In Part I and Part II of this series, we’ve talked about a new condition, known as moral injury, which is plaquing physicians and nurses who are employed by hospitals and large corporations, because they feel they must compromise their best judgement in treating patients. The pressure from their employers is making them treat their patients in ways that sacrifice their moral values for the sake of corporate profits.

Eyal Press, writing in The New York Times, has called attention to this phenomenon, which was first reported by a psychiatrist, Dr. Wendy Dean, who worked for the U.S. Army. Dean has continued her study of the problem and finds it is increasing as more and more physicians leave private practice and join hospital or large corporate staffs.

 Press interviewed one emergency room physician who insisted she remain anonymous for the interview. She had recently taken a leave of absence and was unsure if she would return. “It’s all about the almighty dollar and all about productivity,” she said, “which is obviously not why most of us sign up to do the job.”

Press says that’s not always clear to patients, many of whom naturally assume that their doctors are the ones who decide how much time to spend with them and what to charge them for care. “Doctors are increasingly the scapegoats of systemic problems within the health care system,” Mona Masood, a psychiatrist says, “because the patient is not seeing the insurance company that denied them the procedure, they’re not seeing the electronic medical records that are taking up all of our time. They’re just seeing the doctor who can only spend 10 minutes with them in the room, or the doctor who says, ‘I can’t get you this medication, because it costs $500 a month.’ And what ends up happening is we internalize that feeling.”

Press writes, “Concerns about the corporate takeover of America’s medical system are hardly new. More than half a century ago, the writers Barbara and John Ehrenreich assailed the power of pharmaceutical companies and other large corporations in what they termed the “medical industrial complex” which, as the phrase suggests, was anything but a charitable enterprise. In the decades that followed, the official bodies of the medical profession seemed untroubled by this. To the contrary, the American Medical Association consistently opposed efforts to broaden access to health care after World War II, undertaking aggressive lobbying campaigns against proposals for a single-payer public system, which it saw as a threat to physicians’ autonomy.”

I am no fan of the American Medical Association and dropped my membership over thirty years ago. Today, only about 12% of American physicians are members of the AMA. However, I will defend the AMA’s efforts to oppose a single-payer public system, which is simply the road to socialized medicine. Ironically, the same AMA was quite cooperative in facilitating the passage of the Affordable Care Act (ObamaCare) by the Obama Administration some 50 years later, which was a big step forward in the effort to implement socialized medicine.

A single-payer public healthcare system would quickly put private insurance plans out of business since they couldn’t match the lower pricing when the taxpayer picks up the tab for declining revenues. But what is happening now is a gradual corporate takeover leading to a gradual government takeover. The more healthcare is driven by the corporate world, and not independent physicians, the more the government will ultimately be able to control healthcare. That’s the long-term goal of progressives in Washington.

Press writes, “Throughout the medical system, the insistence on revenue and profits has accelerated. This can be seen in the shuttering of pediatric units at many hospitals and regional medical centers, in part because treating children is less lucrative than treating adults, who order more elective surgeries and are less likely to be on Medicaid. It can be seen in emergency rooms that were understaffed because of budgetary constraints long before the pandemic began. And it can be seen in the push by multibillion-dollar companies like CVS and Walmart to buy or invest in primary-care practices, a rapidly consolidating field attractive to investors because many of the patients who seek such care are enrolled in the Medicare Advantage program, which pays out $400 billion to insurers annually. Over the past decade, meanwhile, private-equity investment in the healthcare industry has surged, a wave of acquisitions that has swept up physician practices, hospitals, outpatient clinics, home health agencies. McNamara estimates that the staffing in 30 percent of all emergency rooms is now overseen by private-equity-owned firms. Once in charge, these companies “start squeezing the doctors to see more patients per hour, cutting staff,” he says.

What impact have these changes had on careers in medicine?

(Note: I’ll address this question and more in the next post – Part IV)

In Part I of this series, I discussed a new condition called moral injury, which occurs when physicians and nurses are compelled to make decisions they don’t believe are in the best interests of their patients. There has been a transformation of the healthcare system in the last 50 years that has caused this problem.

Fifty years ago, most physicians were employed in private practices where they had the freedom to make their own decisions without second-guessing. Today, most physicians are employed by hospitals or large corporations that dictate the practices of medicine for them. This can lead to mental anguish, called moral injury, when their decisions conflict with their own moral values. It is a condition not unlike Post Traumatic Stress Disorder (PTSD), which is commonly experienced by soldiers in war.

We know that PTSD is highly correlated with the alarming statistics of suicide in military veterans. It now appears the same phenomenon may be occurring in physicians who no longer work in private practices.

Eyal Press, writing in The New York Times, has called attention to this phenomenon, which was first reported by a psychiatrist, Dr. Wendy Dean, who worked for the U.S. Army. Dean has continued her study of the problem and finds it is increasing as more and more physicians leave private practice and join hospital or large corporate staffs.

Press had interviewed workers in menial occupations whose jobs were ethically compromising, such as prison guards who patrolled the wards of violent penitentiaries, undocumented immigrants who toiled on the “kill floors” of industrial slaughterhouses and roustabouts who worked on offshore rigs in the fossil-fuel industry. But physicians seemed exempt from these work conditions due to their higher wages and prestigious jobs – until now. In recent years, despite the esteem associated with their profession, many physicians have found themselves subjected to practices more commonly associated with manual laborers in auto plants and warehouses, like having their productivity tracked on an hourly basis and being pressured by management to work faster.

Emergency Room doctors seem to be especially vulnerable. E.R. doctors have found themselves at the forefront of these trends as more and more hospitals have outsourced the staffing in emergency departments in order to cut costs. A 2013 study by Robert McNamara, the chairman of the emergency-medicine department at Temple University in Philadelphia, found that 62 percent of emergency physicians in the United States could be fired without due process. Nearly 20 percent of the 389 E.R. doctors surveyed said they had been threatened for raising quality-of-care concerns, and pressured to make decisions based on financial considerations that could be detrimental to the people in their care, like being pushed to discharge Medicare and Medicaid patients or being encouraged to order more testing than necessary. In another study, more than 70 percent of emergency physicians agreed that the corporatization of their field has had a negative or strongly negative impact on the quality of care and on their own job satisfaction.

Of course, many physicians are quite happy with their work and their profession. But most of those in my unofficial surveys are still in private practice. More and more doctors are coming to believe that the pandemic merely worsened the strain on a healthcare system that was already failing because it prioritizes profits over patient care. They are seeing how the emphasis on the bottom line routinely puts them in moral binds, and young doctors in particular are contemplating how to resist.

“I think a lot of doctors are feeling like something is troubling them, something deep in their core that they committed themselves to,” Dean says. She notes that the term moral injury was originally coined by the psychiatrist Jonathan Shay to describe the wound that forms when a person’s sense of what is right is betrayed by leaders in high-stakes situations. “Not only are clinicians feeling betrayed by their leadership,” she says, “but when they allow these barriers to get in the way, they are part of the betrayal. They’re the instrument of betrayal.”

(Note: More on this subject in Part III of this series.)

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.)