Doctors: It's Time To Flip The Script

 

PART I:  Who should be calling the shots in Medicine?

 

                       

 

 

What the drama of COVID-19 exposed about the healthcare system:

 

Remember back in the day when we were going about our merry medical lives dealing with the usual stuff, prior authorizations, millions of EHR clicks, sham peer reviews, Press Gainey scores, and the like? And then 2020 came and hit us with a novel virus? You know the rest. None of us knew exactly what we were dealing with but we still showed up to care for patients because that is the one thing we always do. There were massive shortages in Personal Protective Equipment. Healthcare workers were being asked to put themselves in harm’s way by the hospital executives who were safely sequestered away making executive decisions from home. Initially, the narrative was being carefully curated and I remember in the early days of COVID-19 the floor nurses at a hospital where I worked felt intimidated by superiors for wearing a mask. It would “scare the patients” the administrators furiously typed away from home in their cozy bunny slippers. Then the reality of the pandemic hit and blew up all false narratives. The public reacted with both fear and gratitude, joining hands across the country to thank healthcare workers for risking their own safety in order to care for others. Healthcare workers, not the most glamorous bunch, were finally being championed as selfless heroes for the first time in recent memory. It was a brief moment of gratification in the backdrop of an otherwise deeply traumatic experience.  And though hospital workers grumbled, they showed up to face the crisis. Many of them paid with their lives and were lost to COVID-19. Others grappled with the daily dread of potentially passing the virus onto their loved ones. Doctors were told their salaries would be drastically cut [1] citing the economy (pay cuts did not apply to administrators), though physicians would still have to perform all of their clinical and administrative duties nonetheless [2]. It’s all about patient care, we were told by employers. [3] There was chaos and uncertainty, but at least we still have doctors to lead with some key medical solutions during a pandemic, right? Wrong. Nobody with authority wanted to hear the doctors.

 

Do Doctors have a seat at the table?

 

The idea of consulting doctors for medical decisions did not strike healthcare executives as a logical one. Doctors are looked upon with disdain in their systems. There are checks in place to penalize doctors for prioritizing clinical care (over profit), in the form of prior authorizations and demerits for not following administrative protocols. While doctors care for patients, an elaborate background operation is in place to feed the healthcare industrial complex at the expense of doctors and patients. The doctor is completely unaware of the deceptive tactics allowing hospitals to declare imaginary losses for tax purposes. During the clinical encounter, the Electronic Health Record, meant to capture medical records, tracks each and every click made by the doctor in order to create practice algorithms to monetize later.  Once the doctor provides the medical treatment, the hospital is then able to sell the patient’s data to third parties. By the time the patient is discharged, the hospital may have sold the doctor’s intellectual capital and the patient’s dignity many times over. 

 

Doctors’ altruism is exploited.

 

 The overworked doctor participates in this system for altruistic reasons, capturing only a small fraction of the exponential capital they generate for their employer. Many can’t leave the system, they are drowning in medical school debt that is impossible to pay off in residency, while interest rapidly accrues. There is nowhere else to turn. They feel trapped. The healthcare executives know for a fact that doctors are trapped and have no leverage. Is there any reason then, why they would feel incentivized to concede to anything doctors care about, like good care, safety, and more time to spend with patients in order to form a deeper connection? It’s not altruism when your goodwill is exploited. That’s called abuse. 

 

What healthcare organizations did when they received COVID relief on behalf of doctors and patients:

 

During the peak of the COVID pandemic, doctors were busy saving lives and had to resort to sterilizing their single issue N95 by baking it in their own home oven. Meanwhile the work from home healthcare executives were speedily devising a brilliant move on their behalf in light of the pandemic. Was the solution going to be more masks? No. Incentives to help attract physicians to the bedside? No, silly! Doctors will show up to help anyway, even if they work without compensation. Could it be that some of the meaningless administrative burden will be scaled back so we can focus on clinical duties for once, during a pandemic? Of course not. The physician community could barely contain its utter shock when doctors started getting fired en masse the moment their hospital systems received their COVID-19 relief packages. Healthcare stocks soared. [4] [5][6] Wait a second. There’s a pandemic. People are dying of a brand new disease that we don’t yet know for certain how to treat. So, we are firing doctors...Now? Yes. Is that safe? Well no, but the healthcare administrators are financially rewarded either way!  Who said it really has to be safe?! It only has to be profitable. But with a perception of safety.

 

Is this what our patients want in their healthcare? The healthcare industry has been extracting value from the doctor-patient relationship for decades. Their latest master stroke is to completely disempower the final barrier standing in the way of total domination and exploitation of patients: the physician.  

 

We have a broken healthcare system that is outrageously costly.

 

Before the pandemic hit we already knew that America’s healthcare is a 3.6 trillion dollar industry [7] that just can’t do its job right. Americans bear more healthcare costs than any other nation[8] . Yet, instead of providing the corresponding quality of care, the system is fraught with patient dissatisfaction [9], sky high costs, pervasive physician burnout [10], and an outrageously growing rate of physician suicide [10]. Physicians spend 20 hours or more per week on administrative tasks on top of clinical care, often uncompensated [11]. 

 

Physicians assumed that surely their professional organizations would tackle these problems on their behalf. Isn’t that what they are for? 

 

Much to their disappointment physicians learned that their professional organizations are more interested in adding to the repertoire of onerous and costly hurdles. In my opinion, MOC® is one of many hurdles that keep doctors from caring for patients[12]. 70 percent of Americans polled believe healthcare is in a “state of crisis”[13]. The public blames physicians for all of these problems. This faulty narrative coupled with the COVID crisis has been used by nurse practitioners to legislate the privilege of practicing medicine without physician supervision in nearly half the country. That was before COVID-19. Billions of dollars have since been raised by healthcare systems under the premise of COVID relief. Everybody agrees the system needs fixing, particularly during a crisis, but peculiarly, one party has not been invited to the table for discussion: physicians.

 

The COVID-19 pandemic exposed that physicians are not allowed to be leaders in Medicine.

 

 The pandemic presented an opportunity to allow medical experts to take the lead in making decisions. If physicians were asked what could help them do their job better, they may have suggested less emphasis on micromanaging coffee cups at the nursing station [14] and more emphasis on administrators focusing on securing key resources like masks [15]. But the behavior of healthcare administrators during the COVID-19 crisis suggests to me that solutions for good clinical care and safety may not be the top priority; perhaps because those solutions are not monetizable under the current system. The actual cost of human health and life doesn’t appear to have devastated the administrators calling the shots from home.  Physicians will not be able to do much about it because they are just not considered integral to the medical system, evidenced by active replacement of physicians by Nurse Practitioners who are taught to operate on algorithmic medicine. 

[16][17]

 

Is the system broken by design?

 

Why does the system function so counterintuitively? Because healthcare is run by middlemen. Every payor, employer, regulator, administrator, manager, and software solution operates as a middleman with a business model based on wedging itself between the doctor and patient and siphoning off the value for itself. Now it makes sense why doctors and patients are so disgruntled despite being in a system that would otherwise topple without them. It also makes sense why healthcare costs are ballooning. The administrators liked to call it “growth”. 

 

Most technology solutions are designed to benefit the healthcare employers, not doctors and patients.

 

 Advancements in technology usually offer solutions to most ailing industries, but in the case of healthcare the majority of healthcare technology solutions aim to further empower the very middlemen causing the problems in the first place. “I don’t think Medicine is more complex than stock trading,” [18] says Vinod Khosla, a venture capitalist backing startups which aim to replace physicians with artificial intelligence and machine learning bots [19]. “If you are the disrupted party it’s not a lot of fun...people in the middle feel threatened”. He is referring to physicians. He appears to believe it is the physicians who are the middleman of Medicine! As far as the human elements of compassion and judgment are concerned, he cites that a nurse could more than sufficiently fulfill the human connection part of the clinical encounter. Nobody likes nor trusts doctors anyways, at least that's the popular sentiment. He implies that doctors are resistant to technology because of insecurity about their jobs. So why are doctors leaving medicine in droves? [20][21] Mr. Khosla did not offer how the robot or the well meaning nurse would be able to answer questions and alleviate concerns traditionally intended for the doctor. He also added that any physician who continues to practice after his artificial intelligence product is released on the market would be “killing patients”. Undoubtedly, these algorithms and bots would recommend the most profitable course of clinical interventions for the hospital system that purchases them

[22]. Based on current behavior of large vertically integrated health systems and the fact that the technology brazenly aims to eliminate doctors, there is a possibility that Khosla AI for replacing doctors will be designed for optimization of profit while giving an illusion of improved care. There will be no doctor around to be able to tell the difference! This sounds like a great deal for both Mr. Khosla and the hospital organizations; not so great for patients.

Legislators empower healthcare giants while restricting doctors.

 

Legislators are more than happy to operate on the premise that doctors are the middleman. They have legislated onerous hurdles and restrictions for physicians on the one hand, while granting the privilege of practicing medicine to people who have never stepped foot in a medical school on the other. And why wouldn’t they?  Doctors and patients don’t have the most powerful lobbies and all of their leverage is trapped within the rigged healthcare system designed to favor the giant centralized powers.

 

Doctors have lost control of their narrative. 

 

Healthcare giants seize full control of the narrative. The barrage of anti-physician sentiment is no coincidence. They create a narrative that physicians are greedy, and that it is the physicians who are restricting access to care and making it unaffordable. The public is aware that healthcare is broken. The public expects you, their doctor, to fix it. They know they are being exploited. The easiest explanation for the faulty system is that you, the doctor, must be benefiting from this system. Physicians absorb this negativity and are left to contend with moral injury and physician suicide.  Meanwhile administrators are working in the background to further restrict access with manufactured scarcity that results in increased profits. 

 

There is a widely held myth that doctors don’t really care about patients and are primarily interested in transactions at the expense of the patient. Doctors, do you think perhaps we inadvertently fuel this myth further when our patients see that we barely get time with them and spend the entire visit babysitting the EHR? Patients are not aware that you spend 8 hours on the weekend entering data in the billing device/medical record for free or that you accept jobs for a small fraction of your worth. They just see that they are paying more and getting less. The last 40 years represent an unusual era in human history where people other than doctors took charge of the practice of medicine. The current system is an anomaly! How has it been working out for you and your patients? Do you think maybe the public expects doctors to be the first line of defense in the system? They are disgruntled with the system and feel abandoned by their doctor. When the doctor continues to participate in a system which leaves patients feeling abandoned, patients tend to assign the blame on their doctor. After all it's the doctor who has taken an oath, not the hospital system. When you let others hijack the very identity of medicine while quietly carrying out your duties, then you are complicit in the very system that exploits you.

It is clear that the middleman giants will never allow their system to work for doctors and patients. Their entire business model is based on betting against us! They will always maintain the upper hand if negotiations take place on their turf. Stop playing out their script! We need to reclaim ownership of our narrative and save the collective destiny of our profession and the medical destiny of our patients. This is our story! We can take it from a downhill dystopian nightmare to one of an upset victory of the underdog vs. the giant. If you act in just the right moment, you can strike a giant squarely between the eyes. But first you have to be bold enough to stand up for yourself, realize you have some things going for you that the giant doesn’t and flip the script!

 

Flip the Script!

 

 

Stay tuned for part 2!