interviews and all have been careful with referrals. All three have been conservative (rather than aggressive) in their treatment and prescriptions. All have at times made critical and excellent referrals for special issues.
Sandeep Jauhar joins Ivan Illich, Michael Moore, critics of the Affordable Care Act, and a host of others who are only too glad to say what’s wrong with American health care in general. The truth is that none of us gets out alive. Unless the transformative power of the Gospel changes the paradigm for health, we are consigned to go with the flow in the search for the fountain of youth. Against that search stands the great challenge of 2 Corinthians 5:17, to accept the reality that “if anyone is in Christ, he is a new creation. The old has passed away; behold, the new has come.” This has profound implications for the individual’s view of herself or himself as a healthy or sick person, and for the community that sustains the sick and the well.