Jeff Lobosky and his book
The story behind a Chico neurosurgeon’s sharp critique of American health care
As a physician, Jeffrey Lobosky has seen the failure of the American health-care system from the inside looking out. But it was never made clearer to him than when his then-14-year-old son, Grayson, was diagnosed with a highly aggressive form of malignant lymphoma.
“Initially, the prognosis was dismal,” the Chico neurosurgeon writes in his remarkable new book, It’s Enough to Make You Sick: The Failure of American Health Care and a Prescription for the Cure. But the Loboskys found their way to Michael Link, a Stanford University pediatric oncologist, who was able to place Grayson into one of Stanford’s experimental clinical protocols.
“The year-long chemotherapy treatments were brutal and, as you can well imagine, extraordinarily expensive,” Lobosky writes. “But fifteen years later, my son is alive, healthy, and free of any residual cancer. My wife and I thank God every day for Michael Link and Stanford University. And I also thank God for my insurance carrier, for even though I am a well-compensated neurosurgeon, without insurance, the financial impact on my family would have been overwhelming.”
In this case, the system worked. Lobosky was able to afford good insurance. But in the middle of Grayson’s ordeal, Lobosky was forced to confront the reality that not everyone is so blessed.
“I remember coming home from Stanford after one of Grayson’s cycles of chemo,” he writes, “and seeing an announcement in the local paper about a fund-raising dinner to be held at the fairgrounds to benefit a family who had racked up over a quarter of a million dollars in medical bills for their son’s leukemia treatment. The glaring inequities of our system were staring me right in the face, just as they do for millions of Americans every day.”
The fact that nearly 50 million Americans have no health insurance, and a similar number have insurance that “is so inadequate they might just as well have none, or they have a policy that is accompanied by such high deductibles and limited benefits that adequate treatment spells financial ruin,” is simply the most obvious and most discussed failing of the health-care system.
It’s not why Lobosky wrote the book, however, or at least not the principal impetus. That came in mid-2006, when Enloe Medical Center, where Lobosky has long practiced, went through a terrible crisis resulting from a clash between the hospital CEO and the group of doctors under contract to provide anesthesiology services. When the doctors quit en masse and were replaced by a smaller number of sometimes unreliable locum tenens, or traveling physicians, the hospital went into a tailspin that began to threaten its very existence.
Lobosky fell into a funk. As he said recently during a book-signing talk at Lyon Books in downtown Chico, the crisis “really changed the way I felt about medicine. It was just not fun to practice anymore.”
For the first time, he didn’t want to go to work. His wife, Diana, became concerned. She reminded him that he’d been editor of his high school newspaper and liked to write, and she suggested he write a book. Writing about what was bothering him would be therapeutic, she said.
He agreed and, in February 2008, started jotting down ideas, focusing on what went wrong at Enloe. “Very quickly,” he said during a recent interview in the CN&R offices, “I realized it wasn’t Enloe, it was the whole system.”
It’s a huge subject, especially for a first-time author. By the time his book went to the printer, Lobosky had researched and analyzed the myriad ways all the major players in American health care—hospitals, the health-insurance industry, the pharmaceutical industry, politicians and lobbyists, doctors, malpractice lawyers and, yes, we patients who all too often take better care of our cars than we do our bodies—have contributed to the failure of the system.
He worked mornings, starting at 5:30 and going until he either had a surgery to perform, usually around 7:30, or until 9, when he would go into his office. He also took Wednesdays off and on weekends often would go up to the family’s second home, at Lake Almanor, where he could work without interruption.
“I never really thought I would finish this,” he said. He tried to quit three times, but each time Diana said, “Get back in there and write some more.” In addition to being his coach, she was also his proofreader and first editor, and he’s quick to say the book wouldn’t have happened without her.
Jeff Lobosky is a soft-spoken, affable man of medium height who looks at least 10 years younger than his 60 years. He and Diana have been married for 40 of those years. They met under rather unusual circumstances, he says.
He was attending Bishop Amat, a Catholic high school in La Puente, in the San Gabriel Valley not far from where he grew up in East Los Angeles. The school had a rule that only seniors could date girls from public high schools. A friend of Lobosky’s, a junior, had been seeing Diana, who attended a public high school, and wanted her to be his date for the last dance of the year at Bishop Amat.
To get around the restriction, the friend turned to Lobosky, who was a senior and, it so happens, dateless, and asked him to squire Diana to the dance. The idea was that, once there, they would trade dates, or something like that.
Unfortunately for the friend, Jeff and Diana hit it off in a big way. They saw each other often that summer, and continued to maintain a long-distance relationship when he went off to Notre Dame University in Indiana.
So strong was their connection that they stayed together despite frequent separations, finally marrying when he was 20 and she 19.
Lobosky knew he wanted to become a doctor when he entered college. He’d chosen that career path when, at the age of 11, he split his chin playing baseball and had to go to the emergency room. He writes about being impressed by the gleaming surfaces and technological wizardry of the hospital, and “mesmerized by the bevy of pretty young nurses who whisked in and out of my cubicle in their starched white dresses, white nylons, and uniquely shaped white caps.”
But what impressed him most was the ER doctor, a man who “projected both confidence and authority, but at the same time, a kindness and compassion that allayed my fears and filled me with trust and awe.” He knew then and there that he wanted to be a doctor, too.
Lobosky attended medical school at UC Irvine and, at the age of 32, completed his residency in neurosurgery at the University of Iowa. “It is remarkable,” he writes, “that the rigors of medical training do not completely extinguish the idealism that characterizes most young physicians.” Fortunately, he continues, “the majority of my classmates and I emerged unscathed, and I entered practice in 1984 ready to live my dream.”
That’s when he and Diana—who by then had given birth to all of the couple’s three children, daughters Holly and Kimberly and the youngest, Grayson—moved to Chico, where he partnered with a fellow neurosurgeon, Bruce Burke, whom he describes as “mentor, teacher, role model and, above all, friend.”
He and Diana both saw that Chico would be a wonderful place for their children to grow up. “It was the best decision we ever made,” he now says.
He’s had a remarkable career here, not only as one of the premier surgeons in his field, but also as Enloe’s former medical chief of staff and current co-director of its Neurotrauma Intensive Care Unit. He is also an associate clinical professor in the Department of Neurological Surgery at UC San Francisco.
He is perhaps most widely known locally for his successful efforts in the early 1990s lobbying for legislation requiring motorcyclists and minor bicyclists to wear helmets. His goal was to prevent injuries and save lives, but he also believed it was wrong for riders to expect taxpayers to pay for their post-accident care if they’d not worn a helmet.
During his decades of practice in Chico he’s witnessed innumerable situations in which the health-care system has failed patients, and he’s sprinkled their stories throughout his book. His analysis of the health-care system is grounded in his own experiences, and in that sense Chico and the North State region make up a big part of the book. Local readers will feel they are on familiar ground as they move through the chapters.
Lobosky’s first task is to debunk the popular notion that the American health-care system is the best in the world. In an early chapter, he argues that for too long we Americans have been resting on our laurels, continuing “to boast about out past accomplishments and trumpet our democratic system without carefully analyzing whether those boasts are still warranted.”
Yes, America has some of the greatest teaching hospitals and research centers in the world. “Most major breakthroughs in medical science and medical technology emanate from the United States,” Lobosky writes. “Patients with means from around the world come here for innovative treatments.”
But, according to the World Health Organization, which gathers data from its 191 member nations on a wide range of health issues, the United States ranks 29th for men and 30th for women in life expectancy, 33rd in infant mortality (tied with Cuba, Croatia, Estonia and Andorra), and 30th in maternal mortality rates.
“Select almost any of the parameters studied by the WHO,” Lobosky writes, “and the U.S. system falls short in almost every single category: cancer-related deaths (ninety-ninth), death from heart disease (twenty-sixth), childhood deaths from pneumonia (twenty-fourth), mortality rates from traumatic injuries (fifty-seventh), and the list goes on.”
The United States comes in first, however, in two categories, according to the Centers for Medicare and Medicaid Services: total expenditure on health care as a percentage of gross domestic product (17.6 percent) and annual per-capita expenditure ($8,086). “Am I the only one who thinks we are spending an extraordinary amount of resources on the health and well-being of our citizens for very modest returns?” Lobosky asks.
America does have outstanding doctors and hospitals, he continues, “but a significant portion of the American population has limited or no access to that care.” For the poor, uninsured and “underinsured,” the nation’s lifesaving system is unavailable.
Yes, Medicaid is available for the very poor, but the reimbursement rates are so low that many doctors no longer take Medicaid patients. And too many people lack insurance altogether because they cannot afford it or have policies with such high deductibles and poor coverage that a serious illness can result in bankruptcy. Indeed, Lobosky notes, catastrophic medical debt is the No. 1 cause of bankruptcy in the country.
How did it get this way?
Those looking for villains in Lobosky’s book won’t find them, though venal politicians who do the bidding of their campaign donors come close, and he believes managed care has deeply damaged the practice of medicine. Otherwise, the overall systemic failure has accreted over time, and our collective inability or unwillingness to address its ever-growing range of problems has only made a bad situation worse.
Every sector involved in health care has contributed to its failure, Lobosky argues. He devotes a chapter each to the insurance industry, the pharmaceutical industry, politicians, hospitals, physicians, lawyers, and the terrible health habits of the American people.
Along the way, he includes a short chapter on the decline in the amounts physicians are reimbursed and its consequences; another on the dramatic increase in female doctors; and a chapter on the crisis in emergency rooms.
In each of these cases, Lobosky’s argument is grounded not only in his wide-ranging research, but also in his personal experiences. Take the chapter on the increase in female doctors, for example. It’s a subject rarely discussed outside the medical profession, but it’s had profound consequences.
Today, there are nearly as many women in medical school as men, and in some specializations they are the majority. That wasn’t the case 40 years ago, when men dominated and an atmosphere of macho competitiveness suffused medical training, especially residency.
“When I was in residency, we worked 100 to 120 hours per week, and we rarely saw our families,” Lobosky writes, “but we were proud of the fact that we were bent but not broken. At least we didn’t consider ourselves broken; I suspect our wives and children may have had a different perspective.”
Most doctors of his generation went on to launch private practices, which required hard work and long hours and took time away from family—“missed baseball games and school plays, dinners without Dad, lost opportunities that could never be recovered and a shifting of the burdens on to spouses.”
The new female doctors changed all that, Lobosky writes. “Once they were represented in sufficient numbers that they no longer had to be concerned with repercussions from their all-male superiors, women started questioning the very tenets that traditionally defined both medical training and medical practice.”
One result is that by law medical trainees’ hours are now limited to 80 per week. Major university teaching hospitals have had to supplement the gaps created by the restricted work week by hiring nurse practitioners and physician assistants. There is concern, too, that trainees are missing out on vital educational experiences because of the reduced work week.
Still, Lobosky says, the changes are welcome: “We give up much to become doctors, everything from our financial resources to our youth. We should not have to also sacrifice our spouses and children on the altar of medicine.”
But one consequence is that young doctors, men and women alike, are no longer willing to put in the hours their counterparts in the boomer generation put in. They’d rather spend more time with their families. Meanwhile, the number of medical schools and graduating doctors has stayed about the same, while the population—and thus the number of patients—has increased.
The result: a serious physician shortage. “Believe me when I tell you that the physician shortage is upon us and it is real,” Lobosky writes. “This is especially true in fields such as neurosurgery, orthopedics, general surgery, gastroenterology, and cardiology.”
Unlike their predecessors, newly minted doctors aren’t interested in setting up their own practices and “are looking instead to work as employees of the hospitals or in existing group practices.” Nor do they want to care “for uninsured patients at inconvenient hours [by being on call] in the emergency room.”
And eventually they begin “to opt out of on-call responsibilities while shifting their now established practices to physician-owned surgery centers and freestanding specialty facilities,” pulling business away from and weakening community hospitals.
Lobosky laments this change but doesn’t blame the young doctors. Remember, he writes, “my generation did not come out of residency with an average debt of more than $150,000. When my generation started practice, insurance carriers were still reimbursing us at a rate that made charity care much easier to absorb. … We did not have to rush patients through in high volumes just to make ends meet, and we had deeper and more rewarding personal relationships with those for whom we cared. It’s hard for a physician to develop a sense of loyalty to a community or for a community to develop a sense of loyalty to a physician in today’s model of assembly line medicine.”
This is the kind of thoughtful, knowledgeable analysis that characterizes It’s Enough to Make You Sick. Lobosky often leavens this seriousness with a quizzical, even jokey tone suggestive of someone saying, “Can you believe this? I couldn’t make this stuff up.” His chapter titles are all written in this vein. Chapter 11, for example is “Crisis in America’s Emergency Rooms: Take Two Aspirins and Call 911 in the Morning.”
He says he wanted to have a conversation with the reader, “but one where I do all the talking.” For a serious book about a complex subject, It’s Enough to Make You Sick is delightfully readable.
Anyone who wants to understand what’s wrong with the American health-care system should read it. Unfortunately, as Lobosky acknowledges, he’s not Sanjay Gupta or Dr. Oz. If either of these celebrity doctors had written the book, it would be flying off the shelves.
Still, the response to the book has been “everything I wanted it to be,” he said. Many people have told him they enjoyed reading it. As one woman put it, “You made a very difficult subject understandable to me.”