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MELISSA BLOCK, host:

Now, we're going to hear from two doctors about the health care system and how it might be redesigned.

George Knaysi is a surgical oncologist in private practice in Richmond, Virginia. Greg Darrow is a family physician. He's medical director of the Jemez Pueblo Health Center in New Mexico. Each of them has been in practice for more than 30 years, and they agree that much has changed since they first began seeing patients in the 1970s. For starters, Dr. Darrow says there's a high premium on meeting targets.

Dr. GREG DARROW (Director, Jemez Pueblo Health Center, New Mexico): I think that when you're an employed physician, especially in one of the larger groups, it's an expectation that you have a production target, a number that it would be desirable for you to hit. There's a lot more to it now than just having a good bedside manner and being an accomplished physician. Now, it's marketing, it's patient satisfaction. There are so many things that go into it, that it can whirl the mind of a young physician.

BLOCK: What about an older physician, like yourself?

Dr. DARROW: Yes, it can whirl the mind of an older physician, too, for sure.

(Soundbite of laughter)

As you get older, you get less patient and less tolerant sometimes of the intrusions. You almost take the mindset: leave me alone. I know what I do best, which is to take good care of people. Why can't you leave me alone to do that instead of being in my face all the time with other things, like my latest quarterly numbers, or my patient satisfaction scores, or the latest competency I must do to fulfill the hoops of the corporation?

BLOCK: Well, Dr. Knaysi, as a surgical oncologist, you've been practicing just about as long as Dr. Darrow. What are your thoughts, as you listen to him talk about the pitfalls of medicine, as its being practiced now?

Dr. GEORGE KNAYSI (Surgical Oncologist, Virginia): Well, Melissa, I've had a fairly different experience, but it's probably because of two things. One is my specialty is different. I'm a breast surgeon. And the other is that I'm still in private practice. We still control our life a little bit more. There's nobody really looking at us telling us how we should do. Although, we have to look at ourselves because over the past 38 years, we've had tremendous change in not just the scientific part of medicine and surgery, but also the business, which I think Dr. Darrow alluded to.

Used to be, I remember in the early days, you'd have a few surgeons sitting around doing their one or two cases, drifting off to the office after a leisurely lunch, and maybe playing a few rounds of holes of golf or something after that. It's not like that anymore.

The overhead keeps going up. The reimbursement keeps going down. And so, just to survive, it becomes a bit of a volume business. I used to joke that we were going from Nordstrom's to Wal-Mart. The big challenge is to maintain quality with high volume.

BLOCK: You know, you were using that analogy of going from Nordstrom to Wal-Mart. At the same time, though, you know, we hear the complaint that part of what's driving up health care costs is that we are getting far more procedures, more tests are being ordered than before, and that that contributes to this spiraling upward of costs. Do you think that's the case?

Dr. KNAYSI: I think it is the case. You know, medicine has gotten so much more complex. The menu of options not only in therapy but in testing goes up. There's no question that the fear of suits, I think, is so engrained in our thinking, not just in the doctor's mind but in the hospital's mind that that also pushes you. I think everybody way back there has this feeling with somebody say, why didn't you order this, when you misdiagnosed something or so forth.

So, I noticed that when I do even just a 20-minute operation, there'll be three people in the operating room, and one of them is just an RN entering data, most of which we don't really use. It's just there in case it's ever needed.

BLOCK: You mean, the nurse is there putting in data in case it's needed if you were to be sued.

Dr. KNAYSI: Yeah. Yeah. At the end of a 20-minute operation, I've signed, dated and timed my name 13 times. And there's a nurse who's probably cranked out maybe 10 or 15 pages of printout. We don't even look at it. It's just there in case something ever happens.

BLOCK: Dr. Darrow, I wonder if you think patient attitudes have changed, too. In other words, we expect a different level of testing procedures, all sorts of medical technology that comes into play than we used to.

Dr. DARROW: I think that is true. I'll give you one example of a patient who might go out and play a weekend basketball game, twist a knee, come in on a Monday with a moderately swollen knee. Fairly normal exam, and as I'm saying, we need to protect this joint and to apply some ice, elevate it, maybe put on crutches, have the patient cock an eye at me and say, well, don't you think I need that MRI now?

BLOCK: And what do you say?

Dr. DARROW: And it's difficult sometimes to explain why not. I take the tack of trying to do what's best and trying to be conservative, but reasonable. But it's increasingly difficult.

BLOCK: Well, as you both think about the plans to overhaul health care, what do you think happens if and when, maybe tens of millions more uninsured, currently uninsured people enter the system?

Dr. Darrow?

Dr. DARROW: I would love to see a single-payer system. It breaks my heart to know that people in my county in New Mexico do not have proper immunizations, that elderly oftentimes take their medicine every second or every third day because they can't afford their prescriptions.

I think that so much of the system that we have now has set up needless duplicity. There are large budgets for marketing. There are huge administrative costs, and none of this translates to enhanced health care at the grassroots level for patients.

BLOCK: And Dr. Knaysi, do you think the system can absorb all these uninsured people and still function?

Dr. KNAYSI: I think the people in this country have begun to feel that health care is probably a right, not a privilege. And so, I'm fairly confident we're working our way to Dr. Darrow's goal.

The elephant in the room, of course, is rationing, and that's what makes me a little uneasy with the single payer system. For instance, if you get to 70 years old and your kidneys fail, are you going to be allowed to have dialysis? Very expensive. Then there could be what we call soft rationing, where we'll do your knee replacement, but you'll be put on a waiting list, and that'll probably be about two years from now.

There are all kinds of decisions that get made based on people's general health and age about whether expensive procedures could be performed. And I think that's really where a lot of the savings comes in with some of the national plans. And I think that's why in some countries now, like England, there is a second plan.

You can pay to be in a second plan. And I think the menu of options for people is so immense now compared to when we began practice. You know, in the old days, if your knee hurts, you got an aspirin. Now, you can get a $40,000 operation, and it helps the quality of your life, but it's big.

Lyndon Johnson had coronary artery disease. All they could give him was nitroglycerin pills. Now, he'd have a stent. He'd have multiple catheterizations. He'd have all kinds of fancy tests. He'd have bypass surgery. But at some point, somebody has to say we can't afford that, and that's where some people are going to say, well, I still want it and I'm willing to pay for it. I think they've got to have a place, those folks.

BLOCK: Well, Dr. Knaysi, Dr. Darrow, thank you both very much for talking with us.

Dr. DARROW: Thank you, Melissa, very much. It's been an honor.

Dr. KNAYSI: It's a pleasure, Melissa. Thank you.

BLOCK: Greg Darrow is medical director of the Jemez Pueblo Health Center in New Mexico. Greg Knaysi is a surgical oncologist in Richmond, Virginia. And tomorrow, we're going to hear from two young doctors who've just finished their residencies in internal medicine. They both started out wanting to be primary care providers. One doctor changed his mind and decided to specialize. The other is sticking with primary care.

Unidentified Woman: A big part of it is that you have this relationship almost to the point where sometimes, the patients come in, and it's almost like you're seeing one of your friends again, and they know about your family and your pets, and you know about theirs.

Unidentified Man: I didn't really have time to talk to the patients, to interact with them, to listen to them. So, I really became disillusioned with primary care.

BLOCK: More from two young doctors tomorrow on ALL THINGS CONSIDERED.

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