It also feels like this is all coinciding with doctors feeling increased financial pressure to move patients in and out of the office so they can see as many folks as possible in a day.
I wrote an essay about this and called it “the 15-minute visit.” It’s an utterly artificial, financially-driven notion. And there’s frankly no reason that patients should put up with it. If they need more time, they should ask for more time, and they should get more time. The 15-minute visit is an artifact of a fee-for-service system. As long as we have that, the doctors are paid to increase volume. You increase the volume by having limited time for each person. Doctors under this system, in most cases, are incentivized to see people. Until the financial incentives change, doctors won’t change. If you had a system that was not fee-for-service, it would change the complexion of visits—including no visits, and much more telephone work and other things to keep people out of your office.
How did you go about asking patients if you could relay their stories?
Most of my patients at this point know that I write books. I usually said to them, “I’m working on a project about money. Do you mind if I write down some of the things that we talked about?” Usually, I’d document it in their medical chart. I always said, “Listen, if I were to ever write about what you tell me, it’s not going to be ‘you.’ I’m not going to mention anything that’s identifying.” Most people were flattered. They like to be heard, especially if I’m not revealing deeply personal things about them.
Their stories are incredible. I was really struck by who worked on lobster boats and decided to go into a boiler system business with a partner, who then revealed that the partner swindled him out of their start-up costs, and that the partner was his dad. When someone says something like that—essentially, that they were deeply screwed by a person they love and trust—how as a doctor or even a person do you respond to that?
I didn’t see him acutely after his split with his father-partner. But he was still very sore about this when I heard about it, and it went on for a long time. He was angry. I’m interested in their health, so the question for me is always, what do these occasions or experiences mean for their decision-making around health? I often talk to people about how not having a lot of income both almost obliges you to make bad decisions, and yet you have no room to make bad decisions.
In the book’s conclusion, you write that talking to patients about money is “a form of preventative care.” It’s a moment that really hammers home the fact that things like diet, exercise, and sleep are economic privileges in many parts of America.
The question is, “What are the things that keep people healthy?” It’s what and how much you eat, how much you exercise, and how much you sleep. But the notion that those three things, which have come to be seen as the holy trinity of self care, are completely under anyone’s control is illusory.
There are communities in this country that may or may not have a supermarket or running water, that may have so much noise outside their window that people can’t sleep. These drivers of health are structural—if you’re poor, more of these things are going to be outside of your control.