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Meeting the challenges of modern medicine will require more than seeing patients.
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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
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In the fall of 2018, the American College of Physicians published a position paper 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 responded with a tweet: “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. 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, 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 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, only thirteen per cent of a physician’s day, on average, is spent on doctor-patient interaction. Another careful study 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, 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. But the country’s largest medical organization, the American Medical Association, has 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 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” 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” and “Why We Get Fat,” 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 at an 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 from Coca-Cola to fund “consumer education content on beverages and sweeteners,” though the partnership ended in 2015. Sunscreen manufacturers once paid 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 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; many have died.) The American Academy of Pediatrics has protested 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 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, while the number of doctors only increased by a hundred and fifty per cent. Several studies have found that outcomes for patients are better when health-care organizations are run by doctors instead of non-physician executives. Often, 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, 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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