The Healthcare Jungle

To be defeated and to acknowledge defeat are two very different things. Though subtle, the difference means everything to those bearing the yoke of oppression.

This was one of the messages conveyed by Upton Sinclair in his seminal novel, The Jungle (1906). Sinclair had intended the novel to be a manifesto for American socialism, but instead the reading public at the time focused on the abhorrent working conditions of the labor class, and began protesting the health violations and unsanitary practices in the American meat packing industry.

For many physicians and nurses working into today’s healthcare system of corporate medicine, the analogy between their lives and the lives of the characters in the novel may appear uncomfortably similar.

The growth of corporate medicine has come at the cost of physician and nurse autonomy, now ignobly lumped together as providers, who find themselves defined by relative value units (RVU) and hollow satisfaction metrics that capture neither the provider’s nor the patient’s satisfaction.

The art of clinical medicine has been supplanted by the business of corporate medicine, with a clear demarcation between the oppressed and the oppressors, the providers and the corporate administrators.

Medicine has always been something of a cottage industry, localized and unique to specific communities in which the congenial physician took care of everyone in town and knew every patient personally.

That bond allowed for physicians and nurses to care for patients, who in turn trusted the care provided. Physicians would gladly work for hours on end, fully satisfied and happy with their quality of life and care provided.

Now, to regain their quality of life, providers are limiting the time spent caring for patients, and pursuing alterative career paths.

Clinical care has somehow become toxic, and to sustain a career in the field of medicine, providers feel they must limit their exposure to levels tolerable over the long haul. Eventually providers will descend to the lowest common denominator, in which patient care will become nothing more than a transaction – a lab test ordered, an imaging study placed, a medication provided, a treatment rendered.

Transactional medicine is bad for patient care. To reduce medicine to its elemental components, like assembly parts in a car, fails to encompass the full gamut of patient care. A patient is more than its component organs or the total number of medications.

A patient is a person with a clinical condition, and the luminaries of medicine always knew to treat the person as much as the disease.

Instead we find ourselves steadily marching towards reductionist medicine. First with evidence based medicine emphasizing data and guidelines; then with insurance companies benchmarking the cost of care with economic output in financial terms; and now with corporate conglomerates spewing spreadsheet after spreadsheet reinforcing cold hard truths that come with seeing patient care through the lens of cash flow statements.

Inevitably providers will push back. Already we are seeing calls for unionization. A recent article by Dr. Walkton-Shirley on Medscape boasted, “Physicians Need to Unionize Now”, in response to the growing labor demands of corporate medicine.

This would be a natural reaction – and a mistake as well.

To respond to corporate medicine with labor based demands, as a union would, further removes medicine from its fundamental humanistic roots of treating the patient as a person first and foremost.

Medicine is not a battle ground for labor disputes. It is an environment for complex thinking designed to elucidate clinical diagnoses and implement therapeutic interventions – while treating the person with the disease. Even something as simple as a prescription refill is not a proxy for labor, to be contested through economic models of labor and work output.

Yet to respond to corporate medicine with a labor-based argument assumes just that – and further reinforces the premise that medicine can be improved upon through production techniques and tools for operational efficiency.

Soon providers will learn kaizen, or Japanese manufacturing techniques for improvement, alongside the fundamentals of clinical medicine.

Physicians and nurses need to reset the context of conversation, and the perception created by corporate medicine – that healthcare can be defined through manufacturing based models.

Medicine is a skill, a complex one at that, not a scalable platform with a defined unit economic model.

Rather than reacting to corporate medicine in a way that legitimizes labor disputes, providers should focus on care models that incorporate social determinants of health, and address complex healthcare disparities – some of which we just learned through the pandemic.

These trends are effectively modern renditions of a time when the town physician knew his and her patients professionally and personally, and reflect a more meaningful shift in medicine.

One that goes away from this manufacturing model of healthcare, and towards the belief that medicine treats all aspects of a patient – person and disease.

For physicians and nurses to relinquish that belief is to truly acknowledge defeat.

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