The practice of medicine in America is changing. The world of medicine I entered in 1975 can hardly be recognized now. As a physician, I am glad I have retired from the active care of patients. As a patient, I’m worried about the future.
When I started medical school in 1975, the vast majority of physicians were in private practice. The only hospital-employed physicians were pathologists, radiologists, and emergency medicine physicians – and many of those were actually privately owned practices with hospital contracts. Everyone else was in private practice. But all of that has changed radically.
Today, most physicians are employed by hospitals or large corporations. The American Medical Association reported in May, 2021 that 49% of all physicians were in private practice. But others report far different figures. Becker’s Hospital Review reported in July, 2022 the number of private physician practices was down to 26%. They say 135,300 physicians are now employed by hospitals or large corporations. They also report 108,700 physicians have left private practice just since January, 2019.
Why does this matter?
A physician in private practice has full freedom to make decisions based on his own opinions of what is the best medical treatment. He or she is only accountable to make decisions backed by the best medical practices – not by hospital or corporate rules and regulations that may be motivated by profit. While there may be some disagreements between other physicians in the same practice, the private-practice of medicine assures freedom from second-guessing by employers.
Not so in hospital or large corporate practices. Now, all decisions are subject to review by employers whose motivations may not coincide with the doctor’s medical opinions. The threat of lost employment is very real, which may present a moral crisis: Do I do what I believe is best for the patient or what my employer wants me to do? This question has become a major concern in the practice of medicine in America with alarming consequences.
Some years ago, a psychiatrist named Dr. Wendy Dean began studying the rate of suicide in doctors. She found they were distressingly common, possibly even higher than the rate among active military members, a notion that startled Dean, who was then working as an administrator at a U.S. Army medical research center in Maryland.
Eyal Press, writing in The New York Times, says Dean started asking the physicians she knew how they felt about their jobs, and many of them confided that they were struggling. Some complained that they didn’t have enough time to talk to their patients because they were too busy filling out electronic medical records. Others bemoaned having to fight with insurers about whether a person with a serious illness would be preapproved for medication. The doctors Dean surveyed were deeply committed to the medical profession. But many of them were frustrated and unhappy, she sensed, not because they were burned out from working too hard but because the health care system made it so difficult to care for their patients.
In July, 2018, Dean published an essay with Simon G. Talbot, a plastic surgeon, that argued that many physicians were suffering from a condition known as moral injury. Military psychiatrists use the term to describe an emotional wound sustained when, in the course of fulfilling their duties, soldiers witnessed or committed acts – raiding a home, killing a noncombatant – that transgressed their core values. Doctors on the front lines of America’s profit-driven healthcare system were also susceptible to such wounds, Dean and Talbot submitted, as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and the “realities of making a profit from people at their sickest and most vulnerable.”
It has now been five years since that article was published and Dean has heard a lot from doctors and nurses who reached out to her when they read the article. One recent survey found that nearly one in five healthcare workers had quit their job since the start of the Covid pandemic and that an additional 31 percent had considered leaving.
Professional organizations like National Nurses United, the largest group of registered nurses in the country, had begun referring to “moral injury” and “moral distress” in pamphlets and news releases. Mona Masood, a psychiatrist who established a support line for doctors shortly after the pandemic began, recalls being struck by how clinicians reacted when she mentioned the term. “I remember all these physicians were like, Wow, that is what I was looking for,” she says. “This is it.”
Moral injury – like Post Traumatic Stress Disorder (PTSD), can have serious consequences leading to suicide. Up to 54% of suicides in people with PTSD are attributable to PTSD, according to ScienceDirect.com. The national Center for PTSD persons with PTSD had 5.3 times the rate of death from suicide than those without PTSD. A subsequent study suggested this rate may be as high as 13 times those without PTSD.
We don’t know a lot about moral injury statistics but Dr. Dean’s work suggests it may be as alarming as PTSD. If it is, America has a real healthcare crisis in the making.
(Note: More on this subject in Part II of this series next post.)
