The practice of medicine has changed tremendously within my lifetime. A retired physician came to my office years ago lamenting that his esteemed profession had turned into a business over the course of his career. That raises something of an ethical dilemma: doctors want to practice medicine but some feel like they’re being forced to practice in ways they find objectionable.
The New York Times explained, “The corporatization of health care has changed the practice of medicine, causing many physicians to feel alienated from their work.”
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.
Wendy Dean, a military psychiatrist, believed that many physicians were suffering from a condition known as moral injury.
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 New York Times explained what causes moral injury:
Military 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.
I wonder if some of what the writer describes in the New York Times article isn’t similar to what many employees feel when they don’t have control over their working conditions. However, medicine is supposed to be different. Physician is also the most prestigious occupation in America and doctors take the Hippocratic Oath.
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.
While physicians were once largely self-employed, most now are employees. Nearly three-fourths of doctors are employed by hospitals, health care systems and private equity firms. Employers hire physicians to generate revenue and these employers exercise a significant control over how their physician employees practice medicine.
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.
Nearly 20 percent of the 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… 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.
I imagine this scenario plays out in many occupations where employees are expected to sell their employers’ services and to even upsell by subterfuge if it boosts revenue. I recall visiting a doctor who told me he was 85% sure my condition was nothing to worry about. If I wanted to be 100% sure there were two tests he could order. One would be performed at the clinic where he worked (about $400), while the other was an MRI that would be done elsewhere. He was honest and said the additional tests were primarily for my peace of mind. The decision was entirely up to me. I can easily imagine situations where he could have been more assertive and made me believe tests were necessary if he had an employer who required him to practice that way.
But more and more doctors 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.
I’ve heard similar complaints from doctors when giving their reasons for considering a change to practice direct primary care (DPC). Physicians turn to employers for solutions to a problem: the hassle of setting up a practice, paying off student loans, borrowing to rent office space and hiring billing staff. Most were never trained to run a small business. Many young physicians are women starting families. They want greater work/life balance than self-employment affords them. The problem is that while turning over control of their license to a third party may pay the bills, it also (sometimes) requires them to practice medicine in ways they find objectionable.
The entire article is worth reading: The Moral Crisis of America’s Doctors – The New York Times