[ "And many physicians are now finding it difficult to quash the
suspicion that our institutions, and much of our work inside them,
primarily serve a moneymaking machine."]
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DOCTORS AREN’T BURNED OUT FROM OVERWORK. WE’RE DEMORALIZED BY OUR
HEALTH SYSTEM.  
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Eric Reinhart
February 5, 2023
The New York Times
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_ "And many physicians are now finding it difficult to quash the
suspicion that our institutions, and much of our work inside them,
primarily serve a moneymaking machine." _

,

 

Doctors have long diagnosed many of our sickest patients with
“demoralization syndrome
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condition commonly associated with terminal illness that’s
characterized by a sense of helplessness and loss of purpose. American
physicians are now increasingly suffering from a similar condition,
except our demoralization is not a reaction to a medical condition,
but rather to the diseased systems for which we work.

The United States is the only large high-income nation that doesn’t
provide universal health care‌ to its citizens. Instead, it
maintains a lucrative system of for-profit medicine. For decades,
‌at least tens of thousands
[[link removed](19)33019-3/fulltext] of preventable
deaths [[link removed]] have occurred
each year because health care here is so expensive.

During the Covid-19 pandemic, the consequences of this policy choice
have intensified. One study estimates at least 338,000 Covid deaths
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the United States could have been prevented by universal health care.
In the wake of this generational catastrophe, many health care workers
have been left shaken.

“For me, doctoring in a broken place required a sustaining belief
that the place would become less broken as a result of my
efforts,” wrote
[[link removed]] Dr.
Rachael Bedard about her decision to quit her job at New York City’s
Rikers Island prison complex during the pandemic. “I couldn’t
sustain that belief any longer.”‌

Thousands of U.S. doctors‌‌, not just at jails but also at wealthy
hospitals, now appear to feel similarly
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report estimated
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in 2021 alone, about 117,000 physicians left the work force,
while fewer than 40,000
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it. This has worsened a chronic physician shortage, leaving many
hospitals and clinics struggling. And the situation is set
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get worse. One in five doctors
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he or she plans to leave practice in the coming years‌.

To try to explain ‌‌this phenomenon, many people have leaned on a
term ‌‌from pop psychology
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the consequences of overwork: burnout. Nearly two-thirds of
physicians report
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are experiencing its symptoms.

But the burnout rhetoric misses the larger issue in this
case:_ _What’s burning out health care workers is less the grueling
conditions we practice under, ‌and more our dwindling faith in the
systems for which we work. What has been identified as occupational
burnout is a symptom of a deeper ‌collapse. We are witnessing the
slow death of American medical ideology.

‌It’s revealing to look at the crisis among health care workers as
at least in part a crisis of ideology‌‌ — that is, a belief
system made up of interlinking political, moral and cultural
narratives upon which we depend to make sense of our social world.
‌Faith in the traditional stories American medicine has told about
itself, stories that have long sustained what should have been an
unsustainable system, is now dissolving.

During the pandemic, physicians have witnessed our hospitals nearly
fall apart as a result of underinvestment
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health systems
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distribution of medical infrastructure
[[link removed](17)30398-7/fulltext].
Long-ignored inequalities
[[link removed](17)30398-7/fulltext] in
the standard of care available to rich and poor Americans
became front-page news
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‌bodies ‌were stacked in empty hospital rooms
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morgues
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Many health care workers have been traumatized by the futility of
their attempts to stem recurrent waves
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death, with nearly one-fifth of physicians reporting
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knew a colleague who had considered, attempted‌‌ or died by
suicide during the first year of the pandemic alone.

Although deaths from Covid have slowed, the ‌disillusionment
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health workers has ‌only increased. Recent exposés have further
laid bare the structural perversity of our institutions‌‌. For
instance, according to an investigation in The New York Times,
ostensibly nonprofit‌ charity hospitals have illegally saddl‌ed
poor patients with debt
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receiving‌‌ care to which they were entitled without cost and have
exploited tax incentives meant to promote care for poor communities to
turn ‌‌large profits
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Hospitals are deliberately understaffing
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and undercutting patient care while sitting on billions of dollars in
cash reserves. Little of this is new, but doctors’ sense of our
complicity in putting profits over people has ‌grown more difficult
to ignore.

Resistance to self-criticism has long been a hallmark of U.S. medicine
and the industry it has shaped. From at least the 1930s
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doctors have organized efforts
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ward off the specter of “socialized medicine
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We have repeatedly defended health care as a business venture against
the threat that it might become a public institution oriented
around rights rather than revenue
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This is in part because doctors were
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if health care were made a public service, we would lose our
professional autonomy and make less money. For a profession that
had fought for more than a century
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achieve elite status, this resonated.

‌And so doctors learned to rationalize a deeply unequal health care
system that emphasizes personal, rather than public,
moral responsibility for protecting health
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We sit ‌at our patients’ bed sides and counsel them on their duty
to counteract the risks of obesity, heart disease and diabetes, for
example, while largely ignoring how those diseases are tied to poor
‌access to quality food because of economic inequities. Or, more
recently, we find ourselves advising patients on how to modulate their
personal choices to reduce their Covid risk while working in jobs with
dismal safety practices and labor protections.

Part of what draws us into this norm is that doctors learn by doing
— that is, via apprenticeship — in which we repeat what’s
modeled for us. This is, to a degree, a necessary aspect of training
in an applied technical field. It is also a fundamentally conservative
model for learning that teaches us to suppress critical thinking and
trust the system, even with its perverse incentives.

It becomes difficult, then, to recognize the origins of much of what
we do and whose interests it serves‌‌. For example, a system of
billing codes
[[link removed]] invented
by the American Medical Association as part of a political
strategy to protect its vision of for-profit health care
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‌aspect of medical practice, producing not just endless
administrative work, but also subtly shaping treatment choices.

Addressing the failures of the health care system will require
uncomfortable reflection and bold action. Any illusion that medicine
and politics are, or should be, separate spheres has been crushed
under the weight of over ‌‌1.1 million Americans killed by a
pandemic that was in many ways a preventable disaster. And many
physicians are now finding it difficult to quash the suspicion that
our institutions, and much of our work inside them, primarily serve a
moneymaking machine.

Doctors can no longer be passive witnesses to these harms. We have a
responsibility to use our collective power to insist on changes:
for universal
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care and paid sick leave
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also investments in community health worker programs
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essential housing
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welfare systems
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Neither major political party ‌‌is making universal health care‌
a priority right now, but doctors nonetheless hold considerable power
to initiate reforms in health policy. We can begin to exercise it by
following the example of colleagues at Montefiore Medical Center
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the Bronx who, like thousands of doctors
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them, recently took steps‌ ‌ to unionize. If we can build an
organizing network through doctors’ unions, then proposals
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universal health care through use of collective civil disobedience
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physicians’ control over health care documentation and billing, for
example, could move from visions to genuinely actionable plans.

Regardless of whether we act through unions or other means, the fact
remains that until doctors join together
[[link removed](21)00937-5/fulltext] to
call for a fundamental reorganization of our medical system, our work
‌won’t do what ‌we were promised it would do, nor will it
prioritize the people we claim to prioritize. To be able to build the
systems we need, we must face an unpleasant truth: Our health care
institutions as they exist today are part of the problem rather than
the solution.

_Dr. Eric Reinhart is political anthropologist and physician at
Northwestern University._

* For Profit Health Care
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* doctors
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* depression
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* universal healthcare
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