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Featuring cardiologist Mark Goldfarb, who discusses his KevinMD article “Why the U.S. health care system is failing patients—what every American should know.” Mark sheds light on the realities of physician shortages, the pitfalls of overreliance on tests over physical exams, and the frustrating complexities of billing and insurance. He also highlights the importance of direct physician-to-physician communication, personalized patient care, and open dialogue to drive meaningful reform. Listeners will walk away with actionable steps to navigate the system more effectively, advocate for thorough exams, and push for a patient-centered approach.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Mark Goldfarb. He is a cardiologist, and today’s KevinMD article is “Why the U.S. health care system is failing patients and what every American should know.” Mark, welcome to the show.
Mark Goldfarb: Thank you. Glad to be here. Thrilled to be here, actually.
Kevin Pho: All right. So before we talk about the article itself, what led you to write it and submit it to KevinMD in the first place?
Mark Goldfarb: I had experienced—I became a patient as the flip side. Rather than being on the physician side, I became a patient. As my wife said, I was a civilian patient. I didn’t have the easy access. I had some difficulties, some things that were upsetting to me, not so much on my personal health, but the delivery of care I received. I just wrote. I wrote it out for myself as a mechanism to vent. I shared it with my wife. She said, Oh, that’s pretty accurate. I shared it with some friends.
Then I shared it with some med school colleagues and friends, some local colleagues and friends. The response was quite positive and went something like, Yeah, I’ve experienced this too, and this is disturbing, and you need to let the word out or share it with other people or a wider audience.
Kevin Pho: All right. Tell us your story. What happened to you?
Mark Goldfarb: So, I had retired. I practiced in Nashville, Tennessee, for 33 years in interventional cardiology. I retired, moved out to Park City, Utah, which is absolutely gorgeous. I started having some health issues, some challenges, and once again, I had no primary care physician, no other physician specialists. In the old days, when I was practicing, I’d run into a colleague/friend in the physician lounge and say, “Hey, I’ve got this,” and they’d say, “Yeah, come on up after lunch,” or “I’ll see you tomorrow morning in the office,” and so on. This became challenging. I’d ask people here whom to go to. I went to one or two people—one left, one was not terribly, in my view, up to standard.
Then I had a more serious issue. I had a rotator cuff surgery. About a week or so afterward, I became literally sick and septic. I went back to the emergency room where I had the procedure, and they immediately took me back to the operating room and had to take out all the hardware. I had a P. acnes infection. Lo and behold, they put me on an antibiotic, and I went to see the infectious disease specialist a week later. Very nice person. She looked me in the eye and said, “You know, the cultures came back. The antibiotic we have you on should be good. We’ll see you in a month.”
I said, “Well, do you mind looking at my shoulder? I mean, just looking.” “Oh, OK. Yeah. Maybe we’ll do that.” And then as she’s about to leave, she says, “Should be good.” I said, “Well, I’m a cardiologist, and maybe I’m overreacting, but, you know, maybe there’s a slight chance of endocarditis. I mean, I was septic, and maybe could you listen?” “Oh, OK. Maybe.” So she—now she has to find a stethoscope—and she comes in, listens, and everything is fine. But I thought, That was not good care. Thank goodness I got better, did rehab, and I’m back to normal.
I subsequently had some back and spinal issues. I went to see—I was referred to—a neurologist who looked at me and said, “Hmm, I don’t know if—do you mind if I…?” and right in front of me, “Do you mind if I look this up on Google?” And then my total faith in this individual was gone. I was referred then to an orthopedic surgeon after we had MRIs and lumbar spine films. Lo and behold, a very nice person said, “This is what we could do; this is what we should do; you’re more active than the average, so let’s wait.”
I told my wife, “I’m curious what’s going to be in the patient portal about the after-visit summary.” Lo and behold, there was an entire physical exam, including strength, range of motion, sensory, in addition to listening to my lungs and heart, which he never, ever, ever touched. I actually wrote him back on the patient portal and sent a note to the head of the university saying, “On one level, this is fraud because you’re upcharging, but that’s not really what I’m concerned about. I’m concerned about if I come back to see you in six months, you have no baseline for my strength or range of motion or sensory. These are serious, serious issues.”
Lastly, I saw the internist. My PSA went up, and I said, “You know, maybe it’s time to see a urologist.” “OK.” Referred me to a urologist, saw the urologist, said, “Let’s repeat it.” We did. It was up a little higher. He said, “Well, let’s follow this.” I said, “Well, I’ve been following it for 25 years. It’s now up; there’s no good reason that it’s up. Why don’t we do an exam?” “Ah, you really can’t feel that much on the exam because you only feel this side of the prostate, not the other side, and I don’t think that’s going to work.” I said, “Please, let’s do an exam.” He did an exam. There was a little asymmetry. Thank goodness. He said, “OK, let’s get an MRI,” and that led to a further evaluation.
I found all three of these incidents very disturbing, disappointing, and then I think, you know, if you’re not in the medical field, the average person (including my wife) would not have known to ask for certain things. You have to be your own advocate, and I’d say 98 percent of the people are not in the medical field and don’t know to ask, nor do they think it’s fair to ask.
Kevin Pho: Now, of course, you’ve been practicing cardiology for decades before this, so from your lens as a physician, what do you think are some of the root causes behind some of that substandard care you received?
Mark Goldfarb: I hate to say this—maybe I sound like a dinosaur—I don’t know if it’s in the training, but I think current-day physicians (and they could argue with me) are more attuned to ordering first and then treating and addressing test results. It looks good in black and white: I can treat that. The nuances seem to be missing, and it may be in the training. It’s been brought to my attention—I understand there’s what appears to be a severe shortage of physicians—so maybe there’s a time crunch. A lot of times, you end up seeing PAs and nurse practitioners, which are wonderful. They’re truly wonderful assets. My daughter is a nurse practitioner, so I’m fully for that. But when you go to see a physician, and you first see the medical assistant, PA, or NP, I’m not sure what the communication is or if they’re just doing it to fill in the EMR, but there’s a lack of communication. And then it kills me when you see the physician and they’re staring at their computer and barely making any eye contact. The rapport in the room is totally missing. It’s a cold encounter. It’s almost like a business encounter rather than dealing with a person who’s ailing and went to you for help.
Kevin Pho: When you were practicing cardiology, did you feel outside forces that influenced some of the care that you gave out?
Mark Goldfarb: I did not. I think I was very, very lucky. I was in a good practice. We were owned by a hospital at a certain point, and maybe they had more decisions about how many staff people, etc., and maybe they did the hiring, and maybe I might not have hired one or two, but overall, I didn’t feel pressure to produce or meet certain thresholds. I felt independent, and I think it was a good milieu.
Kevin Pho: Now, when you offered that feedback, after reading that note, did you receive any response or rectification?
Mark Goldfarb: The physician apologized—directly called me, actually, which I felt was appropriate—and said, “Oh, he was sorry. He was on call the night before, and his MA was typing everything, and he didn’t check it.” Well, I appreciate the apology, but it still falls short of—I don’t know what you did to the next patient, the next week, the next month. It’s your responsibility. Everything that your medical assistant, PA, or nurse practitioner puts in the chart ultimately is your responsibility. So maybe it was a learning experience, or maybe it was just, you know, OK, I’m going to get rid of this guy and move forward.
Kevin Pho: So what are some paths forward? You mentioned some things about the training—perhaps there are external forces that may be pressuring these clinicians to provide lesser care than they would like. What are some paths from your perspective, not only as a retired physician but also from your experience on the patient side?
Mark Goldfarb: Oh, I want to correct one thing. I like to use the term semi-retired. I do volunteer at a clinic for people who don’t have health insurance, and what’s nice is I’m seeing the patient the same way, but I’m not worried about filling in the EMR and what level of service, so on and so forth, and it’s a pleasure to do that—where you’re doing things because it’s the right thing to do. Now, you need to document well because the patient’s going to be seen, in my situation, by the primary care physician, and I will see them in several months, so you need to have accurate documentation. But you’re not worrying, is this a level 3, level 4, etc.
What can we do going forward? It’s tough. I think it starts with the training. Some of it is just basic human—just look the patient in the eye. And I think every physician should also have to go through the process of the patient journey at least once a year. Try to—I mean, I don’t know how they would do this—but make it a mock patient. You call in to get an appointment; you’re having, in my situation, chest pain, and they say, “OK, we can see you in six or seven weeks.” That’s not appropriate. So then you need to call a friend to get you moved up, and then maybe there’s an opening in a week or two, which is better, but the roadblocks to getting care are absolutely horrendous. We need to address that, and that’s whether it’s numbers or there’s a ranked system in terms of severity of symptoms.
And then we also need more primary care physicians. We treat too many basic things in the emergency room, which drives up costs dramatically, rather than seeing them in the private office.
Kevin Pho: Now, did your experience as a patient surprise you? Did it surprise you, the care that you received?
Mark Goldfarb: Absolutely shocked me—both the difficulty getting in, the difficulty getting a follow-up appointment, the difficulty finding the after-visit summary in the electronic medical record, the difficulty understanding the bill. I mean, that’s almost hieroglyphics. I had no idea. You know, you would charge this—this is what’s usual and customary—and then at the very end, there’s This is what you might owe. So that’s impossible. The lack of one major thing is the lack of communication between the physicians. I mean, once again, call me a dinosaur: I would—if a patient was referred to me by a friend who was a primary care provider—rather than just send a note, I would usually say, “Oh, let me just call him or her,” and communicate directly. Right now, it’s in the EMR, and someone puts a note there, and you could also go off on a tangent on EMRs, which is the vast majority cut and paste. But you have to search for the essential meaning and interpretation—what the physician wants to convey. So that’s a major issue that needs to be addressed. I know the EMR is not going to go away, but we need to utilize it in a more proactive, positive manner.
Kevin Pho: When you were practicing cardiology before your semi-retirement, did you have to grapple with all these EMR implementations in your own office?
Mark Goldfarb: Absolutely, yes. And, you know, they would change vendors every couple of years; they would update things. You’d have the men and women in the—almost the construction-worker vests—in the hospital helping you in the hospital, trying to figure it out. Now it’s very challenging.
Kevin Pho: And then how did you manage looking that patient in the eye with the distraction of the computer in the exam room? How did you maintain that relationship that you had with the patient in the exam room?
Mark Goldfarb: I refused to be in a room with a computer. I would never bring it in, ever. The patient-physician interaction is the paramount point of what you’re doing each and every day.
Kevin Pho: In terms of your experience as a patient, is it unique to your area, or is this happening all across the country? Are you hearing your colleagues, when they seek medical care every day, going through the same experiences as you were?
Mark Goldfarb: Based on my distributing my letter or editorial to former physician friends and physicians all over the country, everyone says, “Oh, I’ve experienced that.” It hurts as a physician, but I’ve had one or two friends with very serious health issues who have said, “Oh my goodness, you’re telling exactly what I have experienced. I thought I was going to die, and no one… you know, it was terrible.”
Kevin Pho: Now, you alluded to this earlier in terms of physicians needing to communicate with one another. Physicians needing to look patients in the eye when they’re talking to them, despite having electronic medical records in the room. What other pieces of advice can you share with the clinicians listening to you today? They may be going through burnout and all these external pressures, but despite all that, tell us the messages and pieces of advice that you want to give clinicians to maintain that patient relationship, despite everything else going on with our health care system.
Mark Goldfarb: I think the most important thing is have integrity and be honest. So when you fill out the EMR, don’t hit a template that says “normal.” Don’t, in some capacity, let the MA totally populate the history. Use your interpretation. Use the patient’s words rather than “Patient was on the portal the night before: yes, no, yes, no,” whatever. It has to be totally accurate and with integrity. And above that—perhaps most important—treat every patient like you would your mother. With respect, honesty—you can put your hand on their shoulder: We’ll get through this together. I understand what you’re experiencing. This is what I think it is. If you want a second opinion, feel free. Let’s work through this together, and I will be here for you.
Kevin Pho: How about advice to other patients? Because you also mentioned that if you weren’t a physician yourself, you wouldn’t have pushed and asked these follow-up questions. A lot of patients simply would have just accepted their experience with a physician. So tell us what kind of advice you have for patients going through the health care system and experiencing the same roadblocks that you faced.
Mark Goldfarb: I think it’s almost imperative that each patient bring a family member with them—particularly my parents, who were in their late nineties. They both passed in the last year or two, but they couldn’t navigate the patient portal, and when they were sitting in front of the physician, they were intimidated. Their answers went way off track. You need to have a family member or a trusted friend with you, both to listen, to give you feedback after the visit, and to be a patient advocate. Because elderly people cannot manage the portal. They cannot set up appointments. The medication reconciliation list is a total disaster and needs to be reviewed at each and every visit. You just need somebody with you as a second voice and second set of ears to make sure things are going the way you hope.
Kevin Pho: You mentioned earlier that there’s a severe shortage of primary care physicians. I’m a primary care physician myself, so of course I agree with you and I see that. From a policy standpoint, what can be done? It seems like we’ve been talking about the lack of primary care physicians for decades now, and the needle hasn’t really moved. So if you were in charge of our health care system, what are some things that you would do to help with the primary care shortage?
Mark Goldfarb: It’s a very good question. I’m not a policy person. Your comments are correct; it’s been going on forever. I think everyone should be referred to and read that Commonwealth Fund article, which ranks us out of 10 similar high-income countries in the world. We are 10th. We are last in terms of access to care. So it’s not a surprise. It’s absolutely here. We need more primary care physicians. And maybe it needs to be a financial situation where we are incentivized for preventing disease rather than simply reacting to a crisis. I know all physicians are incentivized for doing a procedure. I mean, in my group of cardiologists when I was practicing, you put patient X on my stretcher in the cath lab, and I have a reputation (and I think appropriately so) for being conservative. I’d say there were one or two, maybe three people in my group, and they’d come out with a stent because they’re incentivized for doing something, and it’s nice to make pretty pictures and get rid of a blockage because you can do it. The big question is, should you do it?
So we definitely need more primary care providers, and we definitely need something in the system incentivizing physicians to stop disease before it becomes a major issue.
Kevin Pho: We’re talking to Mark Goldfarb. He’s a cardiologist, and today’s KevinMD article is “Why the U.S. health care system is failing patients and what every American should know.” Mark, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Mark Goldfarb: I think I mentioned it before: treat every patient like you would your mother and your immediate family or your children. You need to have integrity. Look them in the eye. We can get through this. The EMR is not going away, but be honest with what you enter. Treat every patient with respect. Establish a rapport. Probably the best part of my practice was when I retired, the letters I got—because I feel I did a good job establishing a relationship. And I’ve been retired from that practice for five and a half years. I still get phone calls; I still get letters, and that is the most gratifying thing ever.
Kevin Pho: Thank you so much for sharing your story, time, and insight. Thanks again for coming on the show.
Mark Goldfarb: Thank you, Kevin. I appreciate that.
