The Desensitization of Medicine: A Personal Perspective

It has been nearly 24 years since I began practicing medicine. Since that time, I have been witness to changes that represent the complete antithesis of what medicine should be. Our society thinks it is progress. I beg to differ.

The desensitization of medicine has been a laborious, insidious, gradual process that was intentional, born from the minds of entrepreneurs who saw the potential profitability of a system in which a need (or demand) was inherent. There will always be sick people. Sick people will always come to hospitals and doctors. Since most sick people have no wish to die, they will seek out help and pay whatever is necessary to remain alive. If not them, then their families. In other words, there will be a more or less reliable influx of money. In that space, if one can harness it, lies the ability to create a profit. That was the genius of the C-suite. They were able to foresee the financial dividends in sickness and death.

What they lacked, besides ethics, was an ability to control the physicians who not only led medicine, but were patient advocates. Physicians tend to be passive creatures until the well-being of their patients is threatened. The business people knew this. They did their homework. They had to find a way to counter this…convince physicians that an idea, which was not in the best interests of their patients, was in the best interests of their patients. Once the doctors were convinced, then they would be less likely to oppose legislation, which would be the next step. Why? Because once legislation is enacted, it almost takes an act of God to de-legislate. Legislators don’t like admitting they got it wrong. And accepted money in the process of getting it wrong. There would be no going back. The business people got it right. Lock the public into a system in which they really have no choice in their care or management, they just think they do.

It began with the health maintenance organizations (HMOs). Pay a reasonable monthly fee, receive services to maintain one’s health. You know, keep us healthy so we live as long as possible. Good idea, on the surface. It worked…we are living longer than ever. This is where the business people got it wrong. They didn’t think they would be paying out more and more as people aged. Private insurance companies didn’t like it either. Sure, we lived longer, but aging was also accompanied by more medical issues. More money began exiting the business. That was not supposed to happen. Remember, hospitals were physician-led. Patients were admitted because it was necessary and remained until they were stable. Good medical management. But it cost. The business people had to put a stop to this. Turnover of patients needed to occur more rapidly for the profit margin to increase. These individuals recognized that they needed to be in a position to call the shots. They found the physicians and nurses who believed in the business model and had relegated their oath to their patients to the backburner. You know, the ones who placed the almighty dollar above the patients. And the corporate bigwigs enlisted their help. The private insurance companies? They arbitrarily raised their premiums, increased co-pays, co-insurance and deductibles while providing less coverage. And remained under the radar.

The transition of leadership occurred slowly, with many of us not even noticing. Until the clipboard cops began showing up requesting we discharge patients who should not be discharged. Or suggesting we admit patients who didn’t need to be admitted because the census was low. So the hospital could make more money. The underlying threat being that we either gave them the answer they wanted, did what they requested or risked termination. Most of us folded. We allowed the patient to become the commodity, against our better judgment. A funny thing happens when a negative behavior is repeated over and over. We become desensitized. We begin to make excuses so the unpalatable  becomes palatable. Such as sending home the elderly, weak patient because we could not find a source for the weakness. And we ceased being concerned about that person’s social situation. We stopped advocating. We became part of the problem. And attempted to mask it under evidence-based medicine and current practices. Leadership and governmental agencies began creating and demanding that we follow protocols/guidelines/criteria which, when used appropriately, worked well. But when used to make a round stick fit into a square hole, failed. But we did it anyway, we forced the stick into the square hole because we didn’t want to get fired. And we received bonuses for this unconscionable behavior. And then we went home to our families, attended church (or synagogues or mosques, etc.) and pretended to be people of high integrity. When we weren’t. And our colleagues who saw the writing on the wall, spoke up and out and remained true patient advocates…well, we watched them get terminated, demeaned and labeled as “disruptive” or “difficult to work with”. And we said nothing. We attended medical conferences, social gatherings with colleagues, laughed and joked without considering how the individual, who never forgot his oath, was managing to support his family without a job. We dealt with the guilt by blaming the victim. He must have deserved it. We turned our backs on our colleague and supported the C-suite who didn’t give one damn about us. Because that is who signed our paychecks. We sold out. Fear became our God and the hospital, our church.

But it didn’t stop there. The business people decided that physicians were just too damn expensive. But how does one replace a physician? Convince the public they have a cheaper alternative. However, before one can do that, the public has to be persuaded. They needed a wordsmith. Words are powerful and can influence people. That’s why every leader of every country has a speechwriter. From this mentality the word “provider” was born. Physicians, physician assistants (PAs) and nurse practitioners (NPs) became providers. This was no accident. In the past, “PCP” meant primary care physician. By using “provider”, they didn’t have to change the acronym. The public would associate it to mean the same. Genius. It worked. Then the transition began. Over time, physician hours were decreased. More NPs/PAs, also known as mid-level providers (MLPs) were hired. Physicians, at one time, would be able to see every patient that was seen by the MLP. This was imperative to ensure good care and that nothing was missed. It worked for decades. Now it was impossible. A physician with his/her own load of patients cannot see the patients of 2-3 other MLPs. Corporate entities didn’t care since they didn’t own the liability. They would not indemnify the physician so that he/she would not be culpable. Because these businessmen and women did not want the responsibility either. A paradox, since they hired these individuals. They were attempting to make a profit, not lose it in a lawsuit. Let the onus be on the physician. If the doc refused, he/she would be terminated. So the doc accepted the liability because he believed he had no choice. Many times, patients had no idea they were not seeing a physician. However, if they were astute enough to notice, they requested a physician. And got one. Today, the transition is so complete that even if a patient asks for a physician, they are actively discouraged or become a victim of the “bait and switch”. That is, the patient makes an appointment expecting to see a doctor only to find out upon arrival their appointment is with a MLP. If they insist on seeing a physician, they may be advised to make another appointment which might be months away or told to find another practice. And to add insult to injury, the public is being misled into believing that physicians and MLPs are “basically” the same. This is akin to paralegals and attorneys being “basically” the same.

The desensitization of medicine. Patients have no voice and no choice, unless they have good insurance. Eventually, that will provide no guarantee because the C-suite is in control. Put simply, they do not want to pay for physicians or their expertise. The irony is that not one of these corporate individuals uses MLPs in their care. Nope, they want only the best for them and their families. For you, the public? Not so much.

Natalie Newman MD

Dr. Natalie Newman is a residency trained, board­certified emergency physician who has been practicing for nearly 24 years. In 1991, she graduated from California State University in Sacramento, California with a degree in Biological Sciences. She then attended medical school at Case Western Reserve University in Cleveland, Ohio on an Army scholarship. As a graduating senior, Dr. Newman was presented with the Marjorie M. and Henry F. Saunders award for her compassionate care of patients within the family structure. After her graduation in 1995, she was accepted into the Emergency Medicine Residency at North Shore University Hospital in Manhasset, New York. Upon her graduation in 1999, Dr. Newman entered active duty service with the U.S. Army. Her first assignment was at Womack Army Medical Center in Fort Bragg, North Carolina. During her stint in the Army, Dr. Newman was deployed to Bosnia­Herzegovina(formerly Yugoslavia) where she was Chief of the Emergency Department at Eagle Base in Tuzla, Bosnia. She had the honor of serving under the command of Colonel Rhonda Cornum(now a retired brigadier general), a urologist, pilot and former prisoner­of­war during the Persian Gulf War. While in Bosnia, and as the only American female physician in the Balkans at that time, Dr. Newman was assigned as the personal physician for Queen Noor of Jordan during a humanitarian visit to a local hospital in Bosnia. After her return home to the U.S., she was promoted to Major and completed the rest of her Army service at Fort Bragg. Dr. Newman subsequently returned home to California where she continues to practice as a traveling physician and participates in multiple speaking engagements about the values of education, of which she is passionate. She is also a member of Physicians for Patient Protection, a patient and physician advocacy organization. 

  30 comments for “The Desensitization of Medicine: A Personal Perspective

  1. Kurt
    June 27, 2019 at 9:05 pm

    Bottom line is until patients are held accountable for their lousy health behaviors, nothing is going to change in this country. Stay the h#ll out of primary care altogether unless you can turn a DPC gig. I know danged well if somebody tried DPC where I’m at they’d go bankrupt pretty quickly.

  2. Mario
    June 21, 2019 at 1:34 pm

    Well said, Dr. Newman, well said. You speak for many of us. Every medical and nursing student should hear your voice.

    10
  3. Michelle
    June 21, 2019 at 12:43 pm

    The light is starting to shine on the cockroaches that have taken over our medical field. We are fighting back.

  4. Fear of retaliation
    June 21, 2019 at 12:20 pm

    I am a rather new physician. It took me almost 15 years from start to finish with over $430,000 in student loan debt and interest. My life has been devoted to the study of science and medicine for the entirety of that time. I worked for 15 years over 100 hrs per week between school, studying, and my job. I further raised 2 children while doing it. I believed in the power of medicine. I believed in the system. I believed In the collaborative strength of the highly educated physicians to advocate for the patient and be heard. It took me one year to realize that physicians are now humbled servants of the insurance companies (against our will) and the hospital administrators….trying tirelessly to “please” the patients because of satisfaction scores. Maybe, just maybe even once in a while you get someone who really wants to hear what you will say, not fight with you about it, or attempt to negotiate what knowledge they will and will not accept. Those are the gems of my day, for those people I return.

    It took 7 months for me to realize that my “team” had no desire for a physician to lead them. The toxic agenda was simply debilitating. I lost my job attempting to advocate, I was considered disruptive. Physicians became uninvited and midlevels stepped in. They are now the new negotiators and have deemed themselves worthy of all decision making abilities without discussion. Physicians are forced to leave the table with their heads down low or be terminated.

    17
    • Natalie Newman
      June 22, 2019 at 4:30 am

      You are not alone. But you will stand alone. I’ve paid the price for being an advocate as well. Being a patient/physician advocate is in direct opposition to the business of medicine. Your sense of integrity has to be stone cold solid because the isolation you will experience when asserting your beliefs will make you question your decisions. Don’t. Always bring it back to the fundamentals. We took a Hippocratic Oath, not a Hypocritic Oath. You either meant it or you didn’t. Appears as if you did.

      The oath arises from the art of medicine and its meaning. Your integrity is instilled early on; a legacy of your family and/or upbringing. In corporate medicine, the oath is often forgotten. However, one’s integrity is never forgotten. It is relinquished. It takes one of great strength and fortitude to maintain that sense of morality in the “healthcare” environment in which we exist today. Consider the consequences you have suffered notches on your belt. They are your battle scars.

      Oh yeah….and always have two jobs.

    • Gerard Mazza
      June 30, 2019 at 6:59 am

      I am one of the dinosaurs of medicine, still in private practice, but at an age facing retirement. I can still do some of what is in the best interest of the patient, but it is becoming less and less due to the over regulation of medicine by the government and insurance companies. Private practice is now just too expensive for someone just starting, and just about too expensive for an established practice. The expense comes from the cost of all the “compliance” requirements that do nothing to improve patient care, but waste a lot of time and money. The other expense that is drowning us is having a cost of $97,000 a year to process billing to the insurance companies, and we are a small office. When I first started as a young doc in town, an old physician about to retire said to me “medicine used to be so much fun, but the government and insurance companies ruined it”. That was 35 years ago. Now 35 years later, I say they have completely destroyed it. It is a shame for anybody going into medicine today, and for the patients that depend on us.

      • Donna A
        June 30, 2019 at 10:09 am

        I am in the same boat. A few years ago when my dad was ill I went to working 3 days a week. It was not enough to cover ongoing practice costs and resulted in practice debt that I am now scrambling to overcome. I’m thinking of selling to private equity. A year ago I would have never ever thought this way but I need a way to work on an exit strategy for my practice over the next 5 years without going broke or driving my self insane. It is discouraging to be in this position and I feel that my soul is being deeply eroded. Yet I have midlevels who command a high salary and can leave at a moments notice. Meanwhile I remain tethered to a practice that is becoming harder and harder to manage.

  5. Pat
    June 21, 2019 at 9:47 am

    This is a great column, but I disagree with the timeline. It did not begin with doctors taking easy HMO cash, that merely accelerate things.

    It began when doctors started taking easy Medicare cash. Buying into an arbitrary government assertion of the elderly’s “right” to care was the point where our profession betrayed everything.

  6. RSW
    June 21, 2019 at 9:28 am

    Great post.

    And this sad, sad story is incomplete without mentioning the Quisling-like behavior of our medical societies, from the AMA on down – for the past three decades, they have been at the beck and call of CMS and insurers, always ready to do their dirty work for them and stab practicing physicians in the back .

    14
    • Sara O’Heron MD
      June 21, 2019 at 2:19 pm

      As the comments have shown there is so much more to add to this sad sad state of affairs. Thank you for being a clear voice and opening the dialogue so truth can be heard!

    • donna
      June 27, 2019 at 10:46 pm

      Yes our societies have betrayed us while the NP and PA societies advocate for their members.. best wishes docs .. I’ve tried my best to advocate on our behalf… time to pass on the torch

  7. Steve O'
    June 21, 2019 at 9:17 am

    Dr. Newman describes “the movement” with great clarity. She is a brilliant demonstrator of the cultivated skill of observation, which is a major component of the Real School of Medicine – the critical skills one needs to succeed as a doctor.
    I wonder if we are not seeing the end-stages of a pernicious poisoning of a society itself by its stubborn refusal to address its own intolerance. Like rheumatoid arthritis, it is a systemic disease masquerading as a local manifestation.
    By allowing groups to be degraded and abused, we are seeing, as Martin Niemoller offered:

    First they came for the socialists, and I did not speak out—because I was not a socialist.
    Then they came for the trade unionists, and I did not speak out— because I was not a trade unionist.
    Then they came for the Jews, and I did not speak out—because I was not a Jew.
    Then they came for me—and there was no one left to speak for me.

    Our country was founded and survived with the ongoing theft of land and labor from those who were called “subhuman.” Now, we are seeing that the root of these malign actions come from contempt for “humans” ourselves.
    The phrase “to err is human” was twisted into an instrument of contempt. When it once meant that we are human and infallible, now means that humans deserve to be the Helots, the servants of the inhuman corporation, or government, or whatever does not breathe.
    Whatever breathes should not be trusted.
    We have placed ourselves in the Gulag, and live with the superstition that we can construct machines, factories and bureaucracies, masters and methods and Artificial Intelligence which, by their very superiority, deserve to own us. This is no different than the pernicious manifestation of these beliefs when people used to “own” other humans.
    I do not see that it can be cured, nor palliated for long. DPC is a step in the right direction, but it generates hatred amongst the Heloi who believe that they are subhuman. To change the desensitization of medicine, we have to address the degradation of humanity. And we cannot answer the statement of the Little Rabbi – “Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.'” Look what we are doing to the least of our people, those who are human. Shame.

    11
    • Natalie Newman
      June 21, 2019 at 12:14 pm

      This should be its own commentary. Beautifully stated.

      Here is where I have hope. Similar to the housing bubble, we exist in a medical bubble. It is unsustainable. And it is not too big to fail. When it does, it will be with a resounding crash.

      Here is why I have hope. The voice of the public drowns out any other issue. The public is not enamored of the health care system as it exists today. When they are fed up with being commodities, they will act. Their biggest power is with their feet. Don’t like the “service”, they will leave. And take their money with them.

      My hope is that after the inevitable crash or their exit from this godforsaken “health” system, the people will go straight to the Direct Primary Care clinics. Now that we have specialists also engaging in the DPC model, I am even more optimistic that we physicians and patients can take medicine back. Leaving out the middle man is an extremely strong incentive. And desirable.

      “It’s the action, not the fruit of the action, that’s important. You have to do the right thing. It may not be in your power, may not be in your time, that there’ll be any fruit. But that doesn’t mean you stop doing the right thing. You may never know what results come from your action. But if you do nothing, there will be no result.”
      ― Mahatma Gandhi

      14
      • Robin
        June 24, 2019 at 9:15 am

        In the normal scope of consumerism, you can shop for better products and services and drop one for the other. Health insurance (any insurance really) is unlike any other product or service; There isn’t anything to replace it with and switching from one policy to another doesn’t make much of a difference in cost or outcomes.

  8. Elayne DeSimone, PhD,NP
    June 21, 2019 at 9:16 am

    Agree with much. But it’s your fault also.
    BUT
    PAs and NPs are not mid levels. Please advise who lower level are? What are pharmacists or chiropractors or audiologists? All “doctors” by the way? High levels? And don’t tell me nurses are lower levels? And of course physicians have allowed themselves to become providers, so not all bad. What level is that?
    Yes, I am making a point. Let’s not use words that antagonize, unless that is your intent. If it is-let us know that. Much more honest.
    And clearly no intent to be a team here. Let’s be honest about that also.

    1
    31
    • Douglas Farrago MD
      June 21, 2019 at 9:27 am

      I will stop any other pile on by NPs. NPs have chosen competition with doctors versus collaboration. See the AANP goals. I will just delete any more NP attacks via these remarks.

      24
    • Pat
      June 21, 2019 at 9:43 am

      Oh, I want to antagonize. The NP industry plays off a sense of egalitarian phoniness, where we are all “ valuable members of the team.” It mills out those who would like to burnish their self-esteem and their wallets by becoming “doctors” without taking the time and expense and wear to become physicians. Doug named you long ago: LELT. The Less Educated, Less Trained.

      I have no desire, and no intent to “be a team.” Precise enough?

      19
      • PW
        June 21, 2019 at 10:37 am

        Yeah, the “team” thing ended with independent practice for NPs.

        13
    • Jaclyn Nadler
      June 21, 2019 at 1:04 pm

      Elayne, I completely disagree. NPs are very much mid-levels, there training is far inferior to physician’s training and yet they try to fool the public to believe they are equivalent. Physician training for treating patients (medical care) is where the bar is set, any training short of that would be mid-level or if you prefer sub-par. Chiropractors and pharmacists have their own specialties, but when it migrates over to “medical” care for patients, yes they would be inadequately trained midlevels.

      As for “we” have allowed ourselves to become providers, many of us have not. I will not allow anyone to refer to me as a provider and any forms I sign with this term, will be corrected to physician. Our profession has been forced to take on this term due to influences we had no control over, but I see that changing soon. NPs will soon see a similar fate with the destruction of their profession as watered down diploma mills programs continue to churn out poorer and poorer quality NPs and corporate medicine, insurance companies and our own legal systems continue to manipulate and control them for cheaper care.

      As I have mentioned in previous posts, NPs and PAs have a tremendous role in our health care system. I have worked with amazing ones, but unfortunately over the past several years some very dangerous ones; but they should NOT be practicing as independent clinicians since they do not possess the training or knowledge to do so safely. NPs and PAs working collaboratively with appropriate physician-led care should be the standard. Respectfully, a former NP.

      18
    • Pat
      June 21, 2019 at 1:44 pm

      Aw heck, a sharp LPN can do most of what a NP can do. Why not hire more of them to be Triage Providers”? It would take the burden off overworked NP’s, be FAR more cost effective, and allow us to get quality health care to far more underserved areas. It doesn’t take an expensive online degree to know when someone needs Amoxicillin. I’m sure Elayne will be on board with this 😉

      • Donna aiudi
        June 21, 2019 at 2:12 pm

        Soon we will all be replaced by community health workers and computerized protocols. My heart cries for all of these young physicians with tons of debt. They have been mis-led. It is a travesty

      • Steve O'
        June 21, 2019 at 2:23 pm

        Open the pharmacy to the people! No more prescriptions! Open medicine to everyone. No more liability insurance! Make pharmacy like the deli.

    • Steve O'
      June 21, 2019 at 2:14 pm

      The words are there, the message is not. You will do well in Corporate.

  9. PW
    June 21, 2019 at 8:48 am

    Yup, you nailed it. I see three choices:
    1. Do DPC, don’t mess with insurance, Medicare or Medicaid.
    2. Get out of medicine altogether.
    3. Do a medical sideline but don’t treat patients.
    Dr. Hollywood asks how we fix it? I don’t think we can, unless the public revolts and decides they want doctors back in charge.

  10. Donna aiudi
    June 21, 2019 at 8:41 am

    You are right on!!!!!

  11. Jennifer Hollywood
    June 21, 2019 at 7:32 am

    Great article. You expressed so well what I’ve always thought. But the bigger problem is -how do we fix this?

    • Natalie Newman
      June 21, 2019 at 12:19 pm

      The onus is not on us to “fix” a system that does not reflect our values. It is our responsibility to change the model entirely such that this system becomes obsolete. DPC is an auspicious beginning.

      15
  12. Mary Lang Carney, MD
    June 21, 2019 at 7:29 am

    It is a very well written history of the somewhat insidious way that the system now works. Thanks: I have lived through it all.
    I have one son who is an interventional radiologist and another son who works for BCBS.
    The conversations are getting more and more interesting.

  13. June 21, 2019 at 7:22 am

    Wow. Nailed it.

  14. Dr. Bonz
    June 21, 2019 at 7:20 am

    Wow. Amazingly accurate. And equally sad.

Comments are closed.