Medical Alert

For the first time in months, Richard Hahn is happy to be a doctor. In a ramshackle compound of cinderblock buildings near the western border of Thailand, the Southern California surgeon watches intently as his protege medics treat a 20-year-old land-mine victim. He leans in for a closer look at what remains of the man’s left leg--a gruesome tangle of flesh and bone sheared off mid-calf.

The patient, a Burmese farmer who was foraging for food in the jungle when he stepped on the mine, is one of thousands of villagers caught each year in the crossfire of the country’s continuing civil war. His pregnant wife and friend carried him for two days across the border to Thailand, to a clinic that provides medical care for refugees. The farmer lies on a vinyl sheet draped over a wood table; his IV bag hangs from a bamboo pole. The room looks more like a storage shed than a trauma center: The floor is cement, the roof corrugated tin. There is only one surgical mask to go around.

But Hahn, who has performed thousands of life-saving surgeries during his 30-year career, is oblivious to the surroundings. He is focused on the patient’s leg, and on the medics he has helped train. The head medic, 32-year-old Win Kyaw, wields the scalpel. The patient is awake, his pain dulled by anesthetic, and is surrounded by other medics-in-training: One unwraps the leg bandage, one puts his hand on the patient’s chest to monitor breathing, another holds his head still as he moans softly.

Hahn watches as Win Kyaw removes bits of muscle and tissue. Hahn peers at the stump and smiles, nodding, light from the room’s single lamp glinting off his large rectangular glasses. “That looks good. See the amount of pink?” Hahn says, pointing, as a translator repeats his words in Karen, an ethnic hill tribe language. “That’s healthy tissue. The wound was infected when we first saw it. But today, as he was probing, he wasn’t opening up pockets of pus. There’s a good possibility that he might save the knee.”

Hahn looks like a proud father, beaming at the medics, who are refugees themselves. A military regime that took power in 1988 failed to stamp out a decades-long ethnic insurgency, and more than 400,000 Burmese--many of them ethnic minorities--had fled to Thailand by 2003, with an estimated 1 million more displaced within Burma (now known as Myanmar). The Mae Tao Clinic in Thailand has trained several thousand as medics and midwives to help care for other refugees. A small cadre of medics such as Win Kyaw make up the Backpack Health Worker Team, volunteering to return to villages deep inside Myanmar that otherwise would have no access to medical care. Several times a year, these medics cross back over the border into Thailand to replenish supplies and attend training workshops, led by people like Hahn. “They hike through the jungle to come here, they sleep in the jungle, they risk running into the [military], stepping on land mines,” Hahn says. “They are so dedicated in their desire to learn. To see the extent of their perseverance is incredibly inspiring.”

Hahn’s last word is telling. It explains why a 58-year-old surgeon recently abandoned his own surgical practice and spends his vacation working near a war zone rather than relaxing on a beach or touring Europe. “Working here takes us back to why we got into medicine,” he says. Health care is simple: no insurance companies, no paperwork, no lawyers. Just practitioners helping people in desperate medical need.

“At home, medicine is so overshadowed, the pain outweighs the pleasure,” he says. “What I saw too much of was anger, expectation, blame throwing, patients feeling entitled to a good outcome.” Here, he regards the medics’ idealism with something approaching envy. Like many of his colleagues in the United States, Hahn barely remembers what it’s like to feel so energized by medicine, and so hopeful.

Hahn knew he wanted to be a surgeon by the time he was in junior high school. He loved anatomy, and watched his thoracic surgeon father operate on several occasions. “The intervention, the fix-it aspect of surgery appealed to me. It was very definitive,” Hahn says. “There’s an acute problem, and you go in and do something about it, solve it with your mind and your hands.”

He went through medical school and residency at USC in the 1970s, and built up a busy private practice. In 1995 he became chief of surgery at Antelope Valley Hospital in Lancaster. Over the years, as he acquired the trappings of success--house, car, fancy dinners, professional kudos--his enthusiasm died under the weight of sky-high malpractice insurance, burdensome paperwork, long hours, shrinking compensation and late nights on call. Worst were the thankless patients with ever-ready lawsuits.

He recalls a night in the mid-1990s when he agreed to see a woman who was not one of his regular patients. Hahn went to the hospital because the woman, on her doctor’s recommendation, had asked for him. Hahn evaluated her condition and initially advised against surgery. Ultimately, however, Hahn did operate nearly a week later. “She made a full recovery. We saved her life,” he says. “But she was unhappy” because he had not recommended surgery sooner.

“I’m thinking, ‘Wow, we saved your life. You would have been dead.’ She’s thinking, ‘I suffered.’ She thought everything that had happened, her long recovery, was my fault. It’s sort of like half empty, half full,” Hahn says. The patient sued and the parties reached a settlement. But he felt as if he had been punched in the stomach. “She was not only not grateful, but accusative. She accused me of being uncaring and self-serving. Any physician who has extended the health of a patient, reading these [lawsuits] feels like he’s been assaulted and battered. It feels so personal. You think, ‘My God, how could anyone think this of me?’ ” Hahn asks, his voice rising. “It’s just one or two or three times these kinds of things happen in your career. But eventually you feel exhausted and beat up.”

Ask any doctor about practicing medicine in the United States, and you’re likely to get a similar response. Doctors are disillusioned and demoralized: They see managed-care hassles growing and compensation shrinking. At the same time, malpractice lawsuits continue to rise, as do the numbers of uninsured patients. Together, those forces are perverting the nation’s medical care system, stressing it as never before.

“I personally believe that in 10 years the average American will not have access to a physician unless they are rich,” says Dr. Jack Lewin, chief executive officer of the California Medical Assn. “We are extremely worried about the future. It’s a problem that frankly is causing many doctors to be depressed.”

Just how unhappy are doctors? In a 2001 survey by the CMA, 43% of the physicians who responded said they planned to leave patient care, retire early, move out of California, or change professions within three years. Seventy-five percent said that practicing medicine had become less satisfying in the past five years. More than a quarter of the physicians would not choose medicine as a career if they were starting over, and two-thirds of them would not advise their children to follow in their footsteps.

The prime directive of medicine guides doctors to think of patients, not money or liability. But the system has put them in a position where they can’t do that professionally, legally or financially. “The rules have changed quite a bit,” says Glenn Melnick, a professor of health care finance at USC and a senior economist at the Rand Corp. Twenty years ago, doctors “did everything they wanted,” Melnick says. But under managed care, insurers and administrators started looking over doctors’ shoulders, questioning treatment decisions, increasing paperwork--and paying less.

Most doctors still make a good living by any standard. The median annual income for all physicians was $162,000 in 2002, according to the Journal of Medical Economics. But salaries vary so widely, it’s almost useless to lump them into one profession. For every Beverly Hills plastic surgeon topping half a million dollars in annual income, there’s a bevy of pediatricians who don’t break $100,000. Hospitals and physician groups are going broke all over the country, and across the board, compensation for doctors is down. The CMA survey respondents reported an average 26% drop in income between 1995 and 2001.

Doctors say the most satisfying part of their job is spending time with patients. But with one of five residents in California uninsured, reimbursement rates from insurers dropping and malpractice rates rising, doctors are working longer hours and crowding more patients into already busy schedules. They carry an average caseload of 2,500 to 3,000 patients, compared to 1,000 20 years ago, according to Lewin. “You’d spend a half hour with each patient, do an annual physical,” he says. “If you needed to make a house call, you could. That’s what good medical care is about. We’ve destroyed that.”

Now patients are lucky to get 15 minutes of face time with their doctors. “The patient-physician relationship is at the heart of what it means to be a doctor,” Lewin says. “But we are being pulled away from it by all these economic forces and by a disrespectful situation in which the doctor is being devalued.”

Then there’s the risk aspect of medicine. U.S. doctors get sued--a lot. Half of the country’s neurosurgeons are sued each year, along with one-third of the obstetricians. On any given day, more than 125,000 malpractice lawsuits are in progress against America’s doctors. The liability associated with practicing medicine has sent malpractice rates soaring, according to The Doctors Company, a physician-owned medical malpractice insurer based in Napa. In California, rates went up 31% during the last five years. In Florida, the rates increased 105% over six years, and in Nebraska, 184% during the same period. Some specialists pay $200,000 for insurance each year.

There’s no question that doctors make mistakes, some of them egregious. But the eye-popping numbers don’t mean that more physicians are incompetent, just that they are getting accused far more often. Most malpractice cases end in settlement, saving insurers time and money. On average, it costs physicians $77,000 to defend themselves in cases--and that’s when they win. And even when a doctor is vindicated, it can take years for a lawsuit to wind its way through the system. Many physicians have become gun-shy about whom they treat: Every patient who walks through their door is a potential plaintiff.

“If you’re a doctor who’s willing to take care of really sick patients, particularly a poor person you don’t know, or you’re an obstetrician who does a delivery and something goes wrong, it’s guaranteed you’re going to get sued,” Lewin says. “We’ve set up these terrible situations where doctors are advised not to take care of the uninsured, or go into an emergency room.”

Some critics say that physician dissatisfaction is a generational issue. Doctors--particularly those older than 50--are peeved because the halcyon days of medicine are over. No more making a bundle and spending Fridays on the golf course. “They have legitimate gripes,” Melnick says. “But what about computer programmers who were making $150,000, and now all the jobs are going to India? It’s economics.”

Melnick agrees that for thousands of years the ethos for physicians was simple: Do everything possible for the patient. Cost effectiveness wasn’t--and still isn’t--part of the Hippocratic oath. “Physicians had a luxurious world before where they didn’t have to think about economic constraints,” Melnick says. “But no one else who is providing a service or product can do that without thinking about a budget. That’s the reality we have to live with now.”

Still, doctor discontent--like economics--has a trickle-down effect, and everyone pays a price.

Three years ago, Richard Hahn was at a crossroads. buried by a full load of complicated high-risk surgical cases, as well as time-consuming administrative duties at the hospital, he wasn’t ready to retire, but he was burnt out.

His escape route? An “aesthetics” practice, where he could apply his three decades of surgical skills to laser treatments, botox and collagen. After setting up his new practice, he cut back on his work at the hospital. “I was dealing with cancer, trauma, vascular disease, and now I’m doing botox, spider veins, hair removal. I went through some soul-searching,” he admits. “Is this pandering to vain, rich, neurotic people divorced from real medicine?”

He decided it beat his old job. He has happier, healthier patients who are less likely to sue. He spends less time at work, and makes the same amount of money.

Hahn figured he was easing toward a cushy retirement. Then, in 2002, he was approached by Dr. Lawrence Stock, assistant medical director of the Antelope Valley Hospital emergency room. Stock asked him to join the Global Health Access Program, a small group of Santa Monica-based health professionals that formed in 1998 to volunteer on the Thai-Myanmar border. Hahn had never been out of the country, except for a post-college trip to Europe. On a whim, he said yes.

For a man used to staying in five-star hotels, a war zone came as a shock. He slept on a hard bamboo floor under a thatched roof, worked 10-hour days for no pay in an area rife with malaria and dengue fever, pushed his way through a teeming market, buying sugar cane and rubber tubing and other supplies to use in his surgical training course. Overwhelmed after the first trip, he said never again. But after being home for a few weeks, he changed his mind. He couldn’t stop thinking about the refugees--medics and patients alike. He wanted to improve the course he and Stock had developed. He found himself counting the months until he went back.

Single, with no family responsibilities and a less demanding medical practice (he stepped down as chief of surgery late last year), Hahn now has the time and financial freedom to volunteer two months a year on the border.

It is lunchtime in Mae Sot, the Thai town closest to the refugees’ clinic. Hahn and Stock escape the searing tropical heat in a shady roadside restaurant. The two are revamping the syllabus for their surgical course: For the first time this year they will train the more advanced medics to teach the course themselves. But the discussion soon veers from jungle medicine to practicing at home. As an emergency room physician, Stock’s criticisms take a different tack than Hahn’s. But Stock is equally frustrated--perhaps more so, since he is still immersed in hospital care. Stock could follow in Hahn’s footsteps but he isn’t tempted.

“I want to be in the ER, where I can see everyone and not turn anyone away,” Stock says. “It’s a wonderful resource we have. It’s worth preserving.”

At 7:30 on a recent Friday evening at the Antelope Valley Hospital emergency center, the 40-bed unit is jammed with 91 patients. They are everywhere: behind curtains, tucked in alcoves, on gurneys lining the corridors. Machines hum, beep and buzz. Doctors, nurses, technicians scurry around a department that spreads into annexes across a parking lot. With about 300 patients a day, Antelope Valley Hospital’s ER is the second busiest in Los Angeles County, behind County-USC Medical Center.

At 42, Stock looks a bit like a big kid--sneakers, messy blond hair, the sleeves of his white lab coat hanging down past his fingertips. But his appearance belies his efficiency. While genial with patients, he does not linger. He goes hours without a restroom break. He never stops for a meal, subsisting on energy bars. He runs from patient to patient, clocking several miles every shift.

Stock revels in the “managed chaos” of the ER, until the inevitable breakdown turns his enthusiasm to disgust. Tonight, it comes just after 11. William Wilbur, a 63-year-old aerospace engineer from Boron, is wheeled into the emergency room. Two hours earlier, he had been bucked off his horse, breaking his pelvis. While alert, he is in a great deal of pain. Stock and his colleagues use a bedsheet to truss Wilbur back together, wrapping the white cloth tightly around his hips.

Wilbur needs surgery to repair a ligament that holds his pelvis together--a high-risk procedure involving opening his abdomen and moving his internal organs aside to get at the injury. No one at Antelope Valley’s two hospitals is available or willing to do the surgery. Stock must call around to find an orthopedic surgeon.

Wilbur, who has top-notch health insurance, figures it’ll take one phone call and he’ll be on his way. But morning comes and still no orthopedist. In between treating about 40 other patients, Stock has been playing “Dialing for Doctors,” calling 10 hospitals in three counties. Throughout the night, Wilbur could hear Stock on the phone, his voice rising in frustration as he failed yet again to locate a surgeon.

“Either the hospital didn’t have the capacity, or the orthopedist said it wasn’t in his skill set. That skill set would be ‘I’m willing to take it on and I’m not afraid,’ ” Stock says, sounding more resigned than irritated. “This procedure is taught in every [orthopedic] residency program in the U.S., but now no one will take these cases because of the risk of a bad outcome that could lead to a lawsuit.”

Wilbur, although none too happy about his situation, is sympathetic. “You make assumptions that medical assistance will always be available to us. Then you realize there are ambulance chasers looking over the shoulders of doctors and surgeons, waiting for them to make a mistake. That’s going to lead to natural shyness, away from risk. If I was a surgeon, I’d think, ‘Why would I need this grief? I need to protect my family.’ ”

Stock’s shift ends at 7 a.m. Saturday, but he keeps dialing. Two hours later, he finds space at Long Beach Memorial Medical Center, 91 miles away. Stock knows an ER doctor there, who sweet-talks an orthopedist on call. Wilbur arrives by ambulance Saturday afternoon, only to discover that he will have to wait for space in the operating room and for the rest of the orthopedist’s surgical team. It’s Monday--almost three days after falling off his horse--before Wilbur is wheeled into the OR. The sheet Stock knotted around his pelvis is still on.

Wilbur, now on the mend, gives kudos to both hospitals for doing everything possible under the circumstances. But he wonders: “What would have happened if some of my internal organs were injured and I was bleeding? What happens to John Doe who’s critically injured and there’s not a surgical team available?”

Wilbur’s “what if” occurs almost every day in Southern California, where emergency care looks like a line of dominos toppling in a chain reaction. More than 60 California hospitals have closed in the past decade--four since Jan. 1. At the same time, emergency department visits in California have increased sharply, to more than 10 million annually. California’s nearly 7 million uninsured and 3 million noncitizens use the emergency room as a medical office. In addition, more people with private insurance use the ER when they can’t get appointments to see their regular doctors.

Emergency departments in Los Angeles County are so overcrowded that on Friday and Saturday nights, almost every one of them is on diversion status, which means ambulances are routed to other hospitals. But when all the ERs in a region reach diversion status, Alice in Wonderland ensues. All of them, in effect, are forced to begin taking patients again.

Under federal law, hospital emergency departments screen and stabilize any patient who comes through the door. To do so, ERs need an array of specialists on backup call to handle serious cases. But, as Wilbur discovered, an increasing number of specialists are balking. Nearly 40% of physicians have reduced their on-call duties, and 20% have stopped altogether, according to a study in the May 2004 Annals of Emergency Medicine.

In need of a surgeon to treat an emergency case? Good luck. Almost half of the 81 hospitals in Los Angeles County are on permanent diversion for patients needing emergency neurosurgery, and on-call specialists in plastic surgery, orthopedics and ear, nose and throat surgery are also scarce. “We’re one celebrity death away from a solution,” says Dr. Dan Higgins, an emergency physician at St. Francis Hospital in Lynwood and president-elect of the Los Angeles County Medical Assn. “If Bill Gates is driving on the road and dies because he can’t get trauma care, maybe this will get fixed.”

Until then, Higgins says, “We have crisis, cutback, bailout, crisis, cutback, bailout. We’re just waiting for our next crisis.”

Before managed care, specialists took on-call shifts as a way to build their private practices. Now physicians acquire patients through health plan contracts. If a patient is uninsured, or doesn’t have the right insurance, specialists don’t get paid: According to the Annals of Emergency Medicine study, nearly 80% of physicians have trouble obtaining payment for on-call services, and more than half receive no payment at all. In response, many specialists are demanding stipends of $100 to $3,000 a night for an on-call shift--whether or not they go into the hospital. More than 60% of California’s already-strapped hospitals pony up, paying an estimated $300 million a year.

While one hospital administrator likens stipends to blackmail, specialists say the payments are only fair. “They are asking doctors to cover the emergency room to keep the emergency room open,” says Dr. Ted Mazer, a 45-year-old ear, nose and throat surgeon in San Diego. “Doctors are giving up time with their families. You can’t go to a show, have a drink with dinner. Your life is not your own when you’re on call. Should society expect people to give that up without compensation? I can’t think of another field that would put up with that.”

Mazer has operating room privileges at two San Diego hospitals: Sharp Grossmont, where he is on a backup call panel for the ER, and Alvarado, where he refuses to be on call. “You end up taking call every other night. You spend your night in the emergency room, take the liability and fend for yourself, and you probably won’t get paid.”

The ER also means more risk for specialists because the patients they see “are often under-treated to begin with, may have more medical problems, and are more apt to be litigious,” Mazer says. “You don’t have any relationship with them until they are having an acute problem.”

Doctors protect themselves by presenting the worst-case scenario. “A wise surgeon will say, ‘Your family member is very sick. We will do everything we can, but . . . ‘ It’s called ‘hanging crepe,’ ” Stock says. “Then [patients] are overjoyed at good results.”

The reluctance of specialists to answer ER calls often leaves emergency physicians alone on the front lines of health care, where they spend valuable time making phone calls and keeping patients stabilized while waiting five, six, seven hours for a specialist. And when no specialists are available, doctors such as Stock push the limits. “You can’t admit [patients] or transfer them or send them home, so you wait,” Stock says. “If you still can’t find anyone, my solution is to expand my skill set to the doors of the OR. I’m not going to do fine, delicate surgery, but any problem that becomes life-threatening, I will intervene. These kinds of near-misses happen all the time. It puts me at risk.”

As a precaution, Stock keeps a call sheet on each patient, recording how many specialists and hospitals he has contacted, justifying his decisions to provide treatment or to send patients 100 miles away. “Society loses when no one’s willing to be on call,” Stock says. “This isn’t just affecting doctors, it’s affecting patients. We’re entering a chronic state of crisis.”

On a ridge near the northern border of Myanmar and Thailand, Stock stands gazing at the sun streaming into a steep, narrow valley. The air is hazy from dry-season crop burns, the rice terraces brown and fallow. It is late afternoon, quiet and still. But at night in the past, red bursts of tracer fire have arced between nearby military outposts.

Stock has traveled hours by bus and motorbike to teach emergency field skills to 20 medics at a remote fledgling clinic. As he goes over the basics of triage, a trio of curious Akha tribeswomen appears, beaded headdresses framing their lined faces as they watch the medics practice. Stock does rounds with the medics, checking on patients in the tiny bamboo and cinderblock hospital: malaria, pneumonia, gunshot wound. He examines a young woman who had miscarried three days before, checking for signs of infection or bleeding. The woman is understandably reluctant to have a stranger--a male Westerner, at that--touch her. But she relents. Afterward, the woman and her husband each shake Stock’s hand, thanking him in their hill tribe dialect.

Stock, like Hahn, finds solace here in the Third World. He has made seven trips to Thailand, and has volunteered in the Balkans and Liberia. “Every place I’ve been, patients accept that medicine can’t fix everything,” he says. “That doesn’t mean anyone’s to blame. Blame is a First World phenomenon.

“We’re into the quick fix, the computer age, used to things happening fast and exactly right all the time. That’s not the nature of medicine. We can divert or delay the final outcome, but we often can’t change it. People in the developing world get that. They understand patients die.”

Stock eyes the scene around him--villagers lining up for treatment, holding babies close, medic trainees taking patient histories, standing in front of a paper skeleton, learning anatomy. “In Thailand I can practice without the issues that so disaffect doctors in the United States: money, fear and anxiety. Patients here say thank you, and the appreciation is not based on the outcome. It’s based on knowing that we care.

“This is the antidote to what ails us at home,” he says. “I love being a doctor. I hate what’s going on in the U.S.”