Do You Feel in Charge?

Does your hospital run out of your preferred broad-spectrum antibiotic?  Does your clinic run out of fiberglass splint materials, lab testing kits, or on-the-spot IT wizards to fix your damnable EHR?  There is one thing you probably haven’t run out of (yet):  “But one resource that seems endless — and free — is the professional ethic of medical staff members.”

Danielle Ofri, MD has penned an excellent op-ed in the New York Times  “The Business of Health Care Depends on Exploiting Doctors and Nurses” that describes things accurately.  Dr. Ofri describes the conflict between corporatized (and collectivized) medicine, and the seemingly limitless ethic of commitment demonstrated by physicians and nurses. 

“This ethic holds the entire enterprise together. If doctors and nurses clocked out when their paid hours were finished, the effect on patients would be calamitous. Doctors and nurses know this, which is why they don’t shirk. The system knows it, too, and takes advantage.” 

Ofri describes how the increased average complexity and acuity of patients, combined with the increased demands of an EHR culture have soaked the time and energy out of professionals who keep reaching down to give just a bit more, even as the rate of administrator creation has far, far outpaced that of those who actually provide care.  Ofri cites the trending WHO classification of “burnout” as a disease, and relates it well to our present state.  She convincingly argues that “Mission statements for health care systems and hospitals (that) are replete with terms like “excellence,” “high-quality” and “commitment” exploit “the individuals who strive to do the right thing.” 

So why do I give this otherwise excellent piece a B+, when everything it said was true?  Because Ofri’s conclusion was, “The health care system needs to be restructured to reflect the realities of patient care… Health care is about taking care of patients, not paperwork.  Those at the top need to think about the ramifications of their decisions.”  That is the sort of call to arms one expects from the AAFP, with a strongly worded letter to follow.  Dr. Ofri is an accomplished author, has written for Slate and the NYT, practices at Bellevue Hospital, and is a faculty member at NYU School of Medicine.  I don’t know her (ahem) policy leanings, but after reading some of her blog pieces, I can read between the lines.  Arguing for solutions outside of large, collectivized approaches would be unpopular in those circles she frequents.  Pointing out that it was government mandates and the belief in a “right” to health care that have lead to so many of the real problems she cites will not win her praises in the Manhattan media circles.  However it should not, but might surprise Dr. Ofri to learn that “those at the top” have thought about the ramifications of their decisions and – BREAKING NEWS – they don’t care.  Big Insurance and Big Hospital have made every move they could to maximize their profits, while consuming their personnel; Big Government has pursued its own profit, which is control and increasing its size.  In all cases they have been supported by the goodwill elasticity of those who provide patient care, and those are starting to break.

 You won’t read this in Slate, but the only real power physicians and nurses still retain is their ability to refuse to work.  Society, with its emotional expectations, demands, lawyers, and ever-increasing rules will push individuals until they push back.  If the AMA, AAFP, ACP, or any of that rotten cabal retained a shred of relevance, they would be leading this fight, but hey, MOC and the new ICD-11…

 I do not recommend that any student looking for honest, happy work go into medicine, because I don’t think the profession is allowed to value either attribute.  I do hope that one day we see a major tipping point leading to widespread strikes, so that the public can see just what it has demanded.  How much fun will it be on the day that your rheumatologist just decides not to show, and all your only option to treat flared joints is the smiling, robotic CVS nurse practitioner asking you if you’d like a Z-pack?

And how valuable, and inspiring then will be the Direct Primary Care physicians who will be on the job, unaffected, and available to patients who appreciate them?

Pat Conrad MD

Pat Conrad is a full-time rural ER doc on the Florida Gulf Coast. After serving as a carrier naval flight officer, he graduated from the University of Florida College of Medicine, and the Tallahassee Family Medicine residency program. His commentary has appeared in Medical Economics and at . Conrad’s work stresses individual freedom and autonomy as the crucial foundation for medical excellence, is wary of all collective solutions, and recognizes that the vast majority of poisonous snakebites are concurrent with alcohol consumption.

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5 Responses

  1. Terry Nugent says:

    I agree wholeheartedly with you about DPC.

    As to AMA, the reason it is what it is today is that a majority of doctors would not pay dues starting in the 1970s. AMA was borrowing to meet payroll then. So they hired a bunch of MBAs including me to right the ship. They turned it into AMA Inc. Funded by non-dues revenue.

    I drew the short straw and was put in charge if recruiting doctors to join and pay dues which was the most depressing job I ever had amidst stiff competition.

    Even so, AMA does strive mightily to mitigate the damage to medicine perpetrated by the public and private sector powers that be.

    If more critics would join and participate in the AMA’s democratic process, it could be better at it.

    • Pat says:

      Terry, I appreciate your perspective. But the AMA has not opposed, or tried to undo Medicare since it caved in 1965. The AMA has exploited everyone through their ICD/CPT funding scam, and supported the ACA. Along the way the AMA supported HMO down-coding/bundling, and apparently got into some racketeering trouble. Last year, after AMA delegates passed resolutions against racism and homelessness (whatever the hell business of theirs that may be) they cancelled their San Francisco convention rather than preaching their inclusivity in an unsafe environment.

      No sir, the primary purpose of the AMA is to preserve the AMA. Who wants to waste precious time and money trying to convince a lot of quasi-government operatives to be true to their profession, and reverse a half-century of sell-out comfort?

      • RSW says:

        Don’t forget the AMA’s decades -long war to totally destroy primary care via the corrupt RUC.

        They are very bad people.

        I’d change it to:

        “Even so, AMA does strive mightily to participate in and profit from the damage to medicine perpetrated by the public and private sector powers that be.”

    • Randy says:

      First, thanks for your post. I’ve heard it mentioned many times that the docs who are complaining should join the AMA and change it. After being told basically to put up or shut up I joined the AMA a few years ago. My observation is that unless you are already well established in it you will have very little if any power.

      I joined and read through their website, then e-mailed them to see how I could become more involved. They replied that I should join a member group. Well, there aren’t any member groups for non-minority male practicing non-academic physicians. And I’m not begrudging the member groups their voices, they certainly deserve a say. But as far as I can tell the AMA has gotten away from common issues that concern practicing physicians, and has fragmented the membership.

      They then recommended I start working through my state association. Well, I know that it will take decades for me to rise to any position of influence there. So it’s easy to say just join the AMA and change things but realistically if you aren’t going to put a ton of time into it it’s not going to happen. And of course time is something physicians in private practice don’t have an excess of.

      I was actually talking to the medical representative of one of my Senators about MIPS a couple years ago, and she made some comment about AMA’s position on the SGR and how I felt about it. I was temporarily speechless that she thought the AMA somehow represented me, and ended up making some non-committal answer. The view the public and government has of the AMA is much different than that of many doctors “on the ground”.

  2. RSW says:

    I’ve seen several very intelligent non-MD analysts state that the greatest untapped force in medicine is the power of physicians.

    I see no evidence that the sleeping giant is going to wake up any time soon.

    Good post.

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