Dr. Scott Braunstein sits in a hospital room with Sam Bottleman, 91, on the Sunday of Chanukah. Bottleman has a neck brace and a deep wound on his head after falling down 12 steps in his apartment building the day before. Braunstein, 27, a resident in internal medicine at Cedars-Sinai Medical Center, holds Bottleman's hand and asks questions that elicit an entire history.
The patient tells him that he served in the military as a master sergeant during World War II and was a criminal investigator for the Beverly Hills Police Department until he retired in 1975. His wife died in 1973, and he has no children. He has lived in the same apartment since 1945, does his own housekeeping and shopping.
"Do you have any siblings that are still alive?" Braunstein asks.
"I lost my brother July 23 of this year," Bottleman replies. "So I'm the surviving element of the family. The one and only."
"Wow. You're the special one," Braunstein says.
"Not special," Bottleman says. "Not really. Just a process of elimination."
In fact, Bottleman tells the doctor, today is his birthday.
"Happy birthday," Dr. Braunstein says. "This is not where you had hoped to spend it, I bet."
"What difference does it make where I spend it?" Bottleman asks. "As long as I'm alive and can celebrate with friends like you."
In an age of doctors loaded down with too many patients and saddled with all sorts of HMO restrictions, Braunstein works hard to make his patients feel as if he is a friend. Personal contact is, after all, why he entered the field of medicine, and the most important message he gleaned from his years as a student at the Sackler School of Medicine at Tel Aviv University. Some 300 Americans have studied at Sackler, nearly one-quarter of them from Southern California. "The doctors emphasized treating patients with dignity. We'd be harshly reprimanded if we started examining a patient without explaining to them what we were about to do, or taking a detailed history, or placing our cold hands on them without first warming them up."
Braunstein's great-uncle Solomon Griboff, an internist, had passed along the same attitude.
"He taught me that the most important thing you can do for a patient is touch them in some way. Place a hand on their shoulder. Sit down with the patient, look them in the eye. Let them know you're on the same level with them."
That is all the more challenging since Braunstein is entering the medical profession at a time when the Los Angeles Times calls L.A. County "the Chernobyl of health care." Nationwide, HMOs are the object of criticism for diluting the quality, quantity, personal attention and continuity of health care. According to Health Care Management Review, 85 percent of all U.S. employees are now enrolled in managed-care plans. While the government recommends that there be no more than 1,800 patients assigned to any one primary-care physician, many HMOs have a 3,000-to-one ratio.
One-third of insured adults report that they have been enrolled in their current health plan for less than two years, and only 36 percent report having the same primary-care physician for two years. According to survey data collected this year for the Kaiser Family Foundation-Harvard School of Public Health, 75 percent of Americans believe that the problems of managed care have not gotten better. At least 70 percent favor consumer protection legislation.
Braunstein shares these concerns, although he points out that Cedars-Sinai "provides some of the best care in the world. If managed care is a problem at the best of hospitals," he says, "imagine what it's like at lesser ones."
He maintains that physicians are forced to see more patients in their offices, and as a result have much less time to give to their hospital patients.
"You're forced to see them for 15 minutes," he says, "when before you would spend a half-hour or an hour with them. This is often the only contact the patient will have with the doctor in a 24-hour period."
Braunstein hopes that managed care will be forced to become more responsible about its decision-making. "I think their finances should become more of a public record and should be scrutinized. I hope that the patients' bill of rights will be passed."
For now, Braunstein is leaving internal medicine in favor of emergency medicine, where he feels he has the greater freedom to treat patients.
Braunstein admits he is fond of elderly Jewish patients. His relationship with his own grandfather, Abraham Berman, who died on Nov. 21 at 85, was a close one.
"I think my grandfather valued medicine as a higher moral calling than anything else," Braunstein says. "He was really proud that I went to medical school in Israel."
When his grandfather became gravely ill last June, Braunstein helped to treat him in the hospital, returning to see him after treating other patients, especially since he knew his grandfather's private doctors couldn't attend to him around the clock.
One day, Braunstein arrived to find his grandfather "barely arousable. He was lying there with his eyes open and was not responding to me," despite the fact that physicians had already been in that morning.
It turned out that his grandfather had not properly swallowed some food that morning, and some went into his lungs. "If I hadn't come by that day and checked the labs, he would have died for sure."
The problem, says Braunstein, is that "HMOs are keeping costs down because they're rationing what can and can't be done. ... In the end, the cost to human life and resources is higher."