Monday, January 31, 2011

Book Review: The Color of Atmosphere

Pediatrician Maggie Kozel's just-published memoir, "The Color of Atmosphere: One Doctor's Journey In and Out of Medicine," is a perfectly measured tale of a career in the trenches of primary care medicine that also says volumes about the declining state of the American health system. Dr. Kozel's personal narrative - that of an initially idealistic doctor who is eventually worn down by the many perverse financial and structural disincentives to doing the "right thing" for her patients - makes this book a compelling enough read. But what elevates it to another level entirely are her unfiltered observations of patient encounters that illustrate much of what has gone wrong with health care in the U.S. This book is not at all a health policy tome, but it nonetheless provides a clearer rationale for the urgent need for reforms than any previous book I've read, period.

The Color of Atmosphere starts with Dr. Kozel's emergence from a difficult childhood to medical school, pediatric residency, and several years practicing overseas with the Navy (where, she observes, "what has been demonized by our culture in general, the specter of universal health coverage, had been fully embraced by that bastion of socially progressive thinking, the U.S. military.") There, in the 1980s, she is exposed to the team-based model of care that is only now gaining traction in private practice, where primary care physicians coordinate teams of nurses and nurse practitioners who provide routine anticipatory guidance, health maintenance, and immunizations at group visits, leaving the physician plenty of time and energy to deal with any remaining concerns.

After resigning from the Navy, Dr. Kozel works at a community health center and a private practice in Rhode Island, where she stubbornly resists the formulas that many of her colleagues use to stay sane and get ahead in medicine. Want to make more money? See more patients in less time; avoid patients with public insurance; avoid those with complex problems; prescribe excessively rather than get into drawn-out discussions of why drugs such as antibiotics aren't really needed. How to prevent malpractice lawsuits? Avoid treating the patients most likely to have bad outcomes, even if you are the on-call physician and an uninsured child is gasping for breath in the local ER. In other chapters, she explores the mismatch between pediatric residency training and providing primary care for children, and the tilting-at-windmills approaches that physicians and medical societies have increasingly taken to addressing complex social problems such as obesity, physical inactivity, poor parenting, and psychiatric disorders.

When Dr. Kozel announces her decision to leave her practice to take a job as a chemistry teacher at her daughters' private school, many of her physician colleagues admit to her that they are just as frustrated by what the practice of medicine has become as she is. Nonetheless, she says, "Medicine had challenged me, thrilled me, frightened me, and humbled me. But it had never disappointed me. It was the system we use to deliver health care, with its inefficiencies, misplaced incentives, and misguided use of resources, that distorted the doctor-patient relationship and exhausted me. ... I would always feel ambivalence about leaving medicine, I knew, but never any about having entered it." Dr. Kozel is a superb writer, and although her departure from the medical profession is surely a loss for her patients, all of us will benefit if this book is read by policy makers, doctors-to-be, and regular people who will advocate for much-needed health reforms.