Learning about Healthcare Administration

A toy-like cardboard contraption that sells for less than $20 online has helped save the life of a baby who was so sick that doctors told her parents to take her home to die.

Google Cardboard looks like a set of big square goggles. Stick your iPhone inside and with the right app, you can see images in three-dimensional virtual reality.

Doctors at Nicklaus Children's Hospital in Miami used the device to map out an operation they say they couldn't have envisioned otherwise.

On Wednesday, four weeks after her surgery, baby Teegan was taken off a ventilator and is breathing on her own. Doctors expect her to go home within the next two weeks and make a full recovery.

"It was mind-blowing," says Cassidy Lexcen, the baby's mother. "To see this little cardboard box and a phone, and to think this is what saved our daughter's life."

Here's how it was done:

Missing one lung and half a heart

Teegan Lexcen was born in August with a heart and lung defect so unusual that doctors had never seen it before. She has only one lung, and almost all of the left half of her heart is missing.

Her parents, Cassidy and Chad Lexcen, say their doctors in Minnesota told them there was nothing they could do. Soon after she was born, they sent her home with a hospice nurse and medications to make her as comfortable as possible.

When Teegan was still alive two months later, her parents wondered whether the doctors had been right. They started searching for a second opinion.

The Lexcens found out that a friend of a friend of a friend was a nurse in a cardiac intensive care unit in Boston. They made contact, and doctors asked them to send images of Teegan's heart taken at the Minnesota hospital.

Elated, the Lexcens sent the images to Boston. Two weeks passed and they didn't hear anything. Cassidy sent an email, politely reminding them that time was of the essence. She received an apologetic note back, saying there had been a communications glitch, and someone would get back to her soon.

The Lexcens knew that soon might not be soon enough. Teegan has a twin sister, Riley, who was growing steadily, while Teegan stayed tiny. It was a constant reminder of how poorly her heart was working.

"I felt like we were racing against the clock," Cassidy said.

It was around that time that Chad's sister found an article entitled "The 20 Most Innovative Pediatric Surgeons Alive Today."

No. 3 was Dr. Redmond Burke, the chief of cardiovascular surgery at Nicklaus Children's Hospital in Miami.

Chad's sister reached out and heard back immediately. Please send images immediately, a nurse told her. We'll see what we can do.

A broken 3-D printer comes to the rescue

Three times a week, 30 cardiac doctors and nurses sit in a room at Nicklaus Children's Hospital and discuss the treatment road maps for their patients and for children who might become their patients.

"The arc of people's lives get determined in these conferences," Burke said.

On a Wednesday morning in November, they looked at pictures of Teegan's heart.

Like the doctors in Minnesota, the doctors in Miami had never seen a child who was missing a lung and nearly half a heart. They threw out ideas about possible surgeries to help her. No one had a definitive plan. Some were skeptical that they could do anything.

Burke asked Dr. Juan Carlos Muniz, a pediatric cardiologist who specializes in imaging, to make a 3-D model of Teegan's heart. It had helped in complicated cases before.

A few hours later, Muniz reported bad news: Their 3-D printer was broken. "Technology always goes on the fritz at the worst possible time," he lamented.

But it turned out to be the best possible time, because it forced Muniz to come up with an option that worked better.

He'd been chatting with Dr. David Ezon, a pediatric cardiologist at the University of Pittsburgh Medical Center, about using virtual reality -- mainly used for playing video games -- for children's hearts.

After that discussion, Muniz bought a Google Cardboard device and had been playing with it in his office. With the broken printer, now was the time to use it for real, he decided.

Using an app called Sketchfab, Muniz downloaded images of Teegan's heart onto his iPhone and showed them to Burke.

They were similar, yet different from 3-D images they'd been using on computer screens. With the goggles, it was possible to move around and see the heart from every angle -- to almost be inside the heart checking out its structure.

Burke looked through the Google Cardboard, and visualized what he could do to fix Teegan's heart.

Making the difference between life and death

On December 10, 4-month-old Teegan lay on an operating table in Miami.

The first challenge was how to get to her heart. Normally, the heart is in the center of the chest, and to access it doctors make what's called a midline incision, cutting from the top to the bottom of the breastbone.

But Teegan's heart wasn't normal. It was far to the left side of her chest. Before using Google Cardboard, Burke feared he would have to make what's called a clamshell incision, which is a midline incision plus another cut going from the center of her chest all the way to the left side.

"It's massive trauma to a baby -- it's just horrendous," Burke said.

He was worried Teegan wouldn't survive it. "She was dwindling away. She'd been slowly dying for three months," he said.

That's where Google Cardboard proved advantageous over 3-D printing. The printer would have given Burke just her heart -- but to access her heart surgically, he needed to be able to visualize it in context with her ribcage and other structures.

With the use of the virtual image, Burke figured out a way to do just the normal midline incision and spare her the dreaded clamshell cut.

Once he was inside her chest, he says, Google Cardboard helped him out again.

A normal heart has two ventricles. The right one supplies blood to the lungs, and the left one supplies blood to the rest of the body.

But Teegan has only a right ventricle. It had been doing the work of both, but it couldn't do it for much longer. "The right ventricle is the wimpier, weaker ventricle, and if ventricles could talk, it would say 'I can't do this. I'm not designed for this job,'" Burke said.

The usual surgeries on children with only one ventricle wouldn't work on Teegan because of her unique defects and anatomy. Using the virtual image, Burke invented a new surgery, shoring up and rerouting her one ventricle so it could do the work of both ventricles long term.

Figuring all this out was something he had to do before he actually opened her up -- every minute wasted in the operating room trying to map out a plan puts a baby at higher risk for heart and brain damage.

The night before Teegan's surgery, Burke lay in bed imagining her heart based on the Google Cardboard image, mapping out the precise steps he would take in the operating room.

Nursing is Princess Leia

Don’t let the cinnamon hair buns fool you; nursing is the Rebel Badass of the Hospital Universe. Nursing doesn’t take sh*t from anyone, whether it’s being tortured by Darth Vader, inept interns, or patients similar in disposition to Jabba the Hutt. She knows how to use blasters and stethoscopes as weapons, so don’t mess. Obi-Wan Kenobi is her only hope.

Internal Medicine is Luke Skywalker

Smart, full of potentials, but young, naive, awkward, and lacking balls. Internal Medicine needs the help of everyone in the Hospital Universe, yet the Hospital Universe crumbles without Internal Medicine. Internal Medicine always wears a white coat or robe depending on if it’s rounding or shooting womp rats on board T-16 skyhoppers. Like Skywalker, internists have lost their right hands, but they did so in the evil fight with bowel impaction.

Surgery is Han Solo

Surgery is the lovable rogue, the one out for personal gain like Han Solo but likable since he’s honestly trying not to kill anyone. There’s a heart buried somewhere under that scruffy exterior and belt full of lasers, bovies, and power tools. Han Solo freezes upon exposure to carbonite or ECGs. Han Solo is always trying to get into the pants of Princess Leia. His “bucket of bolts” Millennium Falcon is the Da Vinci Robot circa 2000. Yeehaw!

Orthopedic Surgery is Chewbacca

This gentle giant standing tall and furry at eight feet is a reliable sidekick granted he doesn’t know a word of English.  Communication is primarily through grunting and banging on things, definitely not notes.  Weapons of choice: Wookiee bowcaster, hammer, Ancef, medicine consult.

Radiology is R2D2

R2D2 doesn’t say much; neither do radiologists, particularly if findings are negative.  But when either pipe up, everyone listens.  Neither is perfect though: R2D2 has been undone by enemy fire, while radiology always notes incidental findings.

Storm Troopers are Patient Satisfaction Surveys

Clad in white and never ending in number, they are one of Darth Vader’s most annoying instruments to threaten the Rebel Alliance.  The parallels are uncanny.

Pediatrics are the Ewoks

Pediatricians are allies of the Rebel Alliance and natives of the world of Pediatrics, which involves the care of small mammaloid bipeds called “children.”  We like and appreciate the Ewoks, we just don’t want to be an Ewok.

Martin Shkreli is Jabba the Hutt

Gluttony, greed, and deceit in its most wretched form.  If anything, at least he’s slightly likable.  Jabba the Hutt, that is.

Dr. Oz is Jar Jar Binks

Though he is technically one of the good guys, all the good guys actually hate him and can’t stand him.  Anything he says is garbage, reminiscent of a speaking high-pitched fart, and makes you crick your neck in pained dissatisfaction.  Jar Jar Binks lasted only one episode.  Unfortunately, Dr. Oz is still making episode after episode after episode…

Hippocrates is Yoda

Yoda mentored every Jedi.  Hippocrates mentored every doctor indirectly through his Hippocratic Oath, also known as the Medical Force, until he too died at the ripe old age of 900.  Father of Medicine, is he.  Yesssss.

Administration is Darth Vader

It’s not enough that this villain breathes so loud and audibly, but Administration has to breathe down the necks of everyone too and suffocate everyone in its path.  Part man and part machine, Administration has lost touch with its human side and turned to the Dark Side.  His red lightsaber is red tape in all its crippling glory.  Administration is as evil as it looks.  Both Vader and Administration dress in black and wish to be addressed as Lord.  Coincidence?

Palliative Care is Obi-Wan Kenobi

They are the calm sage-like beings within the Hospital Universe who emote love and never give in to hate.  Whereas Obi-Wan is one with The Force, Palliative Care is one with mortality.  Internal Medicine always turns to Palliative Care to answer the toughest question of them all: “Can you make this person a DNR?!” “Luke, use the hospice.”

Electronic Medical Records (EMRs) is C3PO

C3PO and EMRs were designed to serve human beings, often doing good but other times acting like hot bumbling, useless messes, particularly after systems upgrades.  C3PO is fluent in over six million forms of communication; EMRs is fluent in over six millions forms of ICD-10 codes. “If I told you half the things I’ve heard about this EMR upgrade, you’ll probably short circuit.”

Emergency Medicine is Boba Fett

Like the mysterious bounty hunter, Emergency Medicine holds no allegiances: they will admit to any service at any time and do anything as long as they get paid.  Both say very little.  Boba Fett says to Darth Vader, “He’s no good to me dead.”  Emergency Medicine says to inpatient providers, “I have an admission.”

Medical Students are BB-8

What’s more adorable than R2-D2?  Medical students and BB-8.  They are cute and bouncy, rolling about their business.  We don’t know much about BB-8 yet, but the same’s true for medical students.  Both, however, are full of potential.

Utilization Review as the Sarlacc

A Milwaukee hospital is trying a new approach to get newly insured residents to stop using emergency rooms as their main source of medical care and develop relationships with doctors instead.

The pilot project at Aurora Sinai Medical Center, the only hospital left in a mostly poor, black area of downtown Milwaukee, is labor intensive. But it's showing promise in getting patients connected with primary care doctors and in cutting ER costs.

"We're targeting the high utilizers of the emergency department," says Mark Huber, the hospital's senior vice president of social responsibility.

Huber says the hospital placed social workers in the ER full time. It then identified 313 so-called frequent fliers who visited Aurora Sinai's ER at least five times in four months. Those patients alone accounted for 1,827 emergency room visits in that time.

The social workers chose 39 people out of the 313 and spent the next eight months trying to change their habits so that when they get sick, they go to a primary care doctor or clinic rather than the ER.

"These are people who are in crisis all the time," Huber says. "They don't know where they're going to sleep or whether they can get groceries. They can't think about making appointments and planning ahead."

The social workers developed a plan for each patient that included finding transportation to a doctor and securing child care for the appointment. Then they helped the patient make a first appointment. They even sometimes accompanied them to the visit.

After the visit, the social workers ensured that the patient made at least two follow-up appointments.

In the first four months, visits by these 39 people to the Aurora Sinai emergency room fell by 68 percent, from 487 to 155. Compared to four months before the program, the cost fell from $1.5 million to $440,000.

It's a limited group and won't solve all the problems of inappropriate emergency room use. And it's not cheap.

"We're doing this strictly out of our own budget," Huber said. Still, the immediate savings of more than $1 million make the effort appear worthwhile if the patients continue to see their new doctors and don't return to their ER habits.

The efforts are aimed squarely at one of the biggest conundrums emerging from the passage and implementation of the Affordable Care Act. Policymakers thought that once people had health insurance, they'd stop using emergency rooms for basic health care.

Instead, the opposite has happened. Study after study has shown that ER visits skyrocketed once Obamacare was implemented. People newly covered, especially by Medicaid, the federal insurance program for the poor, are flocking to emergency rooms for care.

Wisconsin did not extend Medicaid to as many poor residents as it could have under Obamacare. Still, Gov. Scott Walker did expand the program so that poor adults without children can now get the insurance.

Huber says one of the challenges is that many of these patients have serious physical ailments but also suffer from underlying mental health issues such as anxiety and depression. Those ailments make the prospect of finding a new doctor, making an appointment and following up harder than it is for patients without such challenges.

He says Aurora intends to continue the project, working through the list of ER regulars in an effort to connect them all with doctors.

This is the second part of the series,"Heaven or hospital." Read the first part here.

Five-year-old Julianna Snow has never been healthy enough to attend Sunday school at the City Bible Church in Portland, Oregon, where her family belongs, so most of what she knows about heaven, she knows from her parents.

They tell her that heaven is where she'll be able to run and play and eat, none of which she can do now. Heaven is where she'll meet her great-grandmother, who shared Julianna's love of shiny, sparkly, mismatched clothes.

God will be in heaven, too, they tell her, and he will love her even more than they do.

But Michelle Moon and Steve Snow explain that they won't be in heaven when Julianna arrives there, and neither will her big brother, Alex. She'll go to heaven before them because she has a severe case of an incurable neurodegenerative illness called Charcot-Marie-Tooth disease.

Her coughing and breathing muscles are so weak that the next time she catches even a cold, the infection could settle in her lungs, where it could cause a deadly pneumonia. Her doctors believe that if they can save her under those circumstances -- and that's a big if -- she will likely end up sedated on a respirator with very little quality of life.

There's no debate about the medical facts of Julianna's condition. But there is debate about something her parents have chosen to do: They asked their daughter, at the age of 4, if she would want to go to the hospital the next time she becomes dangerously ill, or would she want to stay home, where she would die.

Julianna has said she doesn't want to go to the hospital. She wants to go to "heaven."

Before having these discussions with her daughter, Michelle looked online for guidance about end-of-life talks with a 4-year-old. Finding nearly nothing, she started a blog of her own in hopes of helping other families in the same situation. Later, she contributed to The Mighty, a website where people write about grappling with disabilities and devastating diseases.

Michelle: Julianna, if you get sick again, do you want to go to the hospital again or stay home?

Julianna: Not the hospital

Michelle: Even if that means that you will go to heaven if you stay home?

Julianna: Yes... I hate NT (naso-tracheal suction, where a tube was placed down her nose into her lungs without sedation). I hate the hospital.

Michelle: Right. So if you get sick again, you want to stay home. But you know that probably means you will go to heaven, right?

Julianna: (nods)

Michelle: And it probably means that you will go to heaven by yourself, and Mommy will join you later.

Julianna: But I won't be alone.

Michelle: That's right. You will not be alone.

Julianna: Do some people go to heaven soon?

Michelle: Yes. We just don't know when we go to heaven. Sometimes babies go to heaven. Sometimes really old people go to heaven.

Julianna: Will Alex (her 6-year-old brother) go to heaven with me?

Michelle: Probably not. Sometimes people go to heaven together at the same time, but most of the time, they go alone. Does that scare you?

Julianna: No, heaven is good. But I don't like dying.

Michelle: I know. That's the hard part. We don't have to be afraid of dying because we believe we go to heaven. But it's sad because I will miss you so much.

Julianna: Don't worry, I won't be alone.

Michelle: I know. I love you.

Julianna: Madly.

Michelle: Yes, I love you madly. I'm so lucky.

Julianna: And I'm so lucky.

Michelle: Why?

Julianna: Because you love me madly.

Before these conversations, Michelle says she and Steve had planned to take Julianna to the hospital if she were to get another infection. But after hearing Julianna's wishes, they changed their minds.

"She made it clear that she doesn't want to go through the hospital again," Michelle wrote CNN in an email. "So we had to let go of that plan because it was selfish."

While most readers left supportive comments on her blog post, some thought Michelle and Steve had made the wrong choice.

"Unbelievable that any parent would think a 4-year-old is able to understand or make a decision on life," commented one mother of a child with a chronic illness. "Clearly that mother asks her leading questions. This article sickens me."

The next week Michelle posted another blog post, further explaining their decision.

"She's scared of dying, but has, to me, demonstrated adequate knowledge of what death is. (J: 'When you die, you don't do anything. You don't think.')," Michelle wrote. "She hasn't changed her mind about going back to the hospital, and she knows that this means she'll go to heaven by herself. If she gets sick, we'll ask her again, and we'll honor her wishes."

She continued: "Very clearly, my 4-year-old daughter was telling me that getting more time at home with her family was not worth the pain of going to the hospital again. I made sure she understood that going to heaven meant dying and leaving this Earth. And I told her that it also meant leaving her family for a while, but we would join her later. Did she still want to skip the hospital and go to heaven? She did."

Should a child decide her own end-of-life care?

For adults, end-of-life decision-making is relatively straightforward: Basically, we get to decide how much medical treatment we want and don't want.

But how much say should a child get? And at what age?

Without realizing it, Michelle and Steve had stepped into a heated debate.

Julianna toward the end of her third hospitalization in October 2014.

Bioethicist Art Caplan has read Michelle's blogs, and he thinks she's made the wrong decision.

"This doesn't sit well with me. It makes me nervous," he says. "I think a 4-year-old might be capable of deciding what music to hear or what picture book they might want to read. But I think there's zero chance a 4-year-old can understand the concept of death. That kind of thinking doesn't really develop until around age 9 or 10."

He says Julianna's parents shouldn't put any stock in what she has to say about end-of-life decisions. Maybe she chose heaven over the hospital because she feels how much her parents hate to see her suffer; young children often pick up cues from their parents and want to please them, he says.

Caplan, before he started the bioethics program at New York University a few years ago, worked at the University of Pennsylvania and consulted on end-of-life cases at Children's Hospital of Philadelphia with Dr. Chris Feudtner, a pediatrician and ethicist there. Caplan respects him a great deal.

Feudtner, it turns out, disagrees with Caplan about Julianna.

"To say her experience is irrelevant doesn't make any sense," he says. "She knows more than anyone what it's like to be not a theoretical girl with a progressive neuromuscular disorder, but to be Julianna."

At his hospital, he has asked dying children her age what they want to do, and in the appropriate circumstances, he has taken it into consideration.

For example, he doesn't take their opinion into account when it's a black and white decision -- children with treatable leukemia must get chemotherapy, for example, no matter how hard they protest. But when the choice is gray, when there's more than one reasonable option, as there is with Julianna, he has put stock in their wishes.

As for a 4-year-old not having the mental capacity to think through death, he's found that even adults often don't think through such issues as carefully as one might like.

"My 86-year-old father died in April, and I'm not sure he truly got it," he says. "He was bed-bound from cancer, and he said, 'If this is the best I get, get me a Smith & Wesson.' Did he mean that? I don't know."

Feudtner, the chairman of the American Academy of Pediatrics section on hospice and palliative medicine, says as best he can tell from Michelle's blogs, Julianna's choice for heaven over the hospital is reasonable and her parents are right to listen to her.

"Palliative care isn't about giving up. It's about choosing how you want to live before you die," he says. "This little girl has chosen how she wants to live."

Julianna is no ordinary 5 year old

Art Caplan's words sting Michelle when she hears them. How could he deign to understand her child? But then a few days later, she wrote to CNN to say that she understands how someone could have a difficult time understanding what she and Steve have decided.

If you haven't met Julianna, she says, it's hard to explain how even at such a young age, she understands the choice that's in front of her, how she's the one who experiences the suffering and should get a say in what will happen to her.

The doctors and nurses who know Julianna best agree.

Dr. Danny Hsia, her pulmonologist, observes that Julianna is wiser than most 5-year-olds. "In that case, it makes a lot of sense to listen to her. I have the utmost faith in her mother and father. They're phenomenal parents and have her best wishes at heart," he says.

He believes that when Julianna gets another infection, the hospital will likely not be able to save her. "For her, there is no light at the end of the tunnel," he says, his voice trailing off. "She doesn't have a long time to live."

Diana Scolaro, the nurse who took care of Julianna through three stays in the intensive care unit, also supports Steve and Michelle's decision to listen to their daughter. "You have to know what it's like to hold down a child and hear them scream so you can stick a tube down their nose. It's one thing to do that when you know you'll have a success at the end, but for Julianna, there is no success," she says. "We pulled her from death's door so many times last year, but she's sicker now than she was then, and I don't think we could pull her through another big crisis."

Diana cries as she tries to express her wishes for Julianna. "I want her living and dying in her princess room, at home, surrounded by her family, not in the cold technology of a hospital," she says. "There is no cure for her. Every day is a blessing. Every day is a gift."

Planning for heaven, enjoying life

For now, Julianna spends nearly all her time in that princess room. In her closet hang dresses for pretty much every Disney princess there is, and each morning she picks out which one she wants to be. Some days she's Rapunzel, other days she's Snow White or Belle or Cinderella or Sleeping Beauty.

She's happy, watching videos and chatting nonstop with a steady stream of family, friends and nurses. She makes up elaborate fantasies, that her bed is a magic carpet, that she and her grandmother go on a shoe shopping trip together; Julianna buys one high-heeled red pair and one "low-heeled" blue pair. Then, they go to a restaurant and she orders macaroni and cheese.

Julianna displays no bitterness that she can't actually eat real food or go on a shopping trip. Instead, Julianna smiles as she watches her brother race up and down the hallway, showing no envy. Her father wheels her into the dining room to eat with the family, and takes a piece of cheese off the pizza and rubs it on Julianna's lips so she can have a taste, and then does the same with a piece of pineapple topping. She never once says how nice it would be if she could eat the pizza like everyone else at the table.

Her parents watch as her disease gets worse in just a matter of months. Last year, on the Fourth of July, Julianna impressed the neighborhood kids by turning circles in the driveway in her wheelchair, working the hand controls by herself. About six months later, her hands were too weak to work the controls at all. In those same six months, she went from needing the breathing mask only while sleeping to needing it nearly all the time.

Michelle and Steve try to prepare themselves and Alex for Julianna's death. Counseling for all of them has helped. Alex is just 6 and doesn't say much, but then he'll surprise his parents by blurting out something insightful.

Once, he asked Michelle if her heart would stop beating when Julianna dies because she will be so sad.

Some days Michelle feels like it will. Other times she doesn't focus on Julianna's death, and just feels grateful to be with her. In a post this summer on The Mighty, she described her daughter's mind and spirit as "bright, sharp and lovely."

Julianna used to turn circles in her wheelchair. Now her hands are too weak to work the controls.

Julianna is planning for her future in heaven, and for her parents' eventual arrival there.

"Do you want me to stand in front of the house, and in front of all the people so you can see me first?" she asks.

"Yes," her mother answers.

"And will you run to me?" she asks.

"Yes, I will run to you," Michelle answers. "And I think you'll run to me, too."

"I'll run fast," Julianna responds, shaking her head back and forth to show how fast she will run.

Residents of Columbia University/NewYork-Presbyterian's Family Medicine Residency Program – 

The room, filled with physicians wearing crisp white coats and solemn faces, was pin-drop silent. Silent, that is, except for the new family medicine intern who could no longer hold back her tears.

Residents at the Columbia University/NewYork-Presbyterian Family Medicine Residency Program do most of their inpatient rotations at The Allen Hospital, a 200-bed, community-based facility.

She was crying because after four years of premedical studies and four years of medical school training, she was being told that her decision to pursue a career in primary care in New York City was foolish.

She was crying because after an anxiety-ridden interview and match process, she had finally matched to her dream residency. Now she realized, just a few months into her training, that her hospital administration looked down on her entire profession.

But mostly, she was crying because after her third straight 80-hour work week, she was being told that she and the more than 30 other primary care physicians in the room were being fired. On Oct. 12, we were informed that the CEO of NewYork-Presbyterian Hospital (NYP) and the dean of the Columbia University College of Physicians and Surgeons (P&S) had decided to divest from primary care and shut down our family medicine residency program. It was not due to financial constraints. After all, NYP ended the 2014 fiscal year with more than $4.6 billion in revenue,(www.modernhealthcare.com) and net revenue exceeded $365 million. Instead, the shell-shocked primary care physicians in the room were simply told that delivering high-quality primary care in the Manhattan/Washington Heights community was no longer a strategic priority for NYP(www.capitalnewyork.com) and that the hospital planned to expand its ambulatory clinics in wealthier areas of the state, such as Westchester,(careers.nyp.org) and focus its resources on high-margin subspecialty care.

Residents (left to right) Zane Martindale, M.D.; Olivia Perlmutt, M.D.; Anoop Raman, M.D., M.B.A.; Emily Holt, D.O., M.P.H.; Michael Spertus, M.D.; and Christine Chang, M.D., entered the Columbia University/NewYork-Presbyterian Family Medicine Residency Program in 2013.

Unfortunately, given the news of late, this may sound all too familiar. Driven by the bottom line,CEOs all over the world make decisions that adversely affect people.(www.nytimes.com) The difference, of course, is that Columbia University and NYP are not-for-profit organizations. They are venerated institutions established with the intention of serving the public good, as enshrined in NYP's motto, "We Put Patients First." The profits they make are not taxed because they are meant to be reinvested in the communities they serve. It's clear that what New York City and America need from our medical academic institutions ismore primary care, not less. With an aging population and millions of people gaining access to health insurance(www.cbo.gov)through the Patient Protection and Affordable Care Act, the need for more centers of excellence for comprehensive primary care has never been more acute. The family medicine residency program at Columbia University/NYP(www.columbiacfcm.org) is a linchpin in this pipeline, especially given its history and reputation. During the two decades that the program has been in existence, we have trained more than 100 family physicians. At our Farrell Community Health Center, new family physicians are trained to be primary care specialists. We learn to deliver prenatal care; to insert intrauterine devices; to manage diabetes, hypertension and heart failure; to perform school physicals; to counsel people on smoking cessation; to see the elderly on home visits in their walk-up apartments. In short, we learn to deliver great primary care to those who need it most. The graduates of the program practice primary care all over the world, from Australia to rural American Indian reservations. But many of our graduates also stay close to where they were trained, working in clinics in both wealthy and underserved areas throughout New York City. And yet, in this moment when the nation and the city need academic medical centers to invest more resources into primary care and innovation in care delivery, Columbia P&S and NYP planned to divest. They planned to tell the more than 5,000 uninsured and underinsured patients we serve at our family health center to go find new physicians. They chose to increase the wait times for underserved patients in Washington Heights to find a primary care doctor and, thus, to increase the already prolonged wait times in the ERs(blogs.wsj.com) where these patients would inevitably end up -- sicker and untreated. And they chose to tell Columbia P&S medical students who were interested in family medicine and primary care that their mentors were being fired.

What is incredible is that these two decision-makers have such awesome power. With one decision, they could rob a community health center of its family physicians and gut a training program that has produced excellent primary care physicians. Perhaps worst of all, their decision sent a ringing message to a generation of medical students that family medicine is not a field they should choose if they go to an elite medical school. And yet, what also is incredible is that less than 36 hours after they handed down their brazen edict, they took it all back. In those hours, the hospital and medical school administration learned how much primary care means to students, the city and the country. In those hours, we learned how much power we have as a community when we come together to make our voices heard. And in those hours, we all learned how much harder we will have to fight to make family medicine a respected profession at this academic institution. What happened during those hours was truly amazing. Moments after the decision was handed down to us in that packed and somber room, the residents and faculty began mobilizing. Residents taught faculty how to send their first tweets. Medical students who heard about the decision via texts and social media began organizing a massive town hall meeting(columbiaspectator.com) and demanded the dean attend to explain the decision. Sympathetic journalists quickly found out about the decision and began reporting.(www.ibtimes.com) Government officials from New York City Hall to the White House were quickly briefed on the situation and began advocating on family medicine's behalf. And as remarkably as the bad news was handed down to us in a quiet room, the announcement reversing the decision was disseminated to us … on Twitter.(twitter.com)

In 2010, people in the United States spent 1.1 billion hours seeking health care for themselves or for loved ones. That time was worth $52 billion.

“That’s about the same as all of the time worked in a year by the entire working population of the city of Dallas,” said Ateev Mehrotra, associate professor of health care policy and medicine at Harvard Medical School (HMS). Mehrotra is a lead author of two studies published this fall that measure the amount of time patients spend seeking care; calculate the total time costs to society; and analyze the difference in time burden by race, ethnicity, and socioeconomic status.

While all groups spent the same 20 minutes face-to-face with physicians, blacks and Hispanics spent approximately 25 percent longer when seeking health care than whites, a result of increased travel, wait, and administrative times. Courtesy of Harvard Medical School

Writing in the American Journal of Managed Care, the researchers reported that the average total visit time for a person seeking care for themselves, a child, or another adult was 121 minutes. That total includes 37 minutes of travel time and 84 minutes in the clinic. Of those 84 minutes, people spent only 20 minutes with physicians; they spent the rest of the time waiting, interacting with nonphysician staff, or completing paperwork or billing.

Economists calculate the value of time spent doing an activity — known as opportunity cost — based on the income that an individual would earn working the same amount of time. The researchers calculated that the average opportunity cost per visit was $43, compared with an average out-of-pocket cost per visit of $32.

“We also found that this time burden fell disproportionately on the disadvantaged,” said Kristin Ray, assistant professor of pediatrics at the University of Pittsburgh School of Medicine.

Writing in JAMA Internal Medicine, the researchers reported that, while all groups spent the same 20 minutes face-to-face with physicians, blacks and Hispanics spent approximately 25 percent longer when seeking health care than whites, a result of increased travel, wait, and administrative times. Lower-income groups and the unemployed also spent more time seeking care than their better-off counterparts.

“Typically, when we talk about how much we spend on health care, we focus on what is paid to doctors and hospitals through co-pays and insurance payments,” said Mehrotra, who is also a physician and HMS professor of medicine at Beth Israel Deaconess Medical Center. “This work helps us put a dollar amount on the significant time it costs people to seek health care.”

The researchers said that it is important to consider time costs when evaluating innovative treatment and care delivery models designed to create higher-value, more-patient-centered care and to reduce health care disparities. They noted that many initiatives currently underway might offer considerable benefits in reducing the time-cost burden of health care. These initiatives include streamlining office visits; incorporating clinics into schools, community centers, and places of work; and using new models of care delivery, such as telemedicine visits, e-visits, and other Internet-powered medicine.

Dear Washington, D.C.:

I am writing this letter because I feel that our leaders and lawmakers do not have an accurate picture of what it actually entails to become a physician today; specifically, the financial, intellectual, social, mental, and physical demands of the profession. This is an opinion that is shared among many of my colleagues. Because of these concerns, I would like to personally relate my own story. My story discusses what it took to mold, educate, and train a young Midwestern boy from modest roots to become an outstanding physician, who is capable of taking care of any medical issues that may plague your own family, friends, or colleagues.

I grew up in the suburbs of southeast Michigan in a middle-class family. My father is an engineer at General Motors and my mother is a Catholic school administrator in my hometown. My family worked hard and sacrificed much to enroll me in a private Catholic elementary school in a small town in Michigan. I thought I wanted to be a doctor in fifth grade based on my love of science and the idea of wanting to help others despite no extended family members involved in medicine. Winning a science fair project about the circulatory system in sixth grade really piqued my interest in the field. Throughout high school, I took several science courses that again reinforced my interest and enthusiasm towards the field of medicine. I then enrolled at St. Louis University to advance my training for a total of eight years of intense education, including undergraduate and medical school. The goal was to prepare me to take care of sick patients and to save the lives of others (four years of undergraduate premedical studies and four years of medical school). After graduation from medical school at age 26, I then pursued training in internal medicine at the University of Michigan, which was a three-year program where I learned to manage complex problems associated with internal organs, including the heart, lungs, gastrointestinal tract, kidneys and others. I then went on to pursue an additional three years of specialty medical training (fellowship) in the field of gastroenterology. The completion of that program culminated 14 years of post-high school education. It was as that point, at the tender age of 32 and searching for my first job, that I could say that my career in medicine began.

Over that 14-year period of training, I, and many others like me, made tremendous sacrifices. Only now, as I sit with my laptop in the dead of night, with the sounds of my children sleeping, can I look back and see where my journey began.

For me, it began in college, taking rigorous pre-medical courses against a large yearly burden of tuition: $27,000 of debt yearly for four years. I was one of the fortunate ones. Because I excelled in a competitive academic environment in high school and was able to maintain a position in the top tier of my class, I obtained an academic scholarship, covering 70% of this tuition. I was fortunate to have graduated from college with “only” $25,000 in student debt. Two weeks after finishing my undergraduate education, I began medical school. After including books, various exams that would typically cost $1,000-$3,000 per test, and medical school tuition, my yearly education costs amounted to $45,000 per year. Unlike most other fields of study, the demands of medical school education, with daytime classes and nighttime studying, make it nearly impossible to hold down an extra source of income. I spent an additional $5,000 in my final year for application fees and interview travel as I sought a residency position in internal medicine. After being “matched” into a residency position in Michigan, I took out yet another $10,000 loan to relocate and pay for my final expenses in medical school, as moving expenses are not paid for by training programs.

At that point, with medical school completed, I was only halfway through my journey to becoming a doctor. I recall a moment then, sitting with a group of students in a room with a financial advisor who was saying something about how to consolidate loans. I stared meekly at numbers on a piece of paper listing what I owed for the two degrees that I had earned, knowing full well that I didn’t yet have the ability to earn a dime. I didn’t know whether to cry at the number or be happy that mine was lower than most of my friends. My number was $196,000.

$196,000. That was the bill, for the tuition, the tests, the books, the late-night pizza. $196,000 financed through a combination of student loans, personal loans, and high-interest credit cards, now consolidated, amalgamated, homogenized into one life-defining number for my personal convenience.

I then relocated to Michigan and moved into a small condo in Ann Arbor, where I started my residency. As a resident in internal medicine, I earned a salary of $39,000. All the while, interest continued to accrue on my motherlode of debt at the rate of $6,000 per year due to the high-debt burden. Paying down this debt was not possible while raising two children. My wife began working, but her meager salary as a teacher was barely enough to cover daycare costs. During residency, my costs for taking licensing examinations, interviewing for specialty training positions, and interest on the large loan ballooned my debt further, now exceeding $230,000, all before I began my career as a “real doctor.”

Relatives and friends often ask me, “Now that you are a ‘real’ doctor, aren’t you making the big bucks?” While I am fortunate to now be making a higher salary, some basics of finance make my salary significantly less than meets the eye (here’s a very in-depth article on how this is so). First, I was 32 years old as I began training and I now had over $230,000 in debt. Had I invested my talents in other pursuits such as law school, I would not have built up this level of debt. Also, as I did not start saving when I was younger, financially speaking, I have lost the past 10 years without the ability to save and invest to earn compounding interest. In addition, as physicians, though we make more money than many others, we are not reimbursed for many of the services that we provide. We, as physicians, are always available for our patients no matter the time of day. We do not record time spent with patients as a means to our reimbursement as other professions do. No, we listen to patients and answer their questions, however long it may take. Even if it is the 30-second straight hour of work, which happens very often, we listen, respond, and formulate a logical plan. If it involves calling a patient at home after I just worked 30 hours in a row and just walked in the door to see my family, I do it. I never come “home” from work. As physicians, we are always available, and have to respond in an intellectual way using the $230,000 rigorous education that we received. And if we don’t do our work well, we don’t just lose business, but we can lose our livelihood through lawsuits.

You may ask why do we do all of this? It’s because we have pride in what we do. We truly care for the well-being of the human race. We have been conditioned to think, act, talk, and work as a very efficient machine, able to handle emotions, different cultures, different ranges of intellect, all to promote the health of America. We are doctors.

In reading this letter, one may think that one has to sacrifice a significant amount to become a great physician. You may think we face physical and mental stress that is unparalleled. You may begin to think that doctors not only have to be smart, but they have to know how to communicate with others during very emotional times. You may think that we must face adversity well and must develop very rough skin to handle all walks of life, especially when dealing with sickness and death on a daily basis.

Now that you see this additional aspect to our career, you may think that we have a tough job to tackle several tasks at once, demanding much versatility. You may think someone needs a great work ethic to do what we do. You must think that not only do we have to know science extremely well, we also have to know other areas such as writing, history, math, even law given the multiple calculations we go through in our heads on a daily basis and conversations we have with families. And finally, you must think we know finance, as we have to try balance a $230,000 loan while making $50,000 at age 30.

Now imagine, if you would, having $230,00 dollars in debt with two young children at age 30 and listening to the news with lawmakers saying that doctors are “rich” and should have their pay cut. Or that “studies show that doctors lack empathy.”

Unfortunately, we physicians do not have much of a voice on Capitol Hill. There are not enough doctors in Washington, D.C., who can give the insight of this letter while you in Washington, D.C., discuss healthcare reform. You may hear from leaders of the American Medical Association, but these are not the doctors on the front lines. These are the older political voices who were physicians when the times were different, when doctors did get reimbursed fairly for their work, when student loan debt was not this high, and when lawsuits were less prevalent. Many of the loudest voices in the healthcare debate are those of lawyers and lobbyists for special interests. They do not care about the well being of patients; that is what doctors do.

I want to make it clear that this letter is not just another story about the difficulties of becoming a doctor and being successful in medicine. I do not want you to think I am complaining about how hard my life is and used to be. In fact, I love my job and there is no other field I would ever imagine myself doing. My true wish is to illustrate the sacrifices doctors do make because I feel we are not represented when laws are made. These sacrifices include a lack of quality family time, our large student loan debt, the age at which we can practically start saving for retirement, and the pressure we face with lawyers watching every move we make. Yet we make these sacrifices gladly for the good of our patients.

I want to challenge our leaders to address the points I have made in this letter, keeping in mind that this is an honest firsthand account of the personal life of a newly practicing physician. It is a letter that speaks for almost all physicians in America and our struggles on our arduous yet personally rewarding life. It is not just a letter of my own journey, but one that represents most physicians’ path on our way to caring for America’s sick.

I've spent half my life in the US and half of it in the UK, so I'm used to both countries' healthcare systems. I recently returned to London after 20 years in America, and after a few doctors' appointments I've come to see the NHS through American eyes.

The National Health Service is, as all Americans know and fear, a completely public "socialized medicine" system. It's dramatically different from the US's patchwork system of private providers and insurance companies.

My story isn't representative, of course. Healthcare delivery is different in the UK depending on where you live and which doctors and hospitals you use — just as it is in the US. But I've now used both systems for about two decades each, so I feel I have a pretty good handle on the main contrasts.

The context here is that the NHS just released its most recent stats on accident and emergency room waiting times. The headline number is that 84% of patients are seen within four hours. In the UK, this is regarded as a huge failure — the standard the NHS is supposed to meet is 95% of patients in four hours. The UK media went into a fury about it, and some hospitals have begun postponing and rescheduling some non-emergency procedures in order to get those waiting times down.

In the US, having sat in many an ER waiting room for hours at a stretch, the idea of a hospital seeing nearly 9 out of 10 patients in four hours would be regarded as a miracle. Bear in mind that within that four-hour period the NHS doctors are triaging patients: If you get hit by a bus, you're going to see someone instantly. If you broke a finger because you fell over while drunk at the pub, you're probably going to wait at the back of the line. It's not like people are literally bleeding to death while they wait for attention (although the British media loves it when it finds individual cases where that has happened).

So my overall impression is that currently, the Brits' complaints that the NHS isn't hitting that 95% mark is akin to saying, "This Rolls Royce isn't moving fast enough!"

SHOW UP WHEN YOU'RE TOLD TO - OR ELSE

The first major difference from the patient's point of view is what happens when you call your doctor for a routine appointment. My specific health issue was that I thought I was going slightly deaf, and wanted it checked out.

I'm a dual US/UK citizen, so I qualify for NHS treatment. Here's what happened to me.

In America, you call your doctor and request an appointment when it's convenient for you. They might ask you what's wrong with you, presumably to make sure it's not something that requires immediate treatment. But basically, it's first come, first served, regardless of how important it is. Usually, you can pick an appointment time that's convenient for you if it is not an emergency.

In the UK, I was given an appointment whether I liked it or not. I called and leave a message. Within an hour or two a nurse practitioner called me back and asked me a few questions about my problem over the phone. (You've got to take the call in a private place if you don't want your office mates to hear.) Then they said: Come in at 9am on Thursday. There was no choice over appointment times — the assumption is that if you're ill, you're going to come to the doctor when they say.

At first I found this jarring. In America, I get to choose when I see the doctor! In Britain, I better show up when I'm told. But the appointment came quickly, as the local health authority in London has targets it needs to meet. Ultimately, I saw the logic of it: This is a public health system. It needs to manage its costs and services. If you're really sick, you'll show up. If you only want to show up when it's convenient for your schedule, then how sick are you, really?

AMERICA IS WORSE AT ON-THE-DAY CARE

In America, I've always had a long wait to see my doctor. I have read many a back issue of Newsweek in my primary care / general practitioner (GP) doctor's office. I've sat there for an hour playing with my phone while the doc sees patients in the order they were booked.

In the UK, I showed up at 9am and was seen instantly, at the Waterloo Health Centre. For an American, this was bizarre: My butt barely touched the seat in the waiting room before my name was called. Turns out my doc and her staff are serious about patient scheduling.

This was one reason I became convinced that the NHS way of scheduling is superior: You might not get the time or date that you want, but once you're in, you get seen super-quick.

THE NHS ACTIVELY DISCOURAGES SOME PATIENTS - FOR GOOD REASON

The NHS actively discourages some types of patients: Interestingly, NHS offices and hospitals have posters up all over the place warning you not to show up at the emergency room if you have a cold or the flu. They're actively discouraging patients with minor ailments from seeking emergency treatment, and trying to get them to see their regular doctors instead. It's sensible — everyone knows that a vast amount of hospital time and money is wasted treating people who are not an emergency. And hospitals and doctor's surgery waiting rooms are a hotbed of germs. But still, it's a culture shock to see a medical institution put up signs that basically say, "go home, you idiot!" in every waiting room.

The US never discourages patients from doing anything. I've never seen any kind of public campaign to persuade patients to apply some common sense before dropping themselves off at an emergency room. The entire US pharmaceutical industry is also dedicated to running ads encouraging people to "go see your doctor" for even the most trivial of conditions.

The treatment from my primary care GP was the same in the UK as it was in the US. I've had great care from 95% of doctors I've ever seen in both the US and the UK. Doctors are doctors. They're mostly really nice and good at what they do. The system that pays them doesn't seem to make them better or worse.

THERE IS BASICALLY NO PAPERWORK WITH THE NHS

There is a load of paperwork for patients in the US. This is easily the worst aspect of US healthcare — the billing paperwork. If you've ever had any health issue that required more than a simple doctor visit, you will know that it precipitates a seemingly never-ending series of forms, bills, and letters. You can be paying bills months, years later. And it's almost impossible to correct a billing error. It's stressful. I developed an intense hatred for health insurance companies in the US because of this.

There was close to zero paperwork in the NHS. I filled in a form telling my doc who I was and where I lived, and that was pretty much it. The only other paperwork I got was a letter in the mail reminding me of my next appointment. They sent me a text reminder, too, which no American doc has ever done. It was incredibly refreshing.

THE STANDARD OF CARE IS THE SAME

So, was I going deaf? Maybe. Maybe not. I'd lost my sense of balance in summer 2014, which an American doctor had diagnosed as Benign Paroxysmal Positional Vertigo. It's a condition of the inner ear. It made my body feel slightly drunk and clumsy even though I am completely sober.

The US doc told me there is no treatment and it goes away on its own, mostly. A lot of people get it, apparently. I was managing fine and it doesn't bother me, anyway.

The UK doc told me the same thing, but also suggested I might have Meniere's Disease, and wanted to send me to a specialist to get it checked out. Meniere's isn't really a disease, it's just a collection of symptoms: dizziness, hearing loss and a ringing in the ears. Again, there is no treatment. But it's rare.

This freaked me out a little bit. I was used to the US system which is heavily "defensive." Doctors tend to over-treat patients because they get sued if they miss something. They also get paid more money for doing more work. Yet it was the NHS doctor that suggested extra treatment.

It was going to be free — so I said yes!

A LONG WAIT FOR NHS TREATMENT ...

I then made an appointment with a specialist at the Guy's and St Thomas' Hospital in London.

In the US, I've always been able to see a specialist within a few days. Score one for America.

In the UK, they said "we'll see you in January." It was late November, six weeks or more away. This was a shock. I was going deaf now — not in six weeks! What the hell?!

NHS waiting times are a real thing, it turns out. I comforted myself with the assumption that the staff had made a decision that my condition was likely not life- or health-threatening, and had moved me to the back of the line. It was frustrating. Ultimately, I also needed to change my appointment because I had to leave the country on business, and this was quite difficult to do. I had to call a few times, basically to catch the hospital booking staff at the right time of day, in order to do it. I wished Guy's and St. Thomas' had an online system for this, but they don't — just a bunch of people answering phones, most of whom don't have access to the right appointment schedule.

It was that appointment system again: You're booked in according to their priority, not yours.The big lesson with the NHS is, it's a lot easier to just show up when you're told.

OLD PEOPLE IN BRITAIN ARE REALLY RUDE

In the US, I expect to wait up to an hour in the specialist's waiting room on the day of my appointment. I often wonder if Time and Newsweek were such big magazines in the US because they're needed for bored patients in American doctors' waiting rooms. Nothing ever happens promptly on the day in US healthcare, as far as I can tell.

In the NHS, again, I waited only a couple of minutes. Credit to the staff at St. Thomas, they are cranking through their patients.

On two occasions I noticed old people complaining angrily (and rudely) to the office staff that they had been made to wait 15 or 20 minutes to see their doctor. As an American, I almost laughed out loud. Fifteen minutes to see a free doctor! This Rolls Royce isn't moving fast enough! I asked a British friend — someone who has ongoing health issues and sees a lot of doctors — if old people complaining like this was common. Turns out, it is. Old British people love to complain to NHS staff if they wait more than 1o minutes. Everyone just expects their appointments to be exactly on time.

Again, the NHS care was great. I saw two different doctors within an hour, one for testing and one for diagnosing. A third admin staffer was coordinating the lists so there was no doctor downtime. It was like being in a highly efficient factory. It looked like hard work. I could tell that one of my doctors was not interested in chatting. She treated me, and wanted me out the door. There was a bunch of patients behind me, after all. In America, docs seem to be happy to chat as long as you want — and you can tell that extra couple of minutes with each patient creates long delays as the day wears on.

The good news: I am not going deaf! I have great hearing, it turns out. They even showed me a chart of it. But the tinnitus — ringing in my ears that started years ago because I used to go to a lot of punk rock gigs in my youth — has gotten worse, making me feel more deaf.

The UK NHS specialist said she was 99% sure there was nothing wrong with me, or at least nothing that could be treated, but she recommended an MRI to see what the condition of my inner ears is like. This was reassuring. In no way was my treatment rationed or denied, the way Americans fear. It was just the same as in the US, with the same number of docs and the same level of high-tech equipment.

THE COST TO THE PATIENT IS MUCH CHEAPER IN THE UK, OBVIOUSLY

So how much did all this NHS care cost me? £0. Nothing. Zero. I paid not a penny for some top-notch healthcare. There is no such thing as a "free," of course, but the per-capita cost of healthcare in the UK (paid by the government via tax collections) is generally lower than the US, according to the World Health Organization. Americans spend $8,362  per capita on healthcare annually, the Brits spend $3,480. Here is a breakdown:

NHS prices

Doctor visit: £0

Specialist: £0

Diagnostic test: £0

MRI: £0

Total: £0

Typical US prices*

Doctor visit: $100

Specialist: $150

Hearing test: $72

MRI: $1,000

Total: $1,372 (Total payable by the patient in cash, or typically 90% from insurance and 10% as a patient copay. Prices taken from Healthcare Bluebook.)

SORRY AMERICA, BUT NHS TREATMENT REALLY IS BETTER OVER ALL

The bottom line: I prefer the NHS to the American private system. It's a little more inconvenient in terms of appointment times, but due to the fact that it is free, has no paperwork, and the treatment on the day is super-fast, the NHS wins. That Rolls Royce is moving at a pretty decent clip.

And, of course, there is the small matter of the fact that the NHS covers everyone equally, whereas Americans get care based on their ability to pay, leaving tens of millions with only minimal access to care. (Obamacare is changing that, but it's leagues behind the NHS if you're comparing them by the standard of universal full-service coverage.)

Over the past decade, an image of the “ideal” healthcare consumer has emerged. Armed with personal health data, ratings and rankings, and driven by financial skin in the game, the ideal healthcare consumer makes the healthcare system better by forcing healthcare providers to compete for her business. Healthcare organizations have pivoted to meet the needs of this ideal consumer and whole new businesses have emerged to help empower patients to manage their own care.

All of this is great—except for the fact that the current mental model of the healthcare consumer is, well, wrong.

Consumer-oriented thinking in healthcare often blindly applies insights from other consumer sectors—assuming that patients will apply the same approach to purchasing an Ikea futon or Toyota Prius to making healthcare decisions. Driven by rationality, they will price-shop, compare quality and reliably choose the highest-value option.

While this mental model has gained a lot of traction, important aspects of health-specific consumer behavior are conspicuously absent from the dialogue:

Most Sick People Don’t Actually Like to Shop for Healthcare

Contrary to other consumer purchases, most patients don’t actually delight in “buying an MRI” or managing their own health information. Quite the contrary, they are eager to be cared for by an efficient and effective healthcare system that respects their preferences. Amidst the burden of experiencing serious illness, optimizing the purchase of every service at every turn is the last thing on their mind. This impediment is only furthered by the fact that many people access healthcare services in emergency or time-pressured settings that preclude the ability to actually shop for them.

The Sum of Healthcare Purchases Do Not Equal the Parts

If healthcare were like any other consumer purchase, it would simply be a matter of buying the best service in every category. The reality is far more complicated—how the pieces fit together is just as important as the quality of individual parts. When I was a resident physician in Boston, I had a patient memorably tell me that he chose to receive his cardiology care at the Brigham and Women’s Hospital and his neurology care at the Massachusetts General Hospital. When I asked why he didn’t consolidate his care at the single institution that was closest to his home he looked at me like I was crazy. “I chose the best (US News and World Report) rated hospital in each category”—ignoring the improved coordination that arises from working within a single system. In healthcare, the sum of the pieces is sometimes worse, sometimes better—but always different—than its component parts.

One Size Does Not Fit All

An implicit assumption in many prevailing views of healthcare consumerism is that care can be objectively characterized as good or bad. While quality measurement standards from groups such as the National Committee for Quality Assurance and the National Quality Forumcan help identify key aspects of clinical quality—there is wide agreement that those measures alone are not enough. Much healthcare remains about a patient’s human connection with their physician. There is an art and style to clinical medicine, and real variability what style patients respond to and prefer. As my colleague Brian Powers and I have written elsewhere, all physicians are not right for all patients—and vice versa. Some patients will happily wait an hour in a waiting room if a physician spends quality time with them in the exam room whereas others will be furious at wait times regardless of the quality of the clinical interaction. Some patients prefer physicians who communicate directly, while others want bad news sugar-coated.

Healthcare Is Local—And It Will Stay That Way

Despite dialogue around national centers of excellence and medical tourism, the last thing most sick patients want to do is travel hundreds or thousands of miles to receive their care. Notwithstanding the importance instances where patients would be well served by traveling, most patients appreciate the convenience of receiving care close to home and near the support of friends, family and loves ones. Growing up in northern New Jersey, I was always confused by neighbors who refused to travel to New York City to be treated for serious conditions at distinguished academic centers, instead choosing local community hospitals in our backyard. I get it now. When you have a major illness or chronic disease that requires not one, but scores, of visits every year, convenience can outweigh most other factors in deciding where to access care.

One night in July—the night before her first day of work—a new doctor picked at a container of sushi in her apartment on a sleepy street in Brooklyn. She tried to swallow a few bites as she chatted on the phone with her best friend from medical school, who was also marking the eve of his first day as a working physician. “Break a leg,” she said. “But not really.”

There wasn’t any street noise to keep her up as she tried to go to sleep early for her 5:00 a.m. start—but even in the silence, heavy with midsummer humidity, she couldn’t drift off. For two months, since she’d graduated medical school, her body had registered her mounting stress leading up to her first day in the hospital. She was plagued by insomnia. Food made her nauseated, except plain donuts, which she ordered twice a day from the diner at the end of her block. She’d eat them while studying diagnoses and procedures that she’d learned in school and long since forgotten, crumbs piling up in the crease of her textbook. In the months between graduating and starting work, she lost more than 15 pounds.

Her first week, she worked more than 80 hours on a general-surgery rotation, charting for her attending physician, checking patients’ vital signs, and trying to restart exhausted hearts long after her shifts ended. “There’s no way to get all of our work done in 80 hours,” she says. “Our supervisors can’t make the work go away.” When her pager beeped with a reminder to clock out for the day, she ignored it, she says, while the more senior physicians looked the other way. Like many of her fellow residents, she went entire days without eating. She was so drained that she was halfway out the door one day before remembering that she’d left an IV in a patient’s arm.

Within her first month, she crumbled under the pressure. After she went to visit the hospital counselor—sobbing through the appointment—a few of her fellow residents told her to suck it up. Feeling frazzled and helpless just comes with the first year territory, they said. It’s a rite of passage. In his memoir Intern, the New York cardiologist Sandeep Jauhar describes residency as “brutal, like a kind of hazing.”

Choosing whether or not to share these concerns with supervisors can be difficult, says a resident in family medicine at a New England hospital. She cites a common fear among residents: that their honesty will lead more senior doctors to write them off entirely. “They don’t want you to show any weakness,” she says. “You almost need to be a robot.” Her anxiety is affecting her daily work. “I’m exhausted because of the existential crisis playing out in my head every minute.”

Two centuries ago, aspiring physicians in the U.S. could just hang a shingle and begin cutting people open with little formal training. As the skeleton of America’s medical-education system emerged—medical schools, exams, and residency and fellowship programs—physicians had to follow a standardized procedure to become licensed. And as much as this system teaches them how to be doctors, it also teaches them how to operate within the medical profession—a lesson that can leave new doctors crippled by fatigue, emotional stress, and self-doubt, affecting their abilities to take care of themselves and their patients. Some in the medical community believe that there must be a better way to do it.

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When they graduate from medical school, newly minted physicians are prepared to recall minute details about a litany of illnesses—but not necessarily confident managing the symptoms. In his memoir The Real Doctor Will See You Shortly: A Physician’s First Year, Matt McCarthy describes the “tectonic shift” from laboratories to hospital life: Throughout much of his rotation in general surgery at Massachusetts General Hospital, where he practiced suturing banana peels back together in his free moments, McCarthy felt unprepared to deal with the onslaught of diseased bodies.

If he had been asked to “recite pages from a journal article on kidney chemistry or coagulation cascades, I could’ve put on quite a show,” he writes. “But I hadn’t learned much of the practical business of keeping people alive, skills like drawing blood or putting in a urinary catheter.”

Many brand-new doctors are painfully aware of the gaps in their knowledge—and in fact, that recognition can be paralyzing. Jauhar refers to his first year of residency as a “disillusioning time.” He writes, “I spent much of it in a state of crisis and doubt.”

Feelings of hopelessness appear to be fairly widespread among medical students and early-career doctors. The worrying combination of plummeting self-worth, and emotional fatigue has reached “epidemic levels,” according to a survey conducted at the University of North Carolina, Chapel Hill. Researchers found that approximately 70 percent of residents met the diagnostic criteria for burnout.

Burnout is a popular topic of discussion among people who run residency programs, and the feeling of being bone-tired and ragged comes up again and again. A study published earlier this year in the Journal of Graduate Medical Education found that nearly 40 percent of residents experienced difficulty sleeping while on call, and more than 80 percent said that they “never, seldom, or only sometimes” met their nutritional needs while on duty.

In a 2009 survey of more than 2,000 medical students and residents, nearly 6 percent reported experiencing suicidal thoughts in the past two weeks; among fourth-year medical students, that number was around 9 percent. Last summer, two new doctors committed suicide in New York City in the same week. Both young physicians jumped to their deaths—one from a New York Presbyterian Hospital facility, and the other from the roof of his former dorm at New York University.

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Three decades ago, Liz Gaufberg slogged through night after night of shifts as a resident in the intensive-care unit of an East Coast hospital. Then she came down with a cold, and the mucus dripping down her throat kept her up at night hacking and gagging. After a few near-sleepless nights, “I was almost delirious,” she says. She recalls standing in the hallway of the hospital and overhearing a page indicating that someone was coding. If the patient died, she could go home and get some rest. If the patient lived, she’d have to stay on. “[I] prayed that they would die so that I wouldn’t have to stay up for two more hours,” says Gaufberg, now a faculty member in the Cambridge Health Alliance Internal Medicine Residency Program. “I remember being so tired that when I looked at patients in beds, I’d think, ‘They’re so lucky that they get to lie down.’”

Duty-hour reform is one way to approach the problem of exhausted residents. In 2003, the Accreditation Council for Graduate Medical Education mandated a maximum 80-hour workweek for resident physicians. The recommendation was modeled, in part, on a 1989 New York law known as the Libby Zion Law, named after an 18-year-old woman whose death was initially attributed to overworked residents. The ACGME also caps individual shifts at 30 hours and requires accredited institutions to give residents at least 10 hours of respite between shifts.

Not everyone believes that these reforms are in the best interest of patients—or even doctors. Hospitalized patients may deal with a number of different physicians who cycle on and off duty, as opposed to having more continuous attention from a single physician who is deeply familiar with the particular case. Moreover, some older physicians feel that contemporary medical education lacks the rigor that they soldiered through. “I think the pendulum has swung too far in one direction, toward making the experience too soft,” the Manhattan internist Robert Press told The New York Times in 2009. “The inmates are running the prison, and it’s a huge challenge.”

Gaufberg disagrees. As the director of the Arnold P. Gold Foundation Research Institute—an organization dedicated to promoting humanism in medicine—she endorses the cap on hours, but thinks it only addresses one layer of a deeper systemic problem. “We all advocate for a humane work environment for our trainees, but I think we hyper-focus on duty hours as though it’s the solution,” she says.

Many medical schools are adopting more humanistic curricula, encouraging future physicians to consider the patients as full-fledged people, not simply constellations of symptoms or puzzles to solve. But that sensitivity to a life outside of the hospital doesn’t necessarily extend to the residents themselves. Gaufberg attributes this, in part, to a discrepancy between what schools and training programs hope to teach, and what they actually convey through institutional culture. “The process of becoming a physician is one of socialization,” she says.

Learning a place’s so-called “hidden curriculum” often involves constructing or adhering to a pre-set personae. Residents “feel that they are evaluated on their ability to fit in and learn the culture,” Gaufberg says. A robust body of researchhas emerged focusing on how to help physicians navigate professional identities that feel authentic to them, as opposed to a caricature of what they’ve been told a doctor should look like.

Gaufberg suggests that mindfulness exercises are one way to decrease the cognitive dissonance that can arise when workplace expectations—namely, compassionate, patient-centered health care—don’t jibe with the institutional culture or the volume and pace of the workload. She facilitates a monthly meditative reflection session outside of the hospital environment, and sometimes brings cohorts of new residents in her program to museums around Boston to look at works of art and get to know each other. Gaufberg also invites interns to draft an oath, outlining how they hope to embody their work and take care of their patients, one another, and themselves.

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That feeling of being watched, of being constantly judged and evaluated by superiors, isn’t paranoia, says McCarthy. It’s justified. “We’re all watching residents incredibly closely,” he explained. And he agrees that residents are being pulled in lots of directions, trying to scale a mountain of projects that keeps growing. “You’re going to be asked to do more things than one person could possibly do,” he notes. “Your pager will go off five times in the span of 10 seconds. Each of those people is very important and has important things to tell you, and you can’t call five people back at the same time.”