Introducing Acute Condition: Mid-COVID-19, what will doctors do now?

Even before the COVID-19 pandemic, the medical field was rife with discontent. The statistics are alarming: doctors have one of the highest suicide rates of any profession; nurses are subject to stagnant wages and restrictive noncompetes. Electronic health records are confusing and frustrating.

A lot of these trends are a direct result of the increased corporatization and consolidation of hospitals. The administrative layer in hospitals has expanded dramatically, by about 3,200% between 1975 and 2010, compared to a 150% increase in practicing physicians over the same time period. The administrators brought on consultants. And consultants worked hard to streamline and optimize hospital operations, while encouraging hospitals to expand their control by buying competitors. Unfortunately, they optimized hospitals for efficiency in billing, rather than superior patient care.

In my job at American Economic Liberties Project, I wrote about these trends before COVID-19. But the pandemic is accelerating the worst parts of the health care system—physicians losing their autonomy, hospitals extending their (expensive and anti-competitive) reach, and the disproportionate effects of these on the most vulnerable—prompting me to write about it more in-depth in this newsletter, Acute Condition.

---

In the simpler times of January 2020, I wrote in Current Affairs about the phenomenon of physician labor organizing to push back against, in a memorable quote by Dr. Eric Topol, their administrative “human overlords.” Topol and others had created organizations and social media groups dedicated to organizing health care workers around patient care, rather than financials or optimization metrics.

Then, the pandemic hit.

COVID-19 exposed the nasty innards of efficient, corporatized health care to the public en masse for the first time. As Dr. Siddhartha Mukherjee wrote in the New Yorker in May, “The numbers in the bean counter’s ledger are now body counts in a morgue.” In other words, the health care system streamlined itself so much that it was unprepared for an actual health crisis.

Hospitals fired some of their most valuable employees but kept their fundraising staff coming into the office. They cut nurses’ pay. At least one spent billions on stock buybacks just before the pandemic hit the US—but then begged the public to donate more PPE. Trapped inside their houses, feverishly following the news, people were left wondering, how are hospitals allowed to do that?

For doctors and nurses on the front lines, asking why their hospital administrators were failing to support them was a luxury. They were buried in COVID patients and working long shifts under the threat of infection. Some health care workers who did speak out were summarily fired. Any plans for organized health care worker protests were necessarily put on hold.

Now that the pandemic has started to crest, I wanted to know how doctors are conceiving of all this. Interestingly, the pandemic seems to have reminded physicians of their value within the medical system (patient care, not electronic medical records) and empowered them to act as patient advocates at a political level. In fact, physician burnout, a perpetual problem, seems to be down now that physicians have a “new sense of shared purpose.”

When I talked to Dr. Eric Topol, he reflected this hopefulness. Not about the course of the virus—he expects we’ll have to deal with it for a few more years—but about how this will impact the medical profession. “It isn’t just one issue. There was the [physician] burnout, there is the pandemic, there is the other virus of racial discrimination, and all of this together is, I think, bringing the physician group, hopefully, to rise and come together to confront it meaningfully, in solidarity.”

Dr. Andrew Goldstein, an internist affiliated with NYC’s major public hospital and who moderates @ProgressiveMDs on Twitter, is also hopeful. In the initial wave of the pandemic, beyond the administration not taking decisive action, he was most frustrated by public health experts. Because physicians can only treat patients once they have symptoms, public health officials are essential to stemming transmission. Being a physician and watching public health leadership be subsumed to political expediency, said Goldstein, is “like [being] in the backseat of a car that you don’t drive and you know exactly the accident that’s about to happen and…all you can do is scream.”

Implicit in his critiques of public health officials and physicians—primarily that they, as a group, have focused too much on personal protective equipment and not enough on sustained political action—is the hope that health workers become more political than they currently are.

And Goldstein is hopeful for a more political future, where doctors have a louder voice in matters of patient care and hospital administration. Public health experts might not have spoken up soon enough, but most areas in the U.S. did shut down for a time. Physicians may not have been loudly calling for contact tracing, but Goldstein was inspired by the many health workers who assisted BLM protestors. “I’m neither hopeful nor pessimistic based on what I saw transpire, because it was both so much better than what it could’ve been, but so much worse than it could’ve been,” said Goldstein. What he sees, then, is “the possibility” for change.

Cynthia Vlad, a fourth year student at Albert Einstein College of Medicine in the Bronx, agrees that the role for physicians is changing. She thinks the pandemic will motivate a big swath of doctors to “actually address access problems” on a political level. “Advocating for patients on a national level [during the pandemic],” she said, “inspires a new wave of doctors who work towards different solutions.”

Similarly, Soleil Shah, a Fulbright scholar and second year student at Stanford Medical School (and a former colleague of mine), thinks there’s a lot of possibility for structural change post-pandemic. He’s “more hopeful that we’ll move away from outdated models and towards better ones,” he wrote me.

There is a chance, though, that rebuilding the health care system post-pandemic looks a lot like further entrenching the existing system. Shah told me that one of his biggest concerns is that independent physician offices “will get acquired by mammoth systems or private equity.” This, he noted, is “bad for patients and doctors alike” and will simply “preserve the status quo.” Indeed, several hospitals have already started to make noise about merging, an arrangement that rarely lives up to its purported benefits and often decreases the power of health care workers within the system.

Now, as we entered a sustained phase of the pandemic, there is a fork in the road for the medical profession. The less hopeful path sees public health officials further silenced, physicians brought to heel under huge hospital systems, and political speech by health workers curbed. The other path—one hoped for by all the medical professionals I spoke to—is a more empowered, diverse health care workforce, with more independent practices and patient relationships. To get there, though, health care workers will have to discover their political voice and start organizing for the future.