[Meeting the challenges of modern medicine will require more than
seeing patients.] [[link removed]]

WHY DOCTORS SHOULD ORGANIZE  
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Eric Topol
August 5, 2019
The New Yorker
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_ Meeting the challenges of modern medicine will require more than
seeing patients. _

Many doctors feel despair about their appalling working conditions
and the deteriorating doctor-patient relationship.But there have been
no protest marches or social-media campaigns. Why not?, Illustration
by Nicole Xu

 

In the fall of 2018, the American College of Physicians published a
position paper
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on gun violence. “Firearm violence continues to be a public health
crisis in the United States,” its authors wrote, in the journal
_Annals of Internal Medicine_. The report argued that assault weapons
should be banned and that “physicians should counsel patients on the
risk of having firearms in the home.” When it was published, the
National Rifle Association
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with a tweet [[link removed]]:
“Someone should tell self-important anti-gun doctors to stay in
their lane.”

The N.R.A.’s tweet provoked an unprecedented response from the
medical profession. Using the hashtag #ThisIsMyLane, emergency-room
physicians, trauma surgeons, pediatricians, and pathologists, all of
whom are involved in the care of patients with gunshot wounds, posted
images of shooting victims and bloodstained hospital floors. Some
shared selfies in which they were splattered with blood. “Do you
have any idea how many bullets I pull out of corpses weekly? This
isn’t just my lane. It’s my fucking highway,” Judy Melinek, a
forensic pathologist, tweeted
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Melinek’s tweet went viral. Doctors appeared on television and wrote
op-eds expressing their disgust with the N.R.A.

As a physician, I was thrilled by this display of solidarity and
political engagement. But I also wondered why such mobilizations
aren’t more common. In October, 1980, when I was a medical resident
at San Francisco General Hospital, a group of interns and residents
went on strike
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protesting a disastrous shortage of nurses. (We also asked for on-site
childcare, and, less crucially, a lounge with a Ping-Pong table and
better food.) At the time, I was a resident in the Coronary Care Unit,
and so was involved in the care of critically ill patients; as a
result, I was allowed to cross the picket line. Still, my peers booed
me. I remember that the chief of the medical service stood at the
hospital entrance, demanding, through a bullhorn, that the doctors get
back to work. My colleagues were defiant, and the strike continued for
a few days, stopping only when the hospital agreed to alleviate the
nursing shortage.

The strike was organized by the San Francisco Interns and Residents
Association—a union whose current iteration, this past March,
protested low pay and poor working conditions with a fifteen-minute
walkoff
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at the University of California, San Francisco’s Medical Center.
There have been some other efforts to form unions of doctors, such as
the California-based Union of American Physicians and Dentists. But
they haven’t caught on industry-wide—the U.A.P.D. has only four
thousand members—and, in my long career, the 1981 strike remains one
of the few times I’ve seen doctors come together around a common
cause.

In truth, its stakes were small compared to the problems physicians
must confront today. Doctors now face a burnout epidemic: thirty-five
per cent of them show signs of high depersonalization, a type of
emotional withdrawal that makes personal connections with their
patients difficult. Administrative tasks have become so burdensome
that, according to one recent report
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only thirteen per cent of a physician’s day, on average, is spent on
doctor-patient interaction. Another careful study
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of doctors’ time has shown that, during an average eleven-hour
workday, six hours are spent at the keyboard, maintaining electronic
health records.

The widespread usage of electronic medical records began in the
nineteen-nineties—it’s taken decades to transform doctors into
data-entry clerks, a process Atul Gawande described
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in this magazine, last year—and yet, in all that time, the adoption
of such systems never met with aggressive pushback. Similarly, doctors
were unsuccessful in resisting the rise of health-management
organizations, which represented only three million patients in 1970
but, by 1999, had enrolled eighty million. Intended to reduce
health-care costs, H.M.O.s have mainly succeeded in shifting control
from doctors to health-care-system managers. In 1992, Medicare adopted
the “relative value unit,” or R.V.U., a compensation metric that
takes into account the medical service provided and the expense
embedded in that service. The formula’s output—currently $36.04
per R.V.U.—structurally overhauled physician reimbursement,
diminishing the value of non-procedural or cognitive doctor activity.
And yet the major medical professional organizations went along with
the practice, helping to negotiate the rate, instead of more seriously
challenging it.

Privately, doctors feel despair about their appalling working
conditions and the deteriorating doctor-patient relationship. But
there have been no marches on Washington, no picket lines, no
social-media campaigns. Why not? Why aren’t doctors standing up for
themselves and their patients?

In theory, doctors could be a powerful force. There are more than a
million physicians in the United States, and around nine hundred
thousand are actively practicing
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largest medical organization, the American Medical Association, has
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only around two hundred and fifty thousand members. (The
next-largest—the American College of Physicians, which represents
internal-medicine specialists—has about a hundred and sixty
thousand.) Most of the smaller societies represent a subspecialty and
have correspondingly fewer members each. The A.M.A. once represented
three-fourths of all American doctors; the growth of subspecialty
societies may have contributed to its diminishment. In any case, there
is no single organization that unifies all doctors. The profession is
balkanized.

The power and impact of medical organizations is further diminished
because their priority—supporting their constituents—is often at
odds with the needs of the public. As a long-term member of the
American College of Cardiology, I was impressed with how effectively
the organization lobbied for preserving the reimbursement rates of
cardiologists. (Since cardiology is a procedure-rich specialty, the
introduction of R.V.U.s has been better for us than for, say,
primary-care physicians.) The college also provides educational
programs for its members and puts on annual national meetings. But the
A.C.C. does very little to promote the interests of patients, which is
why I have recently withheld my dues. Like many medical societies, it
is primarily a trade guild centered on the finances of doctors.

On many occasions, medical societies have turned entirely inward,
pursuing business as an end in itself. In the nineteen-nineties, the
American Medical Association announced a product-endorsement agreement
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with the Sunbeam Corporation, a manufacturer of humidifiers, ice
packs, heating pads, and the like. Amid an uproar, the A.M.A. backed
out of the deal; Sunbeam sued for breach of contract and won a
ten-million-dollar settlement. The American Heart Association,
meanwhile, continues to rent out its name: a qualifying food
manufacturer can get a heart-check-mark logo, signifying “criteria
for heart-healthy meal” status, on its product’s package for an
“administrative fee
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of as much as six thousand dollars. The logo adorns thousands of
low-fat items, such as Cheerios and various breads, which are not in
any meaningful sense heart-healthy. For decades, as part of this
program, the A.H.A. strongly promoted a low-fat diet, advocating the
use of margarine instead of butter, the avoidance of eggs, and the
limiting of saturated fats. As Nina Teicholz and Gary Taubes have
shown, in their respective books “Big Fat Surprise
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We Get Fat [[link removed]],”
this endorsement, which was largely unsupported by data, helped fuel
the obesity epidemic. (The A.H.A. has stood by its recommendations.)

Recently, Ivor Benjamin, the president of the A.H.A., appeared onstage
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Apple special event, where he participated in the announcement of the
newest Apple Watch, which features the ability to detect atrial
fibrillation. Some cardiologists have raised concerns that this
technology will create a wave of false alarms and unnecessary testing
among people who are at low risk for heart-rhythm abnormalities.
(Apple clarified to the Verge that the device is not meant to be a
substitute for a proper EKG.) The American Academy of Family
Physicians, similarly, has accepted a large donation
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to fund “consumer education content on beverages and sweeteners,”
though the partnership ended in 2015. Sunscreen manufacturers once
paid
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the American Academy of Dermatology for its endorsement, too, though
that program is also defunct.

Not all professional medical organizations are so self-interested.
Recently, the Endocrine Society railed
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against the prices of insulin, which have been raised in lockstep by
an oligopoly of three pharmaceutical manufacturers. (Between 2007 and
2017, the wholesale price of insulin tripled, a spike that has led a
significant proportion of patients to ration their dosing
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many have died.) The American Academy of Pediatrics has protested
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immigration policies that separate children from their parents. But
such instances are unusual. And they are, on the whole,
muted—confined to written communications in medical journals or
position statements that are only sometimes announced at press
conferences. Such organizations are ill-equipped to advocate for the
larger interests of doctors or patients.

It’s possible to imagine a new organization of doctors that has
nothing to do with the business of medicine and everything to do with
promoting the health of patients and adroitly confronting the
transformational challenges that lie ahead for the medical profession.
Such an organization wouldn’t be a trade guild protecting the
interests of doctors. It would be a doctors’ organization devoted to
patients. Its top priority might be restoring the human factor—the
essence of medicine—which has slipped away, taking with it the
patient-doctor relationship. It might oppose anti-vaxxers; challenge
drug pricing and direct-to-consumer advertisements; denounce
predatory, unregulated stem-cell clinics; promote awareness of the
health hazards of climate change; and call out the false health claims
for products advocated by celebrities such as Gwyneth Paltrow and
Mehmet Oz. This partial list provides a sense of how many momentous
matters have been left unaddressed by the medical profession as a
whole. Tackling any one of them would be hard; perhaps
patient-advocacy groups could join in common cause.

Such an organization could also address the profound changes that are
on the horizon for the medical profession. In 2018, I had the
privilege of leading a review of England’s National Health Service,
focussing on the digital future of medicine. We investigated, among
other things, the role that artificial intelligence could play in that
future. Our economists projected [[link removed]] that, for
each minute of keyboard work that could be avoided by doctors, four
hundred thousand hours would be freed up for patient interaction—the
equivalent of hiring two hundred and thirty full-time physicians.
Keyboard liberation is just one of the gifts of time that machine
learning might provide: by synthesizing patient data, artificial
intelligence could speed chart review; it could allow for automated
diagnoses of common conditions such as urinary-tract infections, ear
infections in children, or skin rashes; it could help patients
self-manage high blood pressure or diabetes. All this outsourcing and
off-loading could alleviate the burden on doctors and pave the way for
a revitalized connection with patients.

And yet it could also make medicine worse. Unfortunately, unlike
teachers, lawyers, and other professionals, doctors are predominantly
managed by businesspeople. Most medical administrators know very
little about the time it takes to listen; to do a careful physical
examination; to engender trust; to cultivate a deep relationship with
a patient, each of whom has his or her own life story, pain, anxiety,
and anguish. Over the last four decades, the number of health-care
administrators in the United States has grown by thirty-two hundred
per cent
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while the number of doctors only increased by a hundred and fifty per
cent. Several [[link removed]]
studies have found that outcomes
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for patients are better when health-care organizations are run by
doctors instead of non-physician executives
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though, increases in productivity in health care have been used by
managers and administrators to squeeze doctors, who are made to see
more patients, read more scans, interpret more slides, and so on.
Already, the emergence of machine learning has led some observers to
proclaim that, in the future, hospitals will be able to do without
radiologists, pathologists, and other medical specialists. That
isn’t true—deep-learning algorithms have, at best, narrow
capabilities—and yet it seems inevitable that managers will ignore
medical realities in favor of the bottom line.

Who will be in charge of our health as we move forward—doctors or
their managers? The potential of A.I. to restore the human dimension
in health care will depend on doctors stepping up to make their voices
heard.

Many would say that such an event is highly unlikely. Doctors
organizing—it’s a crazy idea. The image of residents picketing in
front of a hospital seems to hail from another world. Many people
suspect that doctors suffer from a congenital inability to control
their own destinies. Medical culture seems data-centric, conservative,
heads-down, apolitical. And—surely—doctors are too busy.

In fact, there is plenty of evidence that doctors can organize for the
common good. There are numerous examples of medical activists who work
in underserved communities, fighting against addiction, smoking,
e-cigarettes, and guns. The challenge that lies ahead is building on
these disconnected efforts. Fortunately, there’s a new generation of
young doctors who are digital natives; they’re savvy with social
media and recognize the power of such platforms to affect change. The
increasing diversity of the medical profession is a hopeful sign. Many
of the physician leaders who took on the N.R.A. are women: Esther
Choo, an emergency-room doctor; Judy Melinek, a forensic pathologist;
Stephanie Bonne, a trauma surgeon; Jeannie Moorjani, a pediatrician.
When the water in Flint, Michigan, was revealed to be saturated with
toxic levels of lead, the leader of that exposé was Mona
Hanna-Attisha, another pediatrician. Perhaps dealing with
long-standing gender inequities in medicine has helped these doctors
cultivate a willingness to stand up. We’ve all seen how the student
survivors of Marjory Stoneman Douglas High School, in Parkland,
Florida, have organized a national initiative
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with marches, demonstrations, and active nationwide participation. If
these resourceful, energized, impassioned teen-agers can organize a
movement, shouldn’t doctors be capable of organizing, too?

Because of the unique technological moment at which we live, we may
not see an opportunity like this one for generations to come. We have
a chance to affect the future of medicine; to advocate for patient
interests; to restore the time doctors need to think, to listen, to
establish trust, and build bonds, one encounter at a time. For these
purposes, and in these times, an organization of all doctors is
necessary. Rebuilding our relationships with our patients: _that_ is
our lane.

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Eric Topol, a physician, is the founder and director of the Scripps
Research Translational Institute. His most recent book is “Deep
Medicine: How Artificial Intelligence Can Make Healthcare Human Again
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