Doctors, patients, corporatization, and moral crisis

In the last few years a fair amount has been published, especially in the medical media, about physician burnout. This term includes everything from frustration, to saying they would not encourage their children to become doctors, to leaving the profession or retiring early, to, in extreme but sadly not rare cases, suicide. The emphasis has usually been on the amount of work that the doctors have to do, the stress of new technologies such as the “electronic medical record” that, rather than simplifying things or making them more efficient, mainly create much more time-consuming work, and the ever-present threat of malpractice suits and other litigation against them. Recently, the NY Times Magazine, in “The Moral Crisis of American Doctors” by Eyal Press (June 15, 2023), presents more balanced and accurate coverage.

The article discusses the work of Wendy Dean, a psychiatrist and administrator at the US Army research center. Dr. Dean was shocked to learn that the rate of suicide in physicians was higher than that of the active-duty military.

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.

Dr. Dean thought about this issue in terms of “moral injury”, generally thought to affect those who participated in or observed horrible violations of their moral compass in war, such as the murder of civilians.

Doctors on the front lines of America’s profit-driven health care system were also susceptible to such wounds, Dean and [her co-worker] 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 goes on at length, comparing the doctors to assembly-line workers who fear for their jobs if they speak out, to non-compete and non-disclosure agreements they are forced to sign, to the way that this manifests in particular specialties, such as Emergency Medicine.

This piece gets to the heart of the matter more than almost anything that has been published in the mainstream media. I would summarize the lesson as: The pursuit of profit is dangerous to your health. The transformation of medical care from control by doctors to control by accountants and venture capitalists means that something other than what is best for the health of people, as individuals and as a population, is the primary consideration driving the structure and implementation of health care. It is not a pretty picture. Yes, doctors make and have always made mistakes. Yes, doctor have often been avaricious themselves. Yes, sometimes people have been hurt or died from unnecessary procedures. But at least in theory most doctors believed that what they were doing was for the best interests of their patients.

We have moved beyond (or backward from) that. We have entered an era in which an assembly-line mentality has been implemented in American healthcare, when doctors and other healthcare workers are seen as replaceable cogs, when the provision of healthcare is, like selling cars or liquor or financial instruments, not mainly about the “product” but is just a vehicle for generating money for its owners and managers. Tough luck, all you “burned out” doctors, probably suffering from moral injury. Tough luck, sick people.

This has been a long time coming. The deprofessionalization of medicine should have been predictable decades ago, and it was. In a recent blog post (Private equity, private profit, Medicare and your health: They are incompatible, May 11, 2023) I cite two books. “American Health Empire” (1971) by Barbara and John Ehrenreich and other members of the HealthPAC collective, showed how even then hospitals and health systems were being corporatized. Paul Starr’s 1982 book “The Social Transformation of American Medicine” focused on the impact of this on the professional role of physicians.

Another huge warning signal was, or should have been, the explosion of the space shuttle Challenger on January 28, 1986. As reported at the time and in multiple more recent articles (e.g., Engineer Who Opposed Challenger Launch Offers Personal Look at Tragedy, and Remembering Roger Boisjoly: He Tried To Stop Shuttle Challenger Launch, both from 2012), engineers for the Morton Thiokol corporation knew that there was a problem with key pieces of the shuttle (the infamous “O-rings”), and had been ignored by their bosses when they called attention to it. And never went public with it for fear of losing their livelihoods. Until after the disaster. At the time, it was noted often how this conflicted with the codes of ethics of the engineering profession. But engineers were no longer self-employed independent professionals; they were employees of huge profit-seeking corporations. Many of us who were doctors pointed to this, saying this trend was not limited to engineering, but was happening to other professions, including medicine. It had not yet progressed that far, but was fast moving down that track.

Independent physician practice, solo or group, single or multi-specialty, had begun to disappear, as practices were acquired by larger companies. Sometimes these were physician-owned, and seemed to continue to carry the same “old” values. But then they were bought out by hospitals, health systems and private investors. So were the hospitals. We got a lot of glitz -- fountains and art work in our entry halls and fancy new machines, and investment in our practices, particularly those “product lines” that had the greatest “return on investment” measured, of course, in dollars and not human health. How could we, as ethical medical professionals, buy into the casual use of such terms as “product lines” and “return on investment” when talking about the health of our patients?

Some of the explanation is greed, and some of it is psychological, as doctor began to think that using corporate-speak meant that they were cool, and allowed them to hobnob with the real power players in control of the industry. Many doctors obtained MBAs.  And now some of them are very rich. Some are even CEOs. It’s not surprising that doctors can be smart enough to achieve this, or that they can be as susceptible to the lure of power and money as anyone else. It also does not mean that all doctors who get MBAs use it to limit care in order for their company to make more money. But that does not make it good for the people of the nation. And it can, and often does, create another moral conflict, perhaps even moral crisis.

Another recent piece, by the Reverend William Barber and Gregg Gonsalves in The Guardian, “The fourth leading cause of death in the US? Cumulative poverty”, is scarcely unrelated, although rather than focusing on physicians it focuses on patients (the medical term for “people”). It clearly and thoroughly documents the impact that poverty has upon health. And while the poor are the tip of the iceberg, the most vulnerable, the cutbacks on care that come from megalomaniacal pursuit of money affects much larger parts of the population.

Because we have a healthcare system that is designed to make money for the corporate entities that control it, that system does not deliver quality care to many (or most) people. As a result it creates unfulfilling, stressful, and sometimes intolerable working conditions for its employees, including physicians. Moreover, in the classic “divide and conquer” technique long used by those in control, it leads to people being angry at their doctors for the frustrations and denials that they experience, which they mistakenly believe the doctors control. The denials of care are made by the insurance companies that they have (and often choose, such as Medicare Advantage). The long delays for getting appointments and the inadequate time physicians spend listening is the result of the management of the health systems that employ them, not only treating doctors as assembly-line workers but patients as widgets to be produced. If it seems impersonal and uncaring, it is.

So what is to be done? Doctors can start by demanding that their professional organizations, beginning with the AMA, condemn and resist this corporate transformation. They also must recognize that they are no longer independent practitioners, but employees, just as the Morton Thiokol engineers were, and that the greatest protection that they – and their patients – have is unionization. You, doctors, may be well-paid workers, but you are workers! Unions can educate people, their members and the public, about how the power is actually distributed and who is calling the shots. Other people can respond by contacting their political representatives and demanding that the power and authority of private corporations over their health care be drastically curbed; this includes insurance companies and health-care companies. A great first step would be to repeatedly demand that every representative and senator, every state legislator, sign on to support a universal health insurance system, such as Medicare for All.

There will still be plenty to do after that, but it would provide a structure for making things better.

Flint, lead, medical heroes, O-rings and guns

In January, 1986, 73 seconds after lift-off, the space shuttle Challenger exploded, killing all 7 astronauts on board, including one of the first civilians to go up, New Hampshire teacher Christa McAuliffe. It was a disaster; indeed the words are now paired so that we always say “Challenger disaster”. The cause was a flaw in the design of the solid rocket boosters (“SRB”s) and in the now famous “O-rings”, flexible rubber seals, like max versions of the ones we see on a lot of home tools. It was perhaps the worst domestic disaster of its time, nine years before the 1995 domestic-terrorist white-power bombing in Oklahoma City, almost 16 years before the attack on 9/11. It was a disaster in two ways; the obvious one, the explosion, and in that it could have been prevented; NASA and the company that produced the SRBs, Morton Thiokol, knew about the problem.

Morton Thiokol engineers, and particularly one named Roger Boisjoly, had been worried about the problem for years; Boisjoly had expressed his particular concerns in 1985. Morton Thiokol managers considered telling NASA to scrap the launch, and then decided not to. After the disaster, Boisjoly testified before a commission about the problem, and about the warnings that he had sent to his bosses. In 1988 he was awarded the Award for Scientific Freedom and Responsibility by the American Association for the Advancement of Science. He was shunned and at Morton Thiokol, and resigned. He was right; Morton Thiokol and NASA were wrong, and it led to a disaster. And he was out of a job.

In 2014, Michigan Governor Rick Snyder appointed an emergency manager named Darnell Earley, for the bankrupt city of Flint. One of his cost-cutting measures was to stop buying treated Lake Huron water from the Detroit system and instead supply water from the Flint River. The river was full of corrosives, from decades of industrial discharge, and one effect was to degrade the old lead pipes in many Flint homes, dramatically increasing the lead levels in the water. And in the bodies of Flint’s children. The politics of the decision are continuing to play out, with calls for Snyder’s resignation, and it would have been corrupt and evil even if the problem had been identified and remedied earlier. It wasn’t, and thus became a disaster. Good piece on it in Rolling Stone.

Again, we have a hero, a Flint pediatrician named Mona Hanna-Attisha. Dr. Hanna-Attisha had heard that a team from Virginia Tech had found high lead levels in Flint’s water, and noted that she was seeing a rise in the number of children with high lead levels. She led a team doing “the easiest research project I have ever done”; because Medicaid requires children to be tested for lead at 1 and 2 years of age, she was able to compare the prevalence of high levels from 2013 to 2015.  The percentage of children with elevated lead levels “doubled in the whole city, and in some neighborhoods, it tripled. And it directly correlated with where the water lead levels were the highest” she noted in an interview on “Democracy Now”. She announced it at a press conference, and was immediately attacked by the powers-that-be (I call them the “PTB”); in this case both the political leaders of the state and the state health department.

Well, that evening, we were attacked. So I was called an "unfortunate researcher," that I was causing near hysteria, that I was splicing and dicing numbers, and that the state data was not consistent with my data. And as a scientist, as a researcher, as a professional, you double-check and you triple-check, and the numbers didn’t lie. And we knew that. But when the state, with a team of like 50 epidemiologists, tells you you’re wrong, you second-guess yourself. But that lasted just a short period, and we regrouped and told them why, "No, you were wrong." And after about a week and a half or two weeks, after some good conversations, they relooked at their numbers and finally said that the state’s findings were consistent with my findings.

There is a long and distinguished tradition of doctors making breakthrough discoveries that helped cure or prevent disease in thousands or millions of people. Some of the most storied are Edward Jenner, the 18^th century physician who invented the vaccine to prevent smallpox, 19^th century physicians John Snow, who discovered that the contaminated water from a particular pump in London was the cause of a cholera outbreak, Ignaz Semmelweis, who showed that doctors washing their hands could prevent deaths in post-partum women, Rudolf Virchow, the “father of social medicine”, who showed an outbreak of typhus among miners was the result of the social conditions they lived in, Louis Pasteur, Robert Koch, and Joseph Lister who proved that germs caused those diseases, and 20^th century doctor Jonas Salk, who found the vaccine against polio. Does Mona Hanna-Attisha’s work rise to this standard?

Well, it may not in terms of the total lives saved, although it is worth noting that, like the work noted above, it is about public health, about populations, not individual interventions, and thus has a great impact on so many (despite the fact that in the US at least 95% of all “health spending” is on individual medical care, not public health). But she is heroic in that she stood for the truth and for the health of the children in defiance of the powerful who were trying to minimize or cover up the problem, and who tried for a while the “best defense is a good offense” strategy of attacking her, shamefully. Indeed, this is what it takes to be a hero, to not only do something important that has an impact on many, but even more to do it when you have to stand against the establishment, the PTB, the powers-that-be. This takes a great deal of courage, as well as commitment.

In Kansas, the legislature legalized concealed-carry of guns a couple of years ago, but exempted schools and hospitals until July 2017. As that date approaches in 18 months, there is little indication that the exemption will be extended, and there is great concern. A recent survey found that 70% of faculty and staff at the 6 state Regents universities oppose the law. Faculty are worried about telling students that they are failing them while they sit in their offices armed; doctors worry that if a crazy person pulls a gun in clinic, several others will draw down and make it more dangerous, police worry that they won’t even know who created the original threat. The data shows that there is a real risk of more homicide with more access and carriage of guns; “natural studies” of homicides showed a marked increase after Missouri eliminated its permit laws in 2007 and decrease after Connecticut tightened its laws after Sandy Hook.[1] [2] Moreover, 60% of gun deaths are suicides, and these are also dramatically decreased by making guns less easily accessible.[3]  Doctors and researchers need to speak out about the public health implications of easier access to guns. Luckily, many are; others are worried that perhaps the notoriously-vindictive Kansas legislature may respond by cutting funding for the university. These people will not become heroes, but they may keep their jobs and their funding.

Being a whistleblower is not easy. It is not a way to have a calm, peaceful life. Some folks have made a lot of money and retired far from those they blew the whistle on, but many more I know of are, like Roger Boisjoly, are shunned, forced out of their jobs, threatened, and may even suffer PTSD. It is not easy to take on the PTB. Better to work in their interests; for his great work as emergency manager in Flint, Darrell Earley has just been named emergency head of the Detroit Public Schools!

The full impact of the Flint lead-poisoning disaster is not yet known, because the full impact of these elevated lead levels on the brains and bones of Flint’s largely poor and African-American children will take years to take their toll. Even then, and even if, because they are treated the damage is limited, we will never know what kid who grew up seemingly ok and normal might otherwise have been brilliant.

She might have become a doctor, maybe even a heroic one like Dr. Hanna-Attisha.

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[1] Rudolph, KE et al., Association Between Connecticut’s Permit-to-Purchase Handgun Law and Homicides Am J Public Health. 2015;105:e49–e54. doi:10.2105/AJPH.2015.302703

[2] Webster D, et al., Effects of the Repeal of Missouri’s Handgun Purchaser Licensing Law on Homicides, Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 91, No. 2, doi:10.1007/s11524-014-9865-8

[3]  Crifasi CK et al., Effects of changes in permit-to-purchase handgun laws in Connecticut

and Missouri on suicide rates, Preventive Medicine 79 (2015) 43–49