This is the fourth in a series of posts regarding the moral crisis doctors and nurses are facing in today’s healthcare system. This dilemma is largely experienced by those healthcare providers employed by hospitals and large corporations, who dictate the policies these providers must follow when treating their patients. I strongly encourage you to read the first three parts of this series before reading the fourth. They can all be found on my blog home page on the left side of the screen.
In Part III, I discussed how the corporate world is taking over medicine through large hospital systems and large corporate healthcare providers. Profits are driving the decisions doctors must make or risk losing their jobs. This has created a moral injury when their treatment decisions violate their moral values and medical training. This leads to early retirement, career changes, and even suicides. There is some evidence that these healthcare providers may be experiencing suicide rates approaching the rates of military veterans suffering from PTSD.
This phenomenon is driven by the increasing number of physicians leaving private practice and entering into employment contracts with hospitals and large corporations. Some surveys have estimated only 26% of physicians remain in private practice today. Over 135,300 physicians are now employed by hospitals or large corporations. This is a paradigm shift in the practice of healthcare.
What impact has this paradigm shift had on careers in medicine?
Eyal Press, writing in The New York Times, says, “As the focus on revenue and the adoption of business metrics has grown more pervasive, young people embarking on careers in medicine are beginning to wonder if they are the beneficiaries of capitalism or just another exploited class. In 2021, the average medical student graduated with more than $200,000 in debt. In the past, one privilege conferred on physicians who made these sacrifices was the freedom to control their working conditions in independent practices. But today, 70 percent of doctors work as salaried employees of large hospital systems or corporate entities, taking orders from administrators and executives who do not always share their values or priorities.
Philip Sossenheimer, a 30-year-old medical resident at Stanford, told me that these changes had begun to precipitate a shift in self-perception among doctors. In the past, physicians “didn’t really see themselves as laborers,” he notes. “They viewed themselves as business owners or scientists, as a class above working people.” Sossenheimer feels that it is different for his generation, because younger doctors realize that they will have far less control over their working conditions than their elders did — that the prestige of their profession won’t spare them from the degradation experienced by workers in other sectors of the economy. “For our generation, millennials and below, our feeling is that there is a big power imbalance between employers and workers,” he says.”
This sense of powerlessness has led many resident physicians to form unions. At Stanford, the medical resident voted to form a union by a tally of 835 to214. This has led to others forming unions in an attempt to have some measure of control over their environment and working conditions.
Forming unions is just one way that patient advocates are finding to push back against such inequities. Critics of private equity’s growing role in the health care system are also closely watching a California lawsuit that could have a major impact. In December 2021, the American Academy of Emergency Medicine Physician Group (A.A.E.M.P.G.), part of an association of doctors, residents and medical students, filed a lawsuit accusing Envision Healthcare, a private-equity-backed provider, of violating a California statute that prohibits nonmedical corporations from controlling the delivery of health services. A.A.E.M.P.G.’s aim in bringing the suit is not to punish one company but rather to prohibit such arrangements altogether. “We’re not asking them to pay money, and we will not accept being paid to drop the case,” David Millstein, a lawyer for the A.A.E.M.P.G. has said of the suit. “We are simply asking the court to ban this practice model.” In May 2022, a judge rejected Envision’s motion to dismiss the case, raising hopes that such a ban may take effect.
But the solution is not in litigation; it is in returning to the private practice of medicine. Physicians who have entered into employment agreements with hospitals or large corporations have done so because they were attracted by guaranteed salaries and benefits, freedom from the business of medicine, and regular working hours. But they didn’t recognize they were paying a high price for those benefits – the loss of freedom to make their own medical decisions. That’s a price I would never agree to pay and neither should other physicians. When they realize the price was too high, they will return to the practice of private medicine and both they and their patients will be happier.
