Beyond a Corporate Model of Healthcare (Part I)

As a resident physician, I find it interesting that the most prominent public role models for medical humanism are all dead: Maimodedes, William Carlos Williams and Oliver Wendell Holmes come to mind first. I, like all doctors, have my own medical idols whom I keep cloistered until periods of ennui or desperation. The few that come to mind also happen to be writers: David Hilfiker, an activist for HIV and palliative care patients, and Bernard Lown, a prominent cardiologist who received the Nobel prize for activism on antinuclear weapons. Speaking philosophically, my idols are central to my subjectivity. I mention my own role models as a preface to a few larger questions. What is the response of the medical profession to a renewed call to humanism? How do we understand the forces that shape medicine’s response – ethical, legal, economic? Finally, should we be satisfied with it?

In order to talk about subjectivity, it is helpful to talk about it’s invisible opposing force that gets less airtime: objectification. Marx’s description of objectification as a person’s distance from her products of labor is useful here. Clinician labor is increasingly removed from the living. As medicine becomes more oriented towards reducing risk, the results of our labor becomes more opaque. The surgeon may see their outcomes in the flesh, but for the general practitioner the outcomes are statistical – by giving aspirin to reduce the risk of heart attack by a minute percentage over decades, or decrease the stroke risk by controlling abnormal heart rhythms. As our society becomes more technological, we become objectified and removed from the products of our labor. It is not only clinicians who are subject to objectification; it is also patients.

In the past decade, there is a growing movement of patient advocacy, with heightened awareness of producing physicians who can connect with patients as human beings. The new slogan of Beth Israel Medical Center, a Harvard Affiliate, comes to mind: “Human First,” two words emblazoned on buses and billboards across Boston. One could say that this is a humanistic movement against patient objectification – against the notion of the human body as a machine, but this is only part of the picture. We have come around to this as a profession for more than purely humanistic concerns. Economically, patient satisfaction scores are increasingly used as markers of quality, and are tied to hospital reimbursement. It is also well known that physicians who are able to listen, take ownership of mistakes, and apologize, result in fewer successful lawsuits.

Increasingly, we hear article after article exposing healthcare’s toxic effects on the emotional and psychological lives of caregivers. Physician satisfaction is often framed as an economic issue. After all, happiness leads to productivity. When it comes to the psychological aspects of clinician objectification – decrease in face-to-face communication with colleagues, increasing bureaucratic demands, and devaluation of time spent with patients, the medical profession response is academic and distant. Ironically, the very concept of subjectivity, personhood, or well-being of the physician has been pathologized and codified as one who has “burnout,” characterized by the triad of depersonalization, lack of achievement and emotional exhaustion. There is even a new Journal of Burnout Studies. The ultimate telos of burnout studies may be to increase the well-being of practitioners. However, well-being is not defined in terms of what matters to them, the content of their interactions, or what they care about.

The language of Marx is useful here because it uncovers how economic forces not only contribute to the objectification of workers, but also simultaneously provides the framework for modern medicine’s humanistic turn. The slogan “Human First” is first and foremost a marketing tool to attract patients. In a similar way, the push towards “patient-centered care” comes from the increased reimbursement tied to patient-centered outcomes. Part of the disconnect may be in the process of measurement itself – in medicine’s increasing attempts to describe “physician satisfaction” or “humanism” in strictly quantitative measures. The deeper point is that medicine’s humanistic turn is less a return to first principles and increasingly a response to a corporate model of healthcare, which views patients as consumers (albeit ones who desire human contact) and physicians as productive labor, controlled and motivated by economic incentives.

A hierarchical corporate structure to medical care is not inevitable, but a societal choice, and one that ought to be actively questioned. It should not be surprising that countries with a stronger public health system have higher rates of satisfaction among practitioners, and less need for such a patient advocacy movement. Such countries, the UK in particular, also have a more humane approach to clinical trainees – as recently as 2008 debating seriously reducing maximum work hours of residents from 56 to 48 (in the US, it is unimaginable to cap work at below 80 hours per week). This begs the question: perhaps it is the corporate model itself that contributes to alienation and objectification of its workforce?

I am not satisfied with medicine’s humanistic turn because it conflates the ethical with the economic, and dresses it as human. What I admire in reading David Hilfiker or Bernard Lown is more than their productivity or ability to produce satisfied patients. Yes, they would likely score high on these metrics. But often not. Take the case of an 86-year-old alcoholic, with declining memory due to alcohol use. To explore his reasons for drinking, family situation, degree of cognitive impairment, and provide extensive counseling and close follow-up may neither produce patient satisfaction (the patient wants nothing to do with you) nor be economically productive (his prolonged visit deferred two new physical examinations, which are more highly reimbursed).

What, then, might be a positive notion of patient-clinician subjectivity? I propose two solutions, which I will tackle in the second part of this column.  First, we need to reinvigorate the notion of caring as central to medical practice. Second, we need to recognize and fight against the encroachment of economic language into medical practice.

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4 thoughts on “Beyond a Corporate Model of Healthcare (Part I)

  1. Tom, you make a really clear and important point here: valuing humanity within the medical system is not inherently ethical if it’s only towards economic ends. And your diagnosis of where this comes from is especially interesting to me coming from education, where certain people are more and more apt to use the language of economics (more specifically, business) in order to justify reform.

    I wonder if the sweet spot is finding interventions or reforms that create non-measurable results (happiness in people) and measurable results (economic returns)? As I develop myself as an early learning activist, I am excited by the prospect of universal quality early learning as a program that will increase the unmeasurable and the measurable results that our society seeks.

    Tom, I wonder if there’s something similar in medicine…something that would offer that “sweet spot” that early learning may offer to the world of education?

    Or, given that recent study that linked obesity at ages 0-5 with lifelong obesity, is that sweet spot in medicine also found in early interventions?

    1. Thanks for the insights. Yes, I think there are overwhelming parallels between how education/health care has become corporatized in the US, in particular in regards to narrowly defined measures. In regards to the “sweet spot” you refer to, I actually think that there happiness/well-being can be measured, in the quite simple way of talking to people, asking their experiences, what their vision of their work is, rather than assessing them on scales. I think we do a similar disservice in education by valuing test-taking ability above other forms of assessment/intelligence/leadership, which are better assessed qualitatively. Early intervention is interesting in that it is economically beneficial, but also “ethical” in the sense that most people would agree giving kids authentic learning early on is a good we should value. Again, though I think the economic rhetoric is powerful here. Were it not to save money down the line, we should still do it!

  2. Tom, You’re highlighting important and provocative questions, and I’m eager to see what answers you suggest about how to make caring more important than counting. Given how expensive our current system, it seems unlikely that reforms could take place without reference to the fiscal bottom line, but you’re right to ask whether this really needs to occupy so much of our focus. Do you think the medical home offers a chance to do things better, with less attention to the charge attached to each intervention and more attention to teamwork among those who can confront the alcoholic as well as treat his pancreatitis? And what do you think can help us recover our subjectivity? Maybe we need better connections to what is transcendent for us individually and as teams of clinicians working together…

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