Ringo Chiu via AP
Five years ago, a remarkable article appeared in Stat News proposing a different way to think about the health care industry. Physicians, who typically work in high-pressure environments and establish relationships with sick patients whom they sometimes cannot save, have always been seen as susceptible to burnout, emotional pain, and even PTSD. But that wasn’t quite the way to think about it, according to physicians Wendy Dean and Simon G. Talbot. The problem isn’t coming from dealing with illness and death, which physicians are trained to endure. The problem is a for-profit system that impairs their ability to practice their craft and to protect their patients. And the way to describe it isn’t burnout—it’s moral injury.
Dean and Talbot received so many responses to their initial article that they collected the stories into a book released this year called If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First. The book traces the lives of several medical professionals who bumped up against a system of corporate-run medicine that renders inoperative a practice of treatment that doctors had been pursuing for decades. It’s not just about battles with insurance companies but hospitals and private equity–run practice groups, where most physicians are now employees, cogs in a wheel of for-profit health care.
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.
I spoke to Wendy Dean about her book, about how the system of independent power centers in medicine provided a check on potential abuses, about the losses from consolidation and from new technologies in medicine, and about what changes when doctors are put in the position of workers in the modern economy. The following is a lightly edited transcript.
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.”
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Wendy Dean
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.
What strikes me is that you got into this profession as a doctor, like most people, I assume, to take care of people, to heal people. And I read your book and you’re now forced to think about shareholder value and business ownership and all of these outside issues.
Yes. That’s what I say to every physician. They say, “What do I do?” My first response is that you must educate yourself about the environment in which you’re working. You must know hospital policy, the regulations that govern your field, the governing societies in your field. You need to know how reimbursement works. You need to know the structure of how reimbursement is created. You need to know CPT codes. And you need to know the motivations of the people around you. Those are the basics. In the book I could have delved way deeper into the business side. Knowing the basics is the only way to know where the motivations are. The administrators aren’t necessarily bad people. They are doing their best at what they were trained to do, which is to keep the business alive, and maximize shareholder value.
But that’s a lot to keep in your head as a physician. Medical diagnoses are complex enough, and you have to concern yourself with this web of procedures and whether the hospital is bringing in enough revenue, and the impact on care.
I absolutely agree. That was not the agreement that we thought we were making. When we handed over the reins to administrators to run the business of health care for us, we thought we were doing it in partnership. In most places that hasn’t happened.
Your concluding chapter is interesting. You call for limits on consolidation of health providers but you actually call for less regulation, or at least less documentation and reporting.
But those are two different things. What I think is that less consolidation, where I call for the FTC to take action, that in itself may lower prices. When I talk about fewer regulations in terms of CMS [the Centers for Medicare & Medicaid Services], what I’m talking about is harmonizing reporting requirements across agencies. I’m not saying we should be tracking them less, it’s about getting agencies to agree that metric A and B are close enough to say that we’re combining them.
One of the things that we tend to do when developing policy or legislation, it always happens impulsively or quickly. In the eleventh hour, it tends to become that. What that means is there’s not careful consideration about how that legislation or regulation will get gamed. And we’re human, we’re all going to game it.
I think when you’re talking about less regulation, a lot of that is corporate regulation; the coding, for example, is used to run up billing by adding more codes to a patient diagnosis and game the risk adjustment system.
Exactly. I’m not arguing with that at all. How you know that’s true is: Everything I say is a reasonable idea, and there are huge monied lobbies who are fighting tooth and nail against every one. Physicians are a million strong but we’re outnumbered.
But physicians are the type of people policymakers do listen to: well-educated, relatively wealthy, able to engage with the political system. For years, the AMA was a major player in health debates.
But here’s the other thing that’s changed. When you’re an employed physician, you are effectively a corporate employee, who must value fealty to the corporation. When I’m talking to the AMA, and I say I want this thing that my corporation doesn’t want, and my name is attached, then I’m blackballed and out of a job. Physicians are so afraid to speak up. They’ve been told that if you speak up, then your job is in danger. Ray Brovont, who is in my book, said that when he was fired, it had a chilling effect. Everyone just zipped up.
This is something I hear time and again from those caught up in monopolized systems, this fear of the consequences of speaking out.
And when you’re in a position when your voice is silenced and people’s lives depend on that, and you’re not allowed to speak on it, that’s an untenable position. That’s why burnout is not the right word for it.
What is the new concept in health care that worries you the most?
Hospital at home. You’re relying on 90-year-old folks to take care of their spouses, and you don’t have nurses to take care of them. My apologies if this is your demographic, but this can only have been thought up by white men who never had to take care of anyone in their lives. Who have never changed a diaper or brought someone to the toilet. What I see it as, we can’t pay our staff any less, so we’ll use free help which is their families. We’re not liable for it because if there’s an injury or an error, it’s not their fault. And every time you do it, they make money. People are being sold on this, physicians and patients alike. This spin that makes no sense.
