In Parts I and II, we have discussed a managerial revolution taking place in medicine. This revolution is changing the way medicine is practiced because most doctors (70%) are no longer in private practice but work for a hospital system, corporation, or the government.

In Part II we learned that there are four tenets of the managerial ideology that drives this new method of healthcare delivery. The first was technocratic scientism, which is the belief that everything, including society and human nature, can and should be fully understood and controlled through materialist scientific and technical means, and that those with superior scientific and technical knowledge are therefore best placed to govern society.

In Part III we will discuss the other tenets of managerial ideology.

Aaron Kheriaty, writing in The Epoch Times, tells us the second tenet of our managerial ideology is utopian progressivism, or the belief that a perfect society is possible through perfect application of scientific and technical knowledge and that the Arc of History bends toward utopia as more expert knowledge is acquired. He tells of a conversation with a nurse ethicist from Johns Hopkins a few years ago who was giving a guest lecture at the medical school where he taught. “She remarked that Johns Hopkins Hospital used the marketing tagline “The Place Where Miracles Happen.” Medicine is clearly not immune from utopian progressivism, even if it’s only cynically tapping into this ideology for public relations purposes.

The third feature of the managerialist ideology is liberationism, the belief that individuals and societies are held back from progress by the rules, restraints, relationships, historical institutions, communities, and traditions of the past—all of which are necessarily inferior to the new, and which we must therefore be liberated from in order to move forward. Contrary to this ideology, there are some things in medicine that will never change.

Dr Kheriaty says, “At its foundation, medicine is constituted by a particular kind of relationship, one based upon trust between a patient made vulnerable by illness and a doctor who professes to use his knowledge and skills always and only for the purposes of health and healing. No technological advance, no societal development, will ever alter this. The ends, or purposes, of medicine are baked into the kind of profession that it is, grounded in the realities of health, illness, and the human body.”

This liberationism has led to all kinds of perverse thinking. “Why limit ourselves to healing when we can turn men into women, women into men, and humans into bigger, faster, stronger, smarter post-humans or super-humans? Liberationist projects will free man not just from the ravages of illness, but from the constraints of human nature itself,” says Kheriaty.

The most grotesque example of this kind of thinking is so-called “gender-affirming care.” Kheriaty tells us this is quickly crumbling under the weight of evidence showing that puberty-blocking hormones, cross-sex hormones, and surgeries that destroy healthy reproductive organs have not improved the mental health outcomes of gender-dysphoric youth.

“What has unfolded in the past several years with the explosion of “gender-affirming care” was largely driven not just by the liberationist ideology, but also by financial considerations and the desire to create a cohort of lifelong patients entirely dependent on the health care system, who were once otherwise physically healthy. The result has been a form of institutionalized and medicalized child abuse fueled by social contagion and sustained by the slandering and silencing of critics. Gender medicine will go down as one of the greatest scandals and follies of medical history, and is poised to soon globally collapse under the weight of its own contradictions.”

The fourth feature of the managerial revolution is homogenizing universalism, or the belief that all human beings are fundamentally interchangeable units of a single universal group and that the systemic “best practices” discovered by scientific management are universally applicable in all places and for all peoples. Therefore, any nonsuperficial particularity or diversity of place, culture, custom, nation, or government structure anywhere is evidence of an inefficient failure to converge successfully on the ideal system; progress always naturally entails centralization and homogenization.

What are the outcomes of these tenets of managerial ideology?

Dr. Kheriaty answers, “None of this improves medical outcomes. In fact, they often worsen medical outcomes by mandating a one-size-fits-all approach to clinical care. This compromises physicians’ appropriate clinical judgment and discretionary latitude. Doctors are pushed to hit metrics on measurements like blood pressure, even if this does not actually improve meaningful outcomes like heart attacks or strokes.”

Could there be an incentive for doctors to overprescribe medications?

These guidelines are often pushed by industry groups that have a vested interest in expanding disease categories or widening disease definitions. “Let’s lower the threshold for what counts as hypertension or high cholesterol so that more patients get on antihypertensives and statins,” for example. If doctors don’t comply, we don’t get paid. It does not matter whether putting more patients on statins fails to save lives. This leads, among other issues, to preventative overprescribing. In the United States, 25 percent of people in their 60s are on five or more long-term medications. That number rises to 46 percent for people in their 70s, and 91 percent for nursing home residents.

Dr. Kheriaty calls for the development of parallel medical institutions – entirely new models of clinical care and reimbursement – started by physicians who opt out of this perverse system entirely. For this to happen, we will need an entirely new era of doctors who hold fast to the beliefs of past generations like mine who went into medicine to put the patient ‘s interests first – not the medical institution.

In Part I we talked about a new managerial revolution that is taking place in medicine today.

Aaron Kheriaty, writing in The Epoch Times, tells us the managerialist ideology consists of several core tenets, according to Washington-based writer and analyst N.S. Lyons. The first is technocratic scientism, or the belief that everything, including society and human nature, can and should be fully understood and controlled through materialist scientific and technical means, and that those with superior scientific and technical knowledge are therefore best placed to govern society.

This ideology manifests itself in medicine through the metastatic proliferation of top-down “guidelines,” imposed on physicians to dictate the management of various illnesses. These come not just from professional medical societies but also state and federal regulatory authorities and public health agencies.

“Guidelines” is in fact a euphemism designed to obscure their actual function: They control physicians’ behavior by dictating payments and reimbursement based on hitting certain metrics. In 1990, the number of available guidelines was 70; by 2012, there were more than 7,500. In this metastatic managerial regime, the physician’s clinical discretion goes out the window, sacrificed on the altar of unthinking checklists. As every physician knows from clinical experience, each patient is sui generis, unrepeatably unique.

Dr. Kheriaty says, “Real patients cannot be adequately managed by a diagnostic-based algorithm or treated by an iPad. Checklists are useful only once the problem has been understood. For the practitioner to be able to make sense of problems in the first place requires intuition and imagination—both attributes in which humans still have the edge over the computer. Problem-solving in a complex environment involves cognitive processes analogous to creative endeavors, but medical education as currently configured does not cultivate these capabilities.”

Technocratic scientism has likewise driven the campaign for so-called “evidence-based medicine” (EBM)—the application of rationalized expert knowledge, gleaned typically from controlled clinical trials, to individual clinical cases. At first glance, evidence-based medicine seems hard to argue with—after all, shouldn’t medical interventions be based on the best available evidence? But this model has serious flaws, which have been exploited by Big Pharma. Studies yield statistical averages, which apply to populations but say nothing about individuals. No two human bodies are exactly alike, but technocratic scientism treats bodies as fungible and interchangeable.

By this way of thinking, treating patients might just as easily be done by robots – plug in the symptoms, out comes a diagnosis and treatment. No need for any human intervention. I’m sure there are those who would agree with this approach, but doctors know better. Medicine is both science and art – a unique blend of scientific knowledge and human experience that only can be applied by humans.

EBM proponents claim we should only use the “best available evidence” to make clinical judgments. But this sleight-of-hand is deceptive and wrong: We should use all available evidence, not just that deemed “best” by self-appointed “experts.” The term “evidence-based” functions to smuggle in the claim that double-blinded, randomized, placebo-controlled trials (RCTs) are the best form of evidence and therefore the gold standard for medical knowledge.

Dr. Kheriaty says, “This results in, among other things, the scrapping of the entire discipline of epidemiology. EBM’s criteria constitute Big Pharma propaganda masquerading as the “best” expert scientific and technical knowledge.”

(Note: More on managerial ideology and its impact on medicine next post.)

There is a revolution taking place in medicine and it forebodes poorly for the future of patient healthcare. I’ve written about changes in healthcare in the past and have even published a book, Changing Healthcare, to discuss some of what is happening.

When I began my practice in 1984, most doctors were self-employed or employed by other doctors. The only doctors who weren’t were mostly pathologists and radiologists who worked for hospitals. Today, about 70% of all doctors are employed by hospitals, large healthcare systems, or the government.

What is the impact of this change?

Simply put, doctors are no longer in control of their decisions about treating patients. They are pressured by the employers they work for to save money by limiting costly expenses or make money by performing costly procedures. Money has become the driving influence in healthcare whereas before the patient’s welfare generally came first. Doctors are trained to do what’s best for their patients, but when others have the final say, the patient’s best usually gets forgotten.

To add to this mess, patients are losing trust in their doctors, and in scientists in general. According to Pew Research, the number of U.S. adults who place confidence in medical scientists to act in the best interests of the public declined from 40 percent in 2020 to 29 percent in 2022. You can thank the Covid pandemic for this decline in trust. However, even 40 percent is much lower than the confidence people had in their doctors fifty years ago.

All of this is driving doctors to retire early or leave the profession for greener pastures. I’ve written about the doctor shortage before (Physician Shortage Getting Worse – 2024) so I’ll not belabor that issue here. But there is new information that further explains this decline.

There is a new revolution taking place in medicine that some have called the managerial revolution. Aaron Kheriaty, a physician and fellow at The Ethics and Public Policy Center, writing in The Epoch Times tells us that medicine, like many other contemporary institutions since WWII, has succumbed to managerialism – the unfounded belief that everything can and should be deliberately engineered and managed from the top down. He says, “Managerialism is destroying good medicine.”

The managerialist ideology consists of several core tenets, according to Washington-based writer and analyst N.S. Lyons. The first is technocratic scientism, or the belief that everything, including society and human nature, can and should be fully understood and controlled through materialist scientific and technical means, and that those with superior scientific and technical knowledge are therefore best placed to govern society.

This is a new concept in medicine, but one that has been prevalent in politics for some time. Angelo Codevilla, professor at Boston University, wrote about this in 2010 in a book entitled The Ruling Class. In it he warns us there is an elite group of individuals from both political parties who see themselves as the only ones fit to make decisions for the people “for the good of the country.” This antidemocratic ideology has infiltrated our political system and is a real threat to our democracy.

The same way of thinking threatens our healthcare system as doctors are forced into a one-size-fits-all mentality that may be good for business but not so much for patients. As any physician knows, every patient is an individual and decisions based on the population as a whole rarely are best for that patient.

How does this way of thinking manifest itself in medicine?

(Note: I’ll discuss the answer to this question in the next post.)