The stories follow a pattern: Physicians are blocked from treating patients in the manner they want, and they fight against those who block them. In response, they are often drummed out of the profession or, in one case, driven to suicide. Together it’s a portrait of lost liberty, in a profession that has valued that independence as a way to ensure the best care for patients. In small ways, Dean and Talbot show physicians, administrators, and other professionals who are bucking this system, with new movements toward better organization and models of care. But it’s a long road back from corporate medicine. (...)
David Dayen: You have described the outpouring of contacts from other doctors after your initial moral injury article as unexpected. Do you feel like you gave voice to something that was already out there but by putting a name to it you were able to find a book’s worth of stories about the same phenomenon?
Wendy Dean: By the way, that book’s worth barely scratches the surface. What I think, in the seven years since we started having conversations, five years after the article was published [is it] taps into something that people have felt but have not had the language to express. In all honesty, it wasn’t what we set out to do. The first article was really a thought experiment. This is something that explains our experience. And explains the experience of the colleagues within reach of us that we can touch and talk to. But we don’t know if it’s a broader experience. I regularly have people come up to me almost in tears, and say to me, “This finally gives me language for the experience I had.”
We ran a piece recently about moral injury as it relates to schoolteachers, and how they have been restricted from applying their skills as well. Do you think the concept you gave voice to is a broader part of how we live today in a lot of different professions, where corporate interests hold sway?
I read that and I literally sent it to all my close connections, including the developmental editor for my book, who was a teacher and quit that profession because of moral injury. When I brought to her the initial concept, she said, “Oh my God, I don’t understand it in health care but I do in education.”
I had someone come to me and say, I left my job as a management consultant at McKinsey because of moral injury. After the initial article came out, we heard from not only all walks of clinicians. We heard from veterans, teachers, public defenders. In the fields that are becoming corporatized and where the practitioners are constrained in what they can do by corporate decisions, moral injury becomes a real risk.
We’ve seen private interests involved in health care really from the beginning, going back to the AMA. What is different about this era?
I think it’s like everything else. It happens gradually and then all at once. What used to be true … these are overly simplified explanations, but what used to be true is physicians were their own bosses, and hospitals were a workshop they went to. Hospitals owned the entity, and physicians did their work there. Surgeons did surgery there. But the clinicians were running the care of their patients, separate to how the hospital was run. There was no middleman between patient and physician, or between physician and insurer.
This allowed better checks and balances in a way. To take one example, prior authorization has exploded in the last couple years. Why did that happen? When physicians were still independent, they could make the decision that they were in-network for insurance. So if the insurance company harassed them too much, they could say, “I’m done.” They could tell patients, “Look, this is taking too much energy, I’m sorry for the inconvenience but I can’t do this anymore.” Insurers had a metric for that, called physician abrasion. They tracked it. They didn’t want physicians leaving their networks. What’s changed, physicians now are largely employed, and their employer decides if they’re in-network. They aren’t really tracking the abrasion on their clinicians. There’s no check and balance.
That’s one thing that comes through in the book; we hear a lot about the patient side of health care, the struggles of dealing with insurance and giant bills. But you bring in the other side of that transaction.
That’s the thing, part of the reason I wrote the book was to help patients understand that physicians are equally frustrated, equally angry, equally helpless, equally sad. It is deeply demoralizing to us that we can no longer control a patient’s care. The employment of physicians has really flipped the script in health care. Rather than negotiating as equal entities with hospitals on how to run care, as insurers get bigger, physicians and physician groups had to get bigger. It’s an arms race, who’s going to get bigger faster. But patients and clinicians lose out. Big corporations bashing against each other. What gets lost in that is the individual care.
I’ve called it concentration creep. You have a two-sided transaction, providers on one side and insurers on the other, and each side wants to gain leverage over that transaction, so there’s an incentive to concentrate and monopolize.
I will say, physicians are not entirely innocent in all of this. We did decide at some point that managing this business of health care was getting too complex. So we handed it over to administrators. We thought it would be done in good faith. But in fact that balance has shifted. Now that we are employees, subject to more of that power-wielding, we don’t have a sufficient voice.
One of the really interesting dynamics is how this is forcing doctors to think of themselves as workers in a way that I think we haven’t seen before. So there’s this rise in union activity among internists and residents and even doctors. How do you see that change?
I also think it’s a bit of a shift. The core principle of the book is that we’re separated from this covenant that we have with society, which defines us as a profession. When you separate us from that, what are we? If we don’t have autonomy, if we don’t have decision-making authority, are we a profession? If we are not, holy smokes.
You have this fascinating chapter about electronic medical records, and the downsides of efficiency and technology, what it does to the doctor-patient relationship. Which is the bigger problem: Is it the way this technology has evolved, or just the fact that there’s this technological barrier to care, period?
I think it was a combination of those two. The government requirement to be on electronic medical record systems in such a short time frame meant that the only way to do it was to build it on existing systems. All of the existing systems were billing systems. We now have a cash register, with a clinical note bolted on.
One of the things that medical school does, it trains you not just in the diseases that happen, but it trains you in a very systematic way of analyzing the data you’re getting. The clinical encounter flows in a routine way. The same things happen in a certain order. They get a general story, ask more detailed questions, conduct an exam, and then diagnose and devise a treatment plan. That is a systematic method that’s learned in medical school.
The electronic medical record disrupts that. You’re constantly interrupted by this pop-up, this set of questions: Do you have a flu shot, is there a pneumonia vaccination, does the patient have a throw rug. It’s interrupting that flow with nonsense. It doesn’t always make data available where you want it in an easy way. The workflow of the electronic medical record isn’t designed to mirror the clinical workflow of a patient encounter. That’s what makes it for the clinician so challenging. We’re constantly fighting this electronic record.
by David Dayen, American Prospect | Read more:
Image: Ringo Chiu, AP
[ed. Just had a check-up with my old doctor, who I've been seeing for the last 40 years. He still has an independent practice, and I've often wondered what happened to that model. Now I know. The last time I was in a hospital/clinic for a prescription refill the doctor stared at a screen the whole time, asking questions sideways and typing in my answers - I can't even tell you what she looked like. What a system. Probably sees at least 20-30 patients each day - quantity over quality.]
