Yves here. Readers regularly give updates on the crapification of medicine, mainly from the patient but sometimes the provider side. A big driver is insurance: obstacles like pre-approvals or other gatekeeping delaying or perversely restricting care, or narrow networks excluding certain specialists. But the other is corporatization of medicine, which we’ve been writing about for a decade. That means not just a fixation on cost reduction but also standardization, which proponents insist, without or contrary to evidence, improves care.
The result of all of this, not mentioned often enough, is moral injury. Articles about doctors retiring early may deign to mention burnout, caused by fighting with insurers and particularly post-Covid, thin staffing. But they don’t include often enough moral injury, of feeling they are to violating their ethics by being forced to practice in a substandard or even risky manner.
I ran into a small example yesterday. I always have my blood drawn at a clinical lab because MDs’ nurses usually turn me into a pincushion. I always ask for a butterfly needle.
Today, at a Labcorp, the lab tech said she didn’t have one. She had been ordering them since August and none were being supplied. She said Labcorp was instead giving her similar-gauge needles, which were clearly cheaper than butterflies and not as good for many uses, particularly getting blood from children, the elderly, chemo patients, and patients that needed to be “stuck” many times (she did not elaborate on the latter). This was not a matter of saying “no” to patients. She was clearly upset at being asked as a professional to do her job with improper tools. She seemed to feel demeaned. She said she asked every patient to complain to Labcorp about it.
Multiply stingy indignities like that across the entire medical system in the US.
This wee yet very very typical example illustrates that executives and managers don’t care about the business of the business, even when health and lives are at risk. All that matters is profit.
By Joel Eissenberg. Originally published at Angry Bear
When I was growing up, I viewed being a physician as the zenith of achievement for someone interested in science. That changed when I got to college and became interested in research. I realized I didn’t have the temperament for a physician (OK, maybe a radiologist or a pathologist) and I became a lab rat. I did make a career as a professor in a medical school department and I taught thousands of 1st year medical students, but I really wasn’t interested in medical practice.
When I started my faculty career in 1987, there was a lot of money sloshing around at the medical school. Back then, insurance companies paid a premium for patients seen at academic tertiary care hospitals and clinics. But within a decade, managed care took over and medical schools across the nation were bleeding money. My university sold its hospital to Tenet while the hospital was still profitable. That turned out to be problematic, so eventually they bought it back and sold it to SSM, which was better aligned with the Jesuit Catholic mission of the university.
The basic science curriculum at the medical school has been shortened to make way for more clinical rotations. Meanwhile, for the graduates, the career prospects are evolving. Nurse practitioners and physician assistants are taking over the duties formerly performed by MDs and DOs. AI is more accurate than human radiologists in diagnostic imaging. Private equity is taking over practices and community hospitals and draining resources. Here’s an ophthalmologist in Kansas City:
“Medicine is going to hell. I have been asked to write several editorials but it would be so depressing I would feel bad. My own group, owned by 6 physicians, sold out 2 years ago to private equity (PE). Since then, 5 of us have left. You know the drill: fire local management, install bean counter as head person, golden rule now “MORE REVENUE SO WE CAN SELL OUT AT A PROFIT” down-staffed, told shorter patient contacts/more patients per day, more surgery, more revenue generating tests. Also, by fiat they are shifting all primary eye care to optoms and ophthalmologists do only surgery. This even on patients that have seen an MD and want to see MD not OD for three decades. The partners say no other specialty has had more decline in reimbursement than eye. The younger doctors did not want to buy in as partners and the older doctors had no exit plan. In fact, one of the partners died and they could not raise money to buy her out until sold to PE.
“Scholarship and merit have gone out the windows. The medical students and residents I come in contact with are snowflakes, self-entitled, clueless about intellectual rigor “do it for me” and standards dramatically lowered for some, raised for others in violation of supreme court ruling. You can go on the internet and learn about ‘work arounds” to shape the classes along the lines that are ‘fair’.”
Recently, an MD/PhD who did his PhD in my lab got in touch with me by email. He had initially taken a faculty position at the University of Hawaii medical school. But things changed:
“I am still kind of in academia and made it to associate professor rank but then it was just getting harder as hospitals saw anyone with “MD”s as replaceable billings ($) generating machines and getting rid of all protected time unless you have your own NIH funds (which is hard to do due to very limited support in Hawaii). So I kind of threw in the towel a few years back and started doing private practice (much more flexible schedule), which actually helps to subsidize the limited teach/research I still do pro bono.
Psychiatry is fun in a way that I have been involved in teaching the psych residents on how to translate individual genetic findings into meaningful clinical decision-making. And geriatric psychiatry addressing dementia behavior is still much a learn as you go field so keeps it interesting. The PhD work I had with you made me think more critically and open minded in embracing newer findings (this is like the most important/enlightening thing I picked up as a grad student), as most MDs are trained to think in a cookie cutter manner, so I always have fun putting my MD students on the spot how their textbook knowledge is ever becoming obsolete.
What a tragic waste of a physician-scientist.
I guess the medical profession is no longer quite the meal ticket it once was. The only constant in the world is change, and the economics of medicine is driving change in medical practice.