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?