Doctors in America: “Professionals” or “Providers”

GUEST: Dr. Richard P. Cohen
AIR DATE: 08/27/2011
VTR: 04/28/2011

I’m Richard Heffner, your host on The Open Mind. And some time back I began one of our many conversations here about American medicine by saying that it has been my own very good fortune over the years generally to have enjoyed absolutely splendid medical care at the hands of truly fine, thoughtful and expert physicians…men and women…who have combined great technical skills with a warm and comforting manner.

Of course, that was by way of introducing one of those wonderful people – as I introduce him again today.

Dr. Richard P. Cohen, Clinical Professor of Medicine at Weill Cornell Medical College and Attending Physician at the New York Presbyterian Hospital is really a physician’s physician. And I’m glad he’s mine, too!

I’m also glad that he takes the time to talk with me about contemporary American medical issues…as the other day – after he had cared very well for my gout – and we discussed the recent Gardiner Harris New York Times story titled “Family Physician Can’t Give Away Solo Practice” and Paul Krugman’s Times piece titled “Patients Are Not Consumers”…which, in turn, reminded me very much of Dr. Cohen’s own frequent insistence that he and his medical colleagues be considered “professionals”, not “providers”.

Indeed, there’s no better way to begin today’s conversation than to ask my guest to elaborate on that dichotomy: “professionals”, not “providers”. Fair enough?

COHEN: We, we’ve brought this up before (laughter), and I still feel strongly about the, the concept and it’s actually grown since you and I started the dialogue.

I think, Dick, the difference is that physicians were always professionals and they were guided by a set of principals, the right way to do things, an option for creativity … and opportunity for individual thought and not particularly driven by the notion of protocols or doing things that would generate the kind of paperwork that allowed for reimbursement.

They’ve now become many people, unfortunately, I say … they become providers, driven by protocols, driven by doing things that require documentation or following algorithms which allow for appropriate reimbursement.

And not necessarily leaving room for creativity or even individuality in relationships. And that’s sad.

HEFFNER: You say it’s sad. Do you think it’s inevitable?

COHEN: Yeah. I think there’ll probably be small niche for those who want to remain professionals, but the, the pendulum is swinging … we are considered “providers”. And what, what physicians are able to do and expected to do are not going to be particularly open to people’s creative thought or the way they want to do business.

HEFFNER: But you find, and I’ve asked you this before … that you still think some of the best of the best are going into medicine.

COHEN: Some … yeah … oh, I don’t … I don’t think that, that’s necessarily a problem. I think … it’s not clear to me that surely … that the best of the best are willing to do primary care.

Medicine is still a wonderful field with phenomenal opportunities … I’ll argue that probably there’s no better field. If you start medical school the opportunities to do lots of different things are unsurpassed, from my point of view, in any profession.

But it’s not the same as it was … the opportunities aren’t there … the opportunities for individuality may not be there for people coming out today … whether in terms of what they’re allowed to do, how they do it or, quite candidly, whether they’re going to be able to make a living.

HEFFNER: What about that last point? You mention it last, but it really sometimes comes first, doesn’t it?

COHEN: I think that we find … these are my views now … that medical students are keenly aware that they’re coming out of medical school with debts well in excess of $150,000 or even $200,000 and they need to structure their careers in ways, candidly, that they can put a roof over their head, and make a living. They have a big, big basic rent coming out in terms of paying back those loans. And in this country we’ve not really done very much … my view … to, to alleviate that.

HEFFNER: Like what? How could we?

COHEN: One could make an argument that if you’re going to insist that people do primary care, or you’re going to set a structure where third parties are going to determine what fees are going to be, then maybe medical school should be free in this country.

Ah, or at least aggressively … have aggressive scholarship. Medical school, like a lot of private tuition in the country … really any graduate education … if your parents can afford, then you get to be able to go …come out of those programs without a big nut to crack. As opposed to kids who come less privileged families who have these big rents to pay when they get out before they get into practice.

HEFFNER: Well, I don’t have to worry about this. I’m an old man, you’re a young man, you’re my doctor, you’ll be here when I go. What about the future?

COHEN: I’m not sure. I think the country is … any time we try to change anything here as relates to medicine, a lot of the constituency gets very upset. So things are not … surely to fix that problem is not something that, that I don’t think anyone is aggressively addressing … in my reading … aggressively addressing now.

I mean at Cornell Medical College we have a very strong program of, of scholarship, which I’m involved with. Particularly … I’m particularly interested in scholarship for students who are interested in doing primary care.

So that they have that option of going to work someplace where it may not be that lucrative, without feeling that they can’t do that because they’ve got a big loan they’ve got to pay back.

HEFFNER: Primary care. How do you define that?

COHEN: Primary care … classically in this country are the physicians who are the entry way to the medical system. They have, over the years been internists, general practitioners when you were a kid, but family practitioners today, gynecologists and pediatricians, as opposed to the specialists, who are not providing general care.

HEFFNER: And what are the percentages now? How do the medical school graduates break up in terms of what they choose?

COHEN: You know I don’t know that data that well. But medical students are … there was a real push back from primary care for a while. But as the opportunities in specialty care have gotten tighter and the places for training have gotten tighter, I think more students are interested.

But, there’s a larger cultural shift which, which your … which you may not know you’re alluding to … is that primary care offers for many people today the opportunity to not necessarily work the way I work, but to work part-time. Or to work four …

HEFFNER: What do you mean by part-time.

COHEN: Well, part-time for me … well, part-time for me would be 40 hours a week. But I think part-time for people would mean working two or three days a week. And, and having a life. Remember half our graduates today are women and, and many of them are not walking away from the notion that during the child bearing age it’s not that easy for dual couples to work full time … and medicine offers the opportunity today for people to work part-time. They work in a clinic, they’ll work in a hospital, work in a group where they’re providing care as opposed to the kind of practice I do.

HEFFNER: Do I understand … when you say “the kind of practice you do” … do I understand you’re saying that’s not a very good bargain … that they’re given that opportunity.

COHEN: I don’t know that that’s fair. I don’t … I don’t think that the emotional rewards of doing that approach what I’ve been blessed with.

But these … this … that … this generation doesn’t … they … they’re not necessarily driven by those kind of role models or even those interests.

HEFFNER: That’s interesting … driven by those kinds of role models. In other words, you’re saying you had very specific role models. They were doing what you’re doing now.

COHEN: Right. But the kids look at … the residents look at me or medical students and say, “I don’t really want to do what he does. I’d like a life. I’d like my weekends, I’d like my nights. I’d like to be able to go on vacation and worry about what’s happening’. They have … it’s a different world, it’s a different world. And I don’t know even that that’s unique even to medicine.

HEFFNER: Tell me about that … that that’s perhaps not unique to medicine.

COHEN: Well, I … I’m blessed … I get to see a lot of people or a lot of very interesting people every day. And I was recently with a young man who was on the track to become a partner in a law firm … in one of the New York major corporate law firms. And I know a lot of those corporate lawyers because they also sit at … you know opposite me.

And I said, “How’s it going?” And he said, “Well, I left the firm. I’m working for a corporation now.” And I said, “Oh …” and I was kind of disappointed because I knew this man. And I said, “Why”?

And he said, “Well, I really wanted to have my weekends and I really want to not … you know I wanted to be home to see the baby and … you know when you’re on the track … corporate track at one of the major New York law firms … that’s not really an option for many years.

And I said, “Well, what about the money”. And he said, “Well, I took a small cut, but it was worth it.”

HEFFNER: Okay, Dr. Cohen … let’s say, that’s the way it is … not just in medicine, but in law, etc.

You’ve used the word when we’ve discussed this … “sad”, you say you’re saddened by what you see. But why be sad if that’s the way it is?

COHEN: That’s a fair argument … (laughter) … I just think that …

HEFFNER: It’s not even an argument. It’s an honest question.

COHEN: I think that, that my … what I, what I’ve been able to do and what my friends have been able to do has been profoundly rewarding.

And I, and I think the doctor described in the Times article …the primary care doctor … in that community … he’s had a really good life … as a person, as a profession and as a professional, as I see it. And the doctor described …

HEFFNER: And he can’t, he can’t get rid of his practice, he can’t give it away now.

COHEN: Yeah because people don’t want to … they don’t think what he … what he had was particularly what they want. The article describes him trying to get somebody to work in the office with him. The doctor works for a little while and says, “forget it, I don’t want to be around here all the time, I don’t want to work this many hours. I’ll take something a little less personal, little less involved, to have a different, different lifestyle.

I don’t’ think … my prejudice … I don’t think that that doctor who’s not going to take the opportunities that the doctor had who had that practice, will have as fulfilling surely a professional life … and the way I was raised … that was a … your priority.

We, we were academic people who had a mission and you had a calling and we followed that calling. I wouldn’t do it any differently now.

HEFFNER: You say you wouldn’t do any differently now. You don’t know that and I don’t know that because you’re not being brought up with different role models. You’re not seeing the medical profession as something totally different than it was when you were in training.

COHEN: Fair enough. Fair enough. And also my training … the ethics of my training and the way my training was done … there was … there were no restrictions on the number of hours that we were allowed to work. There were no limits on the number of patients we were allowed to admit. There were no rule that said we couldn’t come back on Saturday morning … if we had a case we were worried about. These … the young people today are raised with rules and make that basically illegal. They’re not allowed in the hospital after so many, so many hours because of regulations.

So, it’s part of the whole culture of the way we’ve changed this game.

HEFFNER: You see one of the things that disturbs me so much … when you talk about the sadness and I see it when, when … that …that you really mean this … is that I always think, “Well, if the government would do something different. If we would provide free medical tuition … ah, etc, etc. … when what you’re talking about is a society, a culture, change in attitudes … having to do much more than with “who pays for what”.

COHEN: I … you and I agree on this. And I don’t … I think, I think … my concern and one of my prejudices when I get annoyed about this is I will say at a meeting, “In those countries that will control a large piece of the world’s economy in the future according to projections … these attitudes may well not exist.”

HEFFNER: Aren’t you talking about us, too? These attitudes that you reflect … that reflect your training, your upbringing, your heroes, your teachers … gone here, too?

COHEN: No, but I’m not sure they’re gone in those other societies.

HEFFNER: You’re, you’re not. I didn’t understand you then … why do you say that?

COHEN: Well, I think … when I read …

HEFFNER: Yeah.

COHEN: … it sounds to me that the, the medical student, as a metaphor in China or the medical student in India, okay, has a kind of a different view than the medical in, in, in, in New York.

HEFFNER: A less materialistic one?

COHEN: No, a, a more professionally driven and surely less restricted in what opportunities they potentially see for themselves down the road. Now it’s kind of unfair to say that about China.

But if you look at countries which are moving up … people are looking to build and grow as opposed … very committed to lifestyle and personal time and recreation.

This country wasn’t … I don’t think this country … we’re getting beyond our, our regular thoughts … but from my view … I talk to a lot of people … I mean, really this country was built by people who wanted to work a lot and wanted to strive and saw tremendous opportunity. I’m not sure that those drives are there anymore for, for people.

HEFFNER: How could a man as young as you be as old fogey-ish as I am? That’s … you’re talking about life attitudes, a life philosophy.

And I wonder, if you had to make a guess, what percentage of the students at Weill Cornell Medical College will reflect more rather than less a desire to have a living … not just make a living, but have a life which means the time that is at a premium when you work the way you do.

You call me on a weekend morning to ask me how I feel after a certain incident. That’s time out of your life.

COHEN: No, that … that’s my life.

HEFFNER: That is your life.

COHEN: That’s my life.

HEFFNER: That’s the point.

COHEN: Don’t ever feel bad for me … don’t ever feel bad for me.

HEFFNER: Because you like what you do.

COHEN: Yeah. Yeah. I … that’s, that’s my life. That’s fine. I would say that there … you know … I would guess that probably 60% or 70% of the medical students think I’m goofy. Okay. You know when the dust settles. But that’s okay. I feel bad for them.

HEFFNER: That’s sad.

COHEN: Sad for me. I mean sad for me in terms of what I value and what, what’s brought me tremendous reward as being a physicians and what I’d like to think as a professional and not just a provider.

HEFFNER: What are the, what are the changes that you anticipate in medicine itself. I’m very interested in, in your projection as to a different kind of physician, a different kind of human being, a different kind of American if you will.

Where work isn’t regarded the same way it was. How do you think that’s going to impact upon the national health?

COHEN: Well, I almost think it’s a perfect storm. Because the, the national health is moving, for lots of reasons, to providers rather than professionals.

And so, the, the physicians will be just part of the picture of para-professionals and nurse practitioners, who do terrific work, but who will be in, in a nature of service where they won’t necessarily be entrepreneurial for sure in what they’re doing.

And they will be working for third parties, who will determine … they will be paying for the care, or supervising how the care is given … setting very specific algorithems at what ought to be done and the, and the providers will be following very specific rules, almost, as to what you do and what you don’t do and when you do and when you don’t.

And not necessarily be vested in what goes on the way I am with you.

HEFFNER: You’re a practitioner … you’re saying they won’t be practicing, they will be fitting into molds established by others.

COHEN: Right.

HEFFNER: And those will be financial.

COHEN: Those will be financial. I mean … I think … and, and they … and, and, and … and they’re not necessarily pleasant for the most part.

HEFFNER: What do you mean?

COHEN: Well, I think … you know, I have friends who practice in that mold, you know … and their decision as to what, what drug to give somebody …

HEFFNER: Yeah.

COHEN: … is not based on what they think necessarily they want to do, but what the plan allows … or what … or where to send a patient for an x-ray or form whom they should see in consultation about their painful knee … must be someone within their system, otherwise there are financial and/or office penalties for not moving that way.

And, and that’s reality. That, that, that’s reality. The, the … you know, think about this … in preparation for talking to you … I had a patient call me the other day who burned his hand. And I said to him, “Tell me about the burn” and it sounded like it really wasn’t much of anything.

I said “Let’s, let’s see what happens, call me back in a couple days if you’re not happy the way it looks.”

And he called me back on Monday and he said, “You know I’m not sure of this …”

I said, “Why don’t you meet me at 8:00 o’clock tomorrow morning. I’ll come in a couple of minutes early. Let me take a look at your burn”. A Wall Street guy, he doesn’t have a lot of time to spend in a doctor’s office.

And I met him in the hall … downstairs … from my office. And I, I said … “Oh, come here, let me take a look at your hand.”

And I looked at his hand and it really was nothing. And I said, “It’s healing really well. There’s nothing to be concerned … get back in the cab and go to work. Keep your regular appointment with me”.

That’s what I’m able to do. The other system … a guy calls on the phone … he gets an email from somebody saying he needs to be seen, or he talks to a nurse-practitioner. I tell him he needs to come over if he wants it examined, okay … because they’re not going to do it over the phone, because they can’t charge for care over the phone and there are productivity notions of what needs to go on.

Doctor needs to see so many people a day …the system wants to create the billing because … when … okay … and then they say “He’s not better” and the doctor says, “Come in” or someone tells him to come in.

And the doctor meets him in the hall … he says, “You must come upstairs. Because if you don’t come upstairs and I don’t write a regular note and I don’t document my examination with all kinds of other things … about the exact size of the burn … we can’t bill and I need to bill you because I have productivity standards and when you come for your regular check-up, the fee that I’m allowed to charge you is determined by the third party … so I’m going to have to grab what I can now to meet my overhead.

When that man comes to see me for the regular check-up, my fee between … my relationship with me and him is between the two of us, so I don’t feel the need to grab $30 or $40 dollars from an insurance company for looking at a hand.

Okay. I can just act as a real professional and say, “This was nothing, come back for your regular appointment”. It’s a very different model. My model’s very unique.

HEFFNER: What, what’s the percentage of those unique models … I mean how many of you are there left?

COHEN: I don’t know. I mean I think Manhattan surely is a place where it goes on. There are docs able to do this in, in major metropolitan areas.

But … again … but it requires a level of commitment on our part, you know. I, I’ve got to come in … I’m happy to come in a couple of minutes early and to take the time to see somebody … you know, a little before hours, if I have to.

I don’t know what the numbers are. Unfortunately, I think a lot of what, what we did … my mentors did … has been a bit bastardized by so-called “conceierge” doctors who create a different type of model with patients, which is also not … to my view … particularly professional. It’s almost more provider … where people pay a users fee to … I say users fee … to access to a doctor who’s going to … not necessarily have the same kind of doctor-patient relationship … but limit his practice and give, you know, 24 hour availability …which I have … but when I’m here talking to you … no one has the expectations that I’m going to be able to call them back in five minutes. You know, I’ll call people back when I finish.

But we have a nice doctor-patient relationship. Not a provider/conceigere relationship.

HEFFNER: That word really gets you, doesn’t it?

COHEN: Yes.

HEFFNER: Provider.

COHEN: Well, I think it’s a useful model to understand how things are changing. The, the … you know, I think it’s emerged for me, at least, explaining what I do … what I’m able to do and what these people are going to be able to do.

HEFFNER: After all of our discussions, I wondered whether the medical students have any real awareness of what is happening and what they’re letting themselves in for.

COHEN: I think they absolutely do.

HEFFNER: You do?

COHEN: Oh, yes.

HEFFNER: And they choose it?

COHEN: Oh, yes. And they, they are very curious and very aware of all of this … it’s, it’s in their face, it’s in their face. (Laugh) And, and, and a third year medical student at, at a medical college who, who looks at his loan portfolio … and sees he’s up to $145,000 … he’s, he’s not … these are very bright kids, they’re not going to … they realize the realities of what they have to do in order to have, have … pay back these loans.

HEFFNER: Very depressing. That’s … I guess that’s why you use the word “sad” so often. But you’re saying you feel sad for them … sadly for them. And you see no change that’s going to take place in this county …

COHEN: Right.

HEFFNER: … that will change that.

COHEN: Yeah, I don’t think that’s anybody’s priority … I don’t think … physicians remaining professionals … for those who are setting healthcare policy … is not mainly a priority.

And they … and I suspect there will … people who will watch this show … and say, “Oh yeah, and he’s an old timer, but he’s wrong, the kind of care that he gave was very expensive and it was very inefficient”. And he did unnecessary tests, etc., etc. But, I’m comfortable that that was never the case.

HEFFNER: But let me ask that … well, you say “never the case”. Let me ask a question about … and we just have two minutes left … about whether it was efficient.

COHEN: Well, I think what I do is not necessarily efficient, but it’s very pleasant for patients.

HEFFNER: Yeah. That I can testify to.

COHEN: And that’s why I became a doctor. I became a doctor so that people would come in and they’d have a problem and even if I didn’t fix their problem … they were better off for having been with me … then … then for not.

And I always wanted to feel that they were as good with me as they could have been with anyone. That was my goal. That that interaction was as, was as, as good as it could be.

And I was vested in that because those were my models. I’m going to see them again … I take care of their families. If I’m just somebody who … they’re going to because I’m in their plan or happen to be the doc on call in the office or the hospital that day … it’s a different mediciene.

HEFFNER: You think people who are in those plans where there are a number of doctors … are … I don’t mean at jeopardy … but are not … probably not getting as good medical care.

COHEN: No, I don’t … I won’t argue that. No. They’re probably getting good medical care, it’s just not aa pleasant. It’s just …. It’s ot as pleasant. It’s, it’s the old … you can get across town, you know, in a yellow cab … it’s not the same as a limo. You know, you’re still getting cross town. And you can get cross town in a bus.

HEFFNER: We’re going to continue these discussions, Dr. Cohen … obviously. As long as you keep me alive.

COHEN: (Laughter)

HEFFNER: I want to thank you for joining me on The Open Mind.

COHEN: It’s a pleasure.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.