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Dr. Then and Dr. Now
by Andrea Adelsen

In 1965, the medical profession arguably was at its peak of power. No one looked over a physician's shoulder. Doctors controlled 80 cents of every dollar spent on health care, deciding who went into the hospital and for how long. Their authority and earning power merited the top tier in social ranking. Physicians lived by the Robin Hood rule: overcharge the rich to take care of the poor. Free-spending drugmakers exclusively pampered doctors, lavishing them with promotional trinkets, front-row event tickets and swanky restaurant meals.

Today, the American Medical Association is embracing doctors' unions and agitating against medical insurers. The medical corporations that now control the purse strings are frequently accused of deferring to Wall Street profit expectations over medical ethics or community values. In a sort of inverse alchemy, HMOs that second-guess physicians' orders have turned healers into money managers. Yet doctors' salaries, along with their social standing, are plummeting. Now, the Robin Hood rule works in reverse: the uninsured pay more for services than those covered by health insurance. The mass media, crowded with brand-name drug advertising, is reaping the drug makers' profligacy.

If the forces transforming health care seem enormously complex, their impact can be simply distilled through the lives of three physician alumni, each a generation removed from the other. Their arc spans the nostalgic simplicity of the post war era to the contentious contemporary fight for patients' rights...

In a small Ohio college town, she teamed up with the community's only other physician, who rented her a second-floor apartment over their office. The doorbell rang for assistance at all hours, every day of the week. She knew her patients by name and became their trusted confidant. An office visit cost $3. Those who couldn't pay were treated anyway, though it parsed her pocket. House calls were $5, no matter the distance traveled. The nearest hospital was staffed by nurses who were not authorized to start intravenous lines or catheters, which meant referring physicians were responsible for their own patients' care, including serving as surgical assistants.

Naively, Christiansen agreed to split fees evenly with the more established doctor under a two-year contract. Too late she realized he meant to collect on every entry, including those where patients had skipped out on their bills. In that first year, of seven obstetric patients, each charged $250 for their care, most fees went uncollected. "I went in the red," Christiansen recalls.

It also seemed a reasonable request when the older doctor asked her to cover his patients when he was out of the office. But shortly after her arrival, he started spending every weekend in an out-of-state hunting cabin. "I thought deer season couldn't last long," Christiansen says. She never figured on the seasons for pheasants, geese, rabbits and wild turkeys.

On her first Ohio Thanksgiving, Christiansen readied a traditional meal for her husband, Robert, and expected visitors. But after hanging up the phone, she headed outside into the snow and ice. Her car spun a full 360 degrees on a curved bridge before she reached the bedside of a farmer, who had a dissecting aortic aneurysm. She called for an ambulance and accompanied her patient to the hospital for an aortic transplant.

The leftovers were put away when she arrived home.

"I was able to save his life," she says.

"Are all of our holidays going to be like this?" her husband wondered.

Christiansen did not renew her contract.

While serving as a generalist was expected of a country doctor, Christiansen delivered a far different level of care as staff physician and director of student health services at the University of Denver in the late '60s. The college required even part-time students to enroll in its modestly priced health plan. Spread over 8,000 students, the plan provided top-quality care from an on-campus infirmary, an old barracks of a Japanese relocation camp. With its own lab and X-ray facility, the college plan treated a range of student problems, from sports injuries to dentistry to mental health.

It was Christiansen's first exposure to universal health care, albeit in a microcosm.

Most colleges provided health services since students who lacked medical insurance frequently ended up dropping their studies due to unexpected health problems. Yet, few colleges specified mandatory enrollment, which made the plan more affordable by spreading costs over a larger group. "It was very visionary and sensible," Christiansen says.

One strong-willed coed truly tested the plan's breadth, which included patient confidentiality. The girl suffered a broken neck in a car accident after taking a joy ride with a boyfriend. She refused to allow Christiansen to inform her parents. She even refused at first to comply with the surgeon's orders to stabilize her neck with a halo brace. Nearly four months elapsed before the girl's parents learned of the accident when the boyfriend unintentionally let it slip in conversation.

The girl's father, it turned out, was a medical malpractice lawyer. The student apparently feared her boyfriend would end up in court. When the anticipated blistering call from the girl's father finally came, Christiansen calmly informed him his daughter's care was well documented and the records available for review if she consented to their release.

He never called back.

Health Services was singled out for an outstanding service award by students the year Christiansen retired. "That was the ultimate compliment," she says.

The big-city hospitals where Margaret Lynn Yonekura '70 worked from the '70s on provided an entirely different set of challenges. One of those was presaged by a college experience that she would always remember as a deciding factor in her choice of specialities.

One of Yonekura's Pomona schoolmates suffered menstrual cramps so severe she sometimes passed out. When the girl sought relief at the school clinic, instead of sympathy and a palliative she was treated with callous contempt. The male doctor dismissed the complaint as hypochondria, telling the student her problem would stop once she bore children.

Later on, in medical school at the University of Southern California, the memory of her friend's humiliation tipped the scale as Yonekura weighed which specialty to pursue. Gender, she realized, would provide invaluable insights in obstetrics and gynecology missed by a male doctor.

Her choice proved beneficial in a career that caromed between three Los Angeles hospitals. But the Pomona clinic incident would also serve as a proxy for the era's prevailing attitude. In the male-dominated culture of medicine Yonekura found pervasive sexism within both academe and its teaching hospitals.

One of only a dozen women in a medical school class of several hundred, Yonekura alone sought admission to a surgical sub-specialty. Usually, the process takes no more than two admission interviews. Instead, she was subjected to eight interrogations by desk-pounding faculty. Their questions were intrusive, doubting her physical stamina and demanding she divulge her timetable for child bearing. Holding a cup of coffee in one 8 a.m. interview, she was literally jolted out of her seat by the initial question. "You're doing this because you're a lesbian, right?" the professor demanded. Coffee ejected across the desk, spilling onto her lap. Regaining her composure, she recalls replying, "Whether I am or not is not relevant."

"I had a lot of battles I had to fight," she admits.

Doing battle with institutional sexism was never Yonekura's goal, but neither was she a willing patsy for inequitable treatment. At one hospital, sleeping quarters for the chief resident were accessible only through the men's locker room. Yonekura's request for a female chief's room was rebuffed. She resorted to a sneak attack.

Lingering in the chief's room after an all-night shift, she bided her time until after 6 a.m. Then, as the locker room rumbled with the voices of outside physicians arriving to perform morning surgeries, she swaggered through the door onto a sea of men in various stages of undress. Some were bent over urinals.

"The next day, I had a new female locker room," she says.

Those personal triumphs draw guffaws at an annual substance-abuse lecture Yonekura gives to current UCLA obstetric residents. "They can't quite believe me," she says. And with good reason. The audience of freshly minted OB physicians is now predominantly female.

The gender shift among American doctors is just one of the important changes the profession has seen in the last few decades. One of the biggest changes, perhaps, is economic. Becoming a doctor today is no longer a financial sinecure. With their incomes slipping as reimbursement rates for procedures are cut by insurers, physicians are job-hopping with the equanimity of option-seeking dot-commers. Once treated with near reverence, doctors now chafe under restrictions that undercut their authority. One rite of medicine, though, appears unchanged. The grueling pace expected of medical-school students would be familiar to any viewer of television's "Chicago Hope" or the archetypal "Dr. Kildare" (which featured Richard Chamberlain '56).

For Scott A. Lehto, a third-year student in clinical training at New York's Cornell University, a typical day begins by joining a group of already-graduated residents, who are working on their specialty in internal medicine at Manhattan's New York Presbyterian Hospital. The mammoth 2,237-bed facility is a warren of adjoining mid-rises, teeming with student doctors from Columbia as well as Cornell.

The attending physician, a senior doctor, leads the white-coated retinue that stops at the bedsides of 40 patients. Each resident and student doctor in turn takes center stage, describing the patient's progress and outlining possible procedures in a two-minute "morning report." Four patients are in Lehto's care.

At noon, the group splits up and the medical students attend a lecture. Afterwards, they follow up to make sure the patient procedures suggested earlier are carried out and to evaluate newcomers. One night a week, Lehto works until midnight. On a recent afternoon, he orders a chest X-ray for one charge and drains fluid from another patient's belly. Another 40 minutes is spent justifying each procedure in paperwork required by medical insurers and litigation-shy hospital administrators.

"I didn't sign up for this job to do paperwork and sit behind a desk," fumes Lehto, a '98 Pomona graduate. Despite the gratification he feels providing patients' care, the 24-year-old cannot sweep aside recurring doubts over pursuing a medical degree. "If I had it to do over again, I'm not so sure I would," he admits.

Like many budding doctors today, Lehto was unprepared for the physician's current professional status, a legacy of Johnson-era Medicare legislation that over time has stripped power from the medical profession and transferred it to insurers. Besides paperwork, Lehto is disturbed that his expected earnings of $35,000 annually during three to five years of residency are substantially less than those of the equivalently educated peer of 20 years ago. Burdened with an expected $100,000 debt by the time he finishes school, Lehto can't help musing about the travel-filled lifestyle of peers who instead pursued careers in investment banking, where starting salaries can average $145,000.

Also nettling to Lehto are patients who upbraid him for refusing to prescribe the latest drug. They often come armed with a drugmaker's pamphlets or downloaded Web pages. Much of Lehto's bedside patter is taken up describing the fine print, such as potential drug interactions and side effects. Sensitized to brand-name drug advertising, patients are attempting to exercise control of their own health decisions, but expect Nordstrom-like service from health-care providers.

Lehto settled on medicine as a way to combine his love for science and people. "I'm finding it not as much fun as I thought," he says. He must soon decide on a specialty and whether to pursue residency in an academic facility or community hospital. Radiology appeals to him since imaging by X-ray, ultrasound or CT scan serves every medical field. "I like it because it's really cool; you get to see the disease process," he says.

Despite misgivings, Lehto rejects pessimism about his future. Within 10 years, he expects critics of managed care will alter the profession. "It's a difficult field because it's changing every minuteÑfrom new treatments to the role of the doctor," he says. "The doctor has changed from healer to educator to counselor."

In fact, physicians who embrace those multiple roles are giving a new dimension to health care. Though products of very different eras, both Yonekura and Christiansen have evolved with the times and become leaders in seeking new solutions.

Rather than breaking gender barriers, Yonekura is now bending rules for another disenfranchised group. She is medical director of perinatal services at California Hospital Medical Center, a 313-bed facility on the grimy fringe of downtown Los Angeles where 5,000 babies are born a year. Granted carte blanche by the hospital's nonprofit owners in 1992, Yonekura is pursuing a novel way to deliver health care to low-income, mostly Latino immigrants in the Pico-Union neighborhood.

Instead of waiting for patients to seek help, the hospital now fields outreach teams to churches, schools and factories. Community health promoters provide on-site health education, diabetes screening and take blood pressures.

Rather than focus exclusively on the health needs of individuals in isolation, the hospital's Hope Street Family Center pulls in a disparate menu of family services. The center, a joint venture with the UCLA Center for Healthier Children, could be a turn-of-the-century settlement house.

Besides prenatal care, the center hosts an Early Head Start program and on-site child care, literacy and recreation programs for school-age children, a satellite office of a state-subsidized food program, a continuation high-school, and parenting and English-as-a-second-language classes for adults. The hospital even agreed to serve as financial fiduciary for a coalition of local community groups.

What does this have to do with medicine? Everything, says Yonekura, 51. How can an illiterate diabetic, unable to read numbers or tell time, follow a doctor's insulin orders without risk of overdosing?

"I think it's important not just to treat blood pressure but to move people to a better place where they can be more involved with their own health care," says Yonekura. A preventive approach, she concedes, "is a big jump for most poor people. They're looking at food for today."

After seven years, the results are beginning to pay off. The hospital is admitting fewer desperately ill patients who put off seeking treatment. A $20 million women's health care center is planned to absorb some of the hospital's now underused acute-care space. The hospital's holistic approach is also drawing recognition, including a procession of visitors such as Rob Reiner and Senator Ted Kennedy. Yonekura, too, was singled out for acknowledgment by the service group Soroptomist International last March and by the L.A. County Commission for Women in 1999.

"When you're trying to be an advocate for under-represented women, it's an endless task," says Yonekura.

Patient advocacy comes naturally to many physicians, but few clamber on the soapbox as enthusiastically as Christiansen. Writing her own life-changing prescription, she cast off the white-coated gentility of traditional medicine. Now she leads medicine's newest shock troopsÑadvocates for universal care.

Her militant transformation occurred after taking a "retirement" job as a clinic physician in rural Colorado in 1990, when the full breadth of health care's evolution descended on her shoulders. The challenge proved far tougher than headstrong college students.

Christiansen established satellite family clinics for the University of Colorado Medical School in the rural mountains an hour's drive west of Denver. To ensure daily office hours between the isolated towns of Black Hawk and Nederland, she drove the 19-mile Peak-to-Peak Highway at lunch, eating an apple and a sandwich en route. One nurse and a receptionist assisted. Seeing 25 to 35 patients a day, she often treated victims of auto accidents along with the more routine broken limbs, pneumonia and heart attacks.

"This was my retirement," Christiansen says. "I learned so much."

She discovered that 70 percent of her patients lacked insurance, just like 44 million other Americans. In rural Colorado, the uninsured were either self-employed or worked for small businesses that lacked fringe benefits. Some were young professionals who dared doing without. Others were the critically ill who spurned emergency rooms out of fear that sky-high bills would put their home or car at risk of foreclosure or repossession. Clinic fees were on a sliding scale, depending in part on whether a patient's home lacked electricity or indoor plumbing.

"Every day we made phone calls for referrals and the first question was ÔIs there insurance?'" she says. "When the answer was 'No,' there would be dead silence.

"You could live in equatorial Africa and get better care!" she rages. "These were public facilities that by law were required to provide services."

In one instance, for 11 weeks the university hospital refused to treat a 43-year-old man in wrenching pain from cancer of the pancreas. When he came to the clinic hemorrhaging, Christiansen ordered an air ambulance evacuation to a private hospital. When the private hospital's admitting office checked his records, university personnel erroneously flagged him as a drug seeker. The man was discharged.

"He was dying of cancer!" cries Christiansen. She demanded the university hospital provide a room. "He's coming by taxi. He'll be there in an hour," she recalls of the fiery conversation. The patient died five days later.

"We have the nerve to boast about the quality of our health care," she says with disgust. "This experience convinced me our health care delivery system is disgraceful. Managed care has only made it worse. We've got to throw out the mess and design a system that is fair to everyone."

Christiansen's career has spanned enormous changes in the medical profession, but more change--and big change--may be in the offing. Few in the medical profession still believe that managed care plans are a panacea for the renewed double-digit escalation of health care costs, which now consume 14 percent of the nation's gross national product, a marked increase from the 1980s, when the figure stood at 9 percent. (By comparison, both Germany and France spend 11 percent.) Neither is there agreement on a politically acceptable prescription.

With 8 of 10 California doctor groups bordering on insolvency and hospital losses climbing from treating the uninsured, a meltdown similar to the electricity crises is looming, predicts Jamie Court '89, author of Making a Killing: HMOs and the Threat to Your Health.

"We've ignored the 'U' word for too long," says Court, who directs a consumer-rights group that in 1999 helped win passage in California of the nation's first "patient bill of rights" law allowing patients to sue their insurer. "My belief is widespread financial failure will cause legislators to step in."

Christiansen, however, thinks real solutions won't originate with politicians. After seeing health-care privations as bad as any her mother endured as a physician in a missionary hospital in China, Christiansen feels compelled to take an active role in redirecting her profession.

"Our medical culture is in the habit of boasting about having the best care in the world. It isn't true," she says, citing World Health Organization figures ranking U.S. infant mortality at 35th while spending twice as much on health care per person as nationalized systems. On a tour of Norway and Finland with the American Women's Medical Association, she was impressed with national health-care systems that give patients equal access to specialists and a choice of physicians while still performing cutting-edge research.

Now as president-elect of the AWMA, a radicalized Christiansen was one of 17 physicians selected to provide Congressional testimony on universal health care last spring. "We hope to reopen the debate to health-care reform based on what is working in other countries," she says.

While lobbyists from insurance companies and drugmakers squelched the Clinton administration's 1992 proposal for universal care, Christiansen believes a second go-around would end differently. Consumers are at the boiling point over insurers that stonewall referrals to specialists, she says, and frustrated physicians are fleeing the profession, discouraging their offspring from pursuing medical careers.

"Physicians should be the leaders in proposing solutions," she says. "Politicians can't solve a problem they don't understand."

--Andrea Adelsen is a free-lance writer living in Laguna Beach.