[ The corporatization of health care has changed the practice of
medicine, causing many physicians to feel alienated from their work.]
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THE MORAL CRISIS OF AMERICA’S DOCTORS  
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Eyal Press
June 15, 2023
New York Times
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_ The corporatization of health care has changed the practice of
medicine, causing many physicians to feel alienated from their work. _


Keith Corl, a critical care specialist who quit a lucrative job in
finance to become a physician., Photo credit: Balazs Gardi for The New
York Times

 

Some years ago, a psychiatrist named Wendy Dean read an article about
a physician who died by suicide. Such deaths were distressingly
common, she discovered. The suicide rate among doctors appeared to be
even higher than the rate among active military members, a notion that
startled Dean, who was then working as an administrator at a U.S. Army
medical research center in Maryland. Dean started asking the
physicians she knew how they felt about their jobs, and many of them
confided that they were struggling. Some complained that they didn’t
have enough time to talk to their patients because they were too busy
filling out electronic medical records. Others bemoaned having to
fight with insurers about whether a person with a serious illness
would be preapproved for medication. The doctors Dean surveyed were
deeply committed to the medical profession. But many of them were
frustrated and unhappy, she sensed, not because they were burned out
from working too hard but because the health care system made it so
difficult to care for their patients.

In July 2018, Dean published an essay with Simon G. Talbot, a plastic
and reconstructive surgeon, that argued that many physicians were
suffering from a condition known as moral injury.
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psychiatrists use the term to describe an emotional wound sustained
when, in the course of fulfilling their duties, soldiers witnessed or
committed acts — raiding a home, killing a noncombatant — that
transgressed their core values. Doctors on the front lines of
America’s profit-driven health care system were also susceptible to
such wounds, Dean and Talbot submitted, as the demands of
administrators, hospital executives and insurers forced them to stray
from the ethical principles that were supposed to govern their
profession. The pull of these forces left many doctors anguished and
distraught, caught between the Hippocratic oath and “the realities
of making a profit from people at their sickest and most
vulnerable.”

The article was published on Stat, a medical-news website with a
modest readership. To Dean’s surprise, it quickly went viral.
Doctors and nurses started reaching out to Dean to tell her how much
the article spoke to them. “It went everywhere,” Dean told me when
I visited her last March in Carlisle, Pa., where she now lives. By the
time we met, the distress among medical professionals had reached
alarming levels: One survey found that nearly one in five health care
workers had quit their job
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the start of the pandemic and that an additional 31 percent had
considered leaving. Professional organizations like National Nurses
United, the largest group of registered nurses in the country, had
begun referring to “moral injury” and “moral distress” in
pamphlets and news releases. Mona Masood, a psychiatrist who
established a support line for doctors shortly after the pandemic
began, recalls being struck by how clinicians reacted when she
mentioned the term. “I remember all these physicians were like, Wow,
that is what I was looking for,” she says. “This is it.”

Dean’s essay caught my eye, too, because I spent much of the
previous few years reporting on moral injury,
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workers in menial occupations whose jobs were ethically compromising.
I spoke to prison guards who patrolled the wards of violent
penitentiaries, undocumented immigrants who toiled on the “kill
floors” of industrial slaughterhouses and roustabouts who worked on
offshore rigs in the fossil-fuel industry. Many of these workers were
hesitant to talk or be identified, knowing how easily they could be
replaced by someone else. Compared with them, physicians were
privileged, earning six-figure salaries and doing prestigious jobs
that spared them from the drudgery endured by so many other members of
the labor force, including nurses and custodial workers in the health
care industry. But in recent years, despite the esteem associated with
their profession, many physicians have found themselves subjected to
practices more commonly associated with manual laborers in auto plants
and Amazon warehouses, like having their productivity tracked on an
hourly basis and being pressured by management to work faster.

Because doctors are highly skilled professionals who are not so easy
to replace, I assumed that they would not be as reluctant to discuss
the distressing conditions at their jobs as the low-wage workers I’d
interviewed. But the physicians I contacted were afraid to talk
openly. “I have since reconsidered this and do not feel this is
something I can do right now,” one doctor wrote to me. Another
texted, “Will need to be anon.” Some sources I tried to reach had
signed nondisclosure agreements that prohibited them from speaking to
the media without permission. Others worried they could be disciplined
or fired if they angered their employers, a concern that seems
particularly well founded in the growing swath of the health care
system that has been taken over by private-equity firms. In March
2020, an emergency-room doctor named Ming Lin was removed from the
rotation at his hospital after airing concerns about its Covid-19
safety protocols. Lin worked at St. Joseph Medical Center, in
Bellingham, Wash. — but his actual employer was TeamHealth, a
company owned by the Blackstone Group.

E.R. doctors have found themselves at the forefront of these trends as
more and more hospitals have outsourced the staffing in emergency
departments in order to cut costs. A 2013 study by Robert McNamara,
the chairman of the emergency-medicine department at Temple University
in Philadelphia, found that 62 percent of emergency physicians in the
United States could be fired without due process.
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389 E.R. doctors surveyed said they had been threatened for raising
quality-of-care concerns, and pressured to make decisions based on
financial considerations that could be detrimental to the people in
their care, like being pushed to discharge Medicare and Medicaid
patients or being encouraged to order more testing than necessary. In
another study, more than 70 percent of emergency physicians agreed
that the corporatization of their field has had a negative or strongly
negative impact on the quality of care and on their own job
satisfaction.

There are, of course, plenty of doctors who like what they do and feel
no need to speak out. Clinicians in high-paying specialties like
orthopedics and plastic surgery “are doing just fine, thank you,”
one physician I know joked. But more and more doctors are coming to
believe that the pandemic merely worsened the strain on a health care
system that was already failing because it prioritizes profits over
patient care. They are noticing how the emphasis on the bottom line
routinely puts them in moral binds, and young doctors in particular
are contemplating how to resist. Some are mulling whether the
sacrifices — and compromises — are even worth it. “I think a lot
of doctors are feeling like something is troubling them, something
deep in their core that they committed themselves to,” Dean says.
She notes that the term moral injury was originally coined by the
psychiatrist Jonathan Shay to describe the wound that forms when a
person’s sense of what is right is betrayed by leaders in
high-stakes situations. “Not only are clinicians feeling betrayed by
their leadership,” she says, “but when they allow these barriers
to get in the way, they are part of the betrayal. They’re the
instruments of betrayal.”

NOT LONG AGO, I spoke to an emergency physician, whom I’ll call A.,
about her experience. (She did not want her name used, explaining that
she knew several doctors who had been fired for voicing concerns about
unsatisfactory working conditions or patient-safety issues.) A
soft-spoken woman with a gentle manner, A. referred to the emergency
room as a “sacred space,” a place she loved working because of the
profound impact she could have on patients’ lives, even those who
weren’t going to pull through. During her training, a patient with a
terminal condition somberly informed her that his daughter couldn’t
make it to the hospital to be with him in his final hours. A. promised
the patient that he wouldn’t die alone and then held his hand until
he passed away. Interactions like that one would not be possible
today, she told me, because of the new emphasis on speed, efficiency
and relative value units (R.V.U.), a metric used to measure physician
reimbursement that some feel rewards doctors for doing tests and
procedures and discourages them from spending too much time on less
remunerative functions, like listening and talking to patients.
“It’s all about R.V.U.s and going faster,” she said of the ethos
that permeated the practice where she’d been working. “Your
door-to-doctor time, your room-to-doctor time, your time from initial
evaluation to discharge.”

Appeasing her peers and superiors without breaching her values became
increasingly difficult for A. On one occasion, a frail, elderly woman
came into the E.R. because she was unable to walk on her own. A nurse
case manager determined that the woman should be discharged because
she didn’t have a specific diagnosis to explain her condition and
Medicare wouldn’t cover her stay, even though she lived alone and
couldn’t get out of a chair to eat or go to the bathroom. A. cried
with the woman and tried to comfort her. Then she pleaded with the
hospitalist on duty to admit her. A.’s appeal was successful, but
afterward, she wondered, What are we being asked to do? When we spoke,
A. had taken a leave from work and was unsure if she would ever go
back, because of how depleted she felt. “It’s all about the
almighty dollar and all about productivity,” she said, “which is
obviously not why most of us sign up to do the job.”

That’s not always clear to patients, many of whom naturally assume
that their doctors are the ones who decide how much time to spend with
them and what to charge them for care. “Doctors are increasingly the
scapegoats of systemic problems within the health care system,”
Masood says, “because the patient is not seeing the insurance
company that denied them the procedure, they’re not seeing the
electronic medical records that are taking up all of our time.
They’re just seeing the doctor who can only spend 10 minutes with
them in the room, or the doctor who says, ‘I can’t get you this
medication, because it costs $500 a month.’ And what ends up
happening is we internalize that feeling.”

I spoke to a rheumatologist named Diana Girnita, who found this cycle
deeply distressing. Originally from Romania, Girnita came to the
United States to do a postdoc at Harvard and was dazzled by the
quality of the training she received. Then she began practicing and
hearing patients complain about the exorbitant bills they were sent
for routine labs and medications. One patient came to her in tears
after being billed $7,000 for an IV infusion, for which the patient
held her responsible. “They have to blame someone, and we are the
interface of the system,” she said. “They think we are the greedy
ones.” Fed up, Girnita eventually left the practice.

Some doctors acknowledged that the pressures of the system had
occasionally led them to betray the oaths they took to their patients.
Among the physicians I spoke to about this, a 45-year-old
critical-care specialist named Keith Corl stood out. Raised in a
working-class town in upstate New York, Corl was an idealist who quit
a lucrative job in finance in his early 20s because he wanted to do
something that would benefit people. During medical school, he felt
inspired watching doctors in the E.R. and I.C.U. stretch themselves to
the breaking point to treat whoever happened to pass through the doors
on a given night. “I want to do that,” he decided instantly. And
he did, spending nearly two decades working long shifts as an
emergency physician in an array of hospitals, in cities from
Providence to Las Vegas to Sacramento, where he now lives. Like many
E.R. physicians, Corl viewed his job as a calling. But over time, his
idealism gave way to disillusionment, as he struggled to provide
patients with the type of care he’d been trained to deliver.
“Every day, you deal with somebody who couldn’t get some test or
some treatment they needed because they didn’t have insurance,” he
said. “Every day, you’re reminded how savage the system is.”

 

After nearly two decades working in emergency rooms around the
country, Corl’s idealism gave way to disillusionment as he struggled
to provide patients with the type of care he’d been trained to
deliver.  (Credit:  Balazs Gardi for The New York Times)
Corl was particularly haunted by something that happened in his late
30s, when he was working in the emergency room of a hospital in
Pawtucket, R.I. It was a frigid winter night, so cold you could see
your breath. The hospital was busy. When Corl arrived for his shift,
all of the facility’s E.R. beds were filled. Corl was especially
concerned about an elderly woman with pneumonia who he feared might be
slipping into sepsis, an extreme, potentially fatal immune response to
infection. As Corl was monitoring her, a call came in from an
ambulance, informing the E.R. staff that another patient would soon be
arriving, a woman with severe mental health problems. The patient was
familiar to Corl — she was a frequent presence in the emergency
room. He knew that she had bipolar disorder. He also knew that she
could be a handful. On a previous visit to the hospital, she detached
the bed rails on her stretcher and fell to the floor, injuring a
nurse.

In a hospital that was adequately staffed, managing such a situation
while keeping tabs on all the other patients might not have been a
problem. But Corl was the sole doctor in the emergency room that
night; he understood this to be in part a result of cost-cutting
measures (the hospital has since closed). After the ambulance arrived,
he and a nurse began talking with the incoming patient to gauge
whether she was suicidal. They determined she was not. But she was
combative, arguing with the nurse in an increasingly aggressive tone.
As the argument grew more heated, Corl began to fear that if he and
the nurse focused too much of their attention on her, other patients
would suffer needlessly and that the woman at risk of septic shock
might die.

Corl decided he could not let that happen. Exchanging glances, he and
the nurse unplugged the patient from the monitor, wheeled her
stretcher down the hall, and pushed it out of the hospital. The blast
of cold air when the door swung open caused Corl to shudder. A nurse
called the police to come pick the patient up. (It turned out that she
had an outstanding warrant and was arrested.) Later, after he returned
to the E.R., Corl could not stop thinking about what he’d done,
imagining how the medical-school version of himself would have judged
his conduct. “He would have been horrified.”

CONCERNS ABOUT THE corporate takeover of America’s medical system
are hardly new. More than half a century ago, the writers Barbara and
John Ehrenreich assailed the power of pharmaceutical companies and
other large corporations in what they termed
the “medical-industrial complex,”
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as the phrase suggests, was anything but a charitable enterprise. In
the decades that followed, the official bodies of the medical
profession seemed untroubled by this. To the contrary, the American
Medical Association consistently opposed efforts to broaden access to
health care after World War II, undertaking aggressive lobbying
campaigns against proposals for a single-payer public system, which it
saw as a threat to physicians’ autonomy.

But as the sociologist Paul Starr noted in “The Social
Transformation of American Medicine,” physicians earned the
public’s trust and derived much of their authority because they were
perceived to be “above the market and pure commercialism.” And in
fields like emergency medicine, an ethos of service and self-sacrifice
prevailed. At academic training programs, Robert McNamara told me,
students were taught that the needs of patients should always come
first, and that doctors should never allow financial interests to
interfere with how they did their jobs. Many of these programs were
based in inner-city hospitals whose emergency rooms were often filled
with indigent patients. Caring for people regardless of their
financial means was both a legal obligation — codified in the
Emergency Medical Treatment and Labor Act, a federal law passed in
1986 — and, in programs like the one McNamara ran at Temple, a point
of pride. But he acknowledged that over time, these values
increasingly clashed with the reality that residents encountered once
they entered the work force. “We’re training people to put the
patient first,” he says, “and they’re running into a buzz
saw.”

 

Throughout the medical system, the insistence on revenue and profits
has accelerated. This can be seen in the shuttering of pediatric
units
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many hospitals and regional medical centers, in part because treating
children is less lucrative than treating adults, who order more
elective surgeries and are less likely to be on Medicaid. It can be
seen in emergency rooms that were understaffed because of budgetary
constraints long before the pandemic began. And it can be seen in the
push by multibillion-dollar companies like CVS and Walmart to buy or
invest in primary-care practices,
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rapidly consolidating field attractive to investors because many of
the patients who seek such care are enrolled in the Medicare Advantage
program, which pays out $400 billion to insurers annually. Over the
past decade, meanwhile, private-equity investment in the health care
industry has surged,
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wave of acquisitions that has swept up physician practices, hospitals,
outpatient clinics, home health agencies. McNamara estimates that the
staffing in 30 percent of all emergency rooms is now overseen by
private-equity-owned firms. Once in charge, these companies “start
squeezing the doctors to see more patients per hour, cutting staff,”
he says.

As the focus on revenue and the adoption of business metrics has grown
more pervasive, young people embarking on careers in medicine are
beginning to wonder if they are the beneficiaries of capitalism or
just another exploited class. In 2021, the average medical student
graduated with more than $200,000 in debt. In the past, one privilege
conferred on physicians who made these sacrifices was the freedom to
control their working conditions in independent practices. But today,
70 percent of doctors work as salaried employees of large hospital
systems or corporate entities, taking orders from administrators and
executives who do not always share their values or priorities.

Philip Sossenheimer, a 30-year-old medical resident at Stanford, told
me that these changes had begun to precipitate a shift in
self-perception among doctors. In the past, physicians “didn’t
really see themselves as laborers,” he notes. “They viewed
themselves as business owners or scientists, as a class above working
people.” Sossenheimer feels that it is different for his generation,
because younger doctors realize that they will have far less control
over their working conditions than their elders did — that the
prestige of their profession won’t spare them from the degradation
experienced by workers in other sectors of the economy. “For our
generation, millennials and below, our feeling is that there is a big
power imbalance between employers and workers,” he says.

Last May, the medical residents at Stanford voted to form a union by a
tally of 835 to 214, a campaign Sossenheimer enthusiastically
supported. “We’ve seen a boom in unionization in many other
industries,” he told me, “and we realize it can level the power
dynamics, not just for other workers but within medicine.” One thing
that drove this home to him was seeing the nurses at Stanford, who
belong to a union, go on strike to advocate for safer staffing and
better working conditions. Their outspokenness stood in striking
contrast to the silence of residents, who risked being singled out and
disciplined if they dared to say anything that might attract the
notice of the administration or their superiors. “That’s a big
reason that unionization is so important,” he says.

The Stanford example has inspired medical residents elsewhere. Not
long ago, I spoke with a group of residents in New York City who were
thinking about unionizing, on the condition that I not disclose their
identities or institutional affiliations. Although the medical
profession has been slow to diversify, the residents came from
strikingly varied backgrounds. Few grew up in wealthy families,
judging by the number of hands that went up when I asked if they’d
taken on debt to finish medical school. “Anyone here _not _take on
debt?” said a woman sitting on the carpet in the living room where
we gathered, prompting several people to laugh.

Having a union, one resident explained, would enable the group to
demand better working conditions without having to worry about getting
in trouble with their superiors or losing fellowship opportunities.
They would be able to advocate for patients rather than apologizing to
them for practices they considered shameful, another added. When I
asked what they meant by shameful, I learned that a number of the
residents had trained at a hospital that served an extremely poor
community with a limited number of I.C.U. beds — beds that during
the pandemic were sometimes given to wealthy “V.I.P.” patients
from other states while sicker patients from the surrounding
neighborhood languished on the general floor.

Forming unions is just one way that patient advocates are finding to
push back against such inequities. Critics of private equity’s
growing role in the health care system are also closely watching a
California lawsuit that could have a major impact. In December 2021,
the American Academy of Emergency Medicine Physician Group
(A.A.E.M.P.G.), part of an association of doctors, residents and
medical students, filed a lawsuit accusing Envision Healthcare, a
private-equity-backed provider, of violating a California statute that
prohibits nonmedical corporations from controlling the delivery of
health services. Private-equity firms often circumvent these
restrictions by transferring ownership, on paper, to doctors, even as
the companies retain control over everything, including the terms of
the physicians’ employment and the rates that patients are charged
for care, according to the lawsuit. A.A.E.M.P.G.’s aim in bringing
the suit is not to punish one company but rather to prohibit such
arrangements altogether. “We’re not asking them to pay money, and
we will not accept being paid to drop the case,” David Millstein, a
lawyer for the A.A.E.M.P.G. has said of the suit. “We are simply
asking the court to ban this practice model.” In May 2022, a judge
rejected Envision’s motion to dismiss the case, raising hopes that
such a ban may take effect.

UNTIL THE SYSTEM changes, some doctors are finding ways to opt out. I
spoke to several physicians who have started direct-care practices, in
which patients pay a modest monthly fee to see doctors who can offer
them more personalized out-of-network care, without having to answer
to administrators or insurers. Diana Girnita, the rheumatologist who
became disillusioned by the astronomical bills her patients kept
receiving, started a direct-care practice in her specialty in 2020.
One afternoon not long ago, I sat in on a virtual appointment she had
with a patient who wished to remain anonymous, a 32-year-old veteran
with an athletic build who began to experience severe joint pain
several months earlier. He asked his primary-care physician for a
referral to see a rheumatologist after a blood test showed a high
level of antinuclear antibodies (ANAs), which can be a sign of an
autoimmune disorder. He called every doctor’s office he could find
within a 100-mile radius of his house, but none could schedule him for
months. His wife then stumbled upon Girnita’s name online and called
her office, and he got a virtual appointment the next day.

 

Diana Girnita, a rheumatologist who was distressed by the astronomical
bills her patients kept receiving and started a direct-care practice.
 (Credit:  Emily Monforte for The New York Times)
The meeting I sat in on was a follow-up appointment. When it began,
Girnita relayed some good news, telling him that his ANA level had
fallen and that his lab results indicated he did not have an
autoimmune disease. The patient was visibly relieved, though he was
still experiencing persistent pain in his wrist. Girnita advised him
to get an MRI, which she said she could order for $800 — a fraction
of the amount that hospitals typically charged. One advantage of the
direct-care model was that physicians negotiated with labs and imaging
centers for tests and services, Girnita told me, bypassing the
corporate middlemen (insurers, pharmacy-benefit managers) that drove
up health care costs.

When he went to medical appointments in the past, Girnita’s patient
told me later, the doctors he saw were often brusque. “They come in,
tell you the medicine you’re going to take and that’s it,” he
said. His first appointment with Girnita lasted an hour, the minimum
amount of time she allotted to all patients in their initial
consultations. During the follow-up appointment I observed, Girnita
spent half an hour answering his questions; she never cut him off and
did not seem rushed or harried. At the end of the appointment, he
thanked her profusely, in a way that made it clear he was not
accustomed to such treatment. It was a novel experience not only for
the patient but also for Girnita, who told me that, in the past, she
often had to squeeze appointments into seven-minute time slots. Before
starting her direct specialty-care practice, she added, she spent so
many hours doing bureaucratic work that she barely had time to see her
family, much less her patients. “The direct-care model is designed
to rebuild trust,” she said, “and to re-establish a normal
relationship between physicians and patients.”

Of course, the model is far from a panacea: Many doctors struggle to
attract enough patients to make a living, which is a problem for
specialists like Girnita, who rely on referrals from primary-care
doctors. Girnita told me she understood why some doctors were choosing
to leave the profession altogether. Two physicians she knew had
switched careers recently, an impulse she fears will overcome more and
more of her peers in the years to come, especially those who chose to
become doctors for altruistic reasons. “They didn’t quit because
they don’t like medicine,” she said. “They were both wonderful
physicians.”

And even running direct-care practices, doctors cannot fully escape
the frustrations and injustices of the health care system. A few
months earlier, Girnita told me, a patient came to her after having a
severe allergic reaction to an ulcer medication that his insurer had
switched him onto because it no longer covered the drug he’d been
taking. Girnita told me she had called her patient’s insurer every
week as his condition deteriorated. When she finally got through, she
was told they needed 30 days to process the appeal. Girnita was livid.
“They are literally putting this patient in danger — it is
sick,” she said. “This is sick medical care.”

_[EYAL PRESS is a journalist and sociologist in New York. He is the
author of, most recently, “Dirty Work
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morally troubling jobs that society tacitly condones.]_

* Healthcare
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* doctors
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* Medicine
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* private insurance
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* privatization
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* Medicare
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* For Profit Health Care
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* Medicare for All
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* direct care medicine
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* physicians
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