Have physicians finally joined the working class?

Physicians are known to be masters of self-sacrifice, and self-control. They undergo years of training and make substantial emotional and financial sacrifices until they complete their training. The reward at the end of the road is a fulfilling job where he or she can treat people who are in need and enjoy the emotional, personal, and financial fruits of their labor.

But is this the reality? At a time when the job satisfaction of physicians is at all time low, and burnout at all-time high, alarming depression rates, and a shocking 400 physicians suicide per year in the United States. One can’t help but wonder if physicians have finally joined the working class.

The popular belief is that working classes are comprised of those who are paid minimum wage and who cannot make ends meet, while physicians are compensated well financially, relative to those in other professions. However, this income-based classification is misleading. The working class represents workers who have lost control over their means of production, and are in turn controlled by members of another class.

With the rapid “industrialization” and “commodification” of medicine, an increasing number of doctors are deserting private practice for large heath systems and employment in hospitals.  Only one-in-three physicians will remain independent by the end of 2016, and three in four medical residents will start their career as employees of a medical group, hospital, or faculty plan.

This trend is not arbitrary; there is a strong movement facilitated by ACA to consolidate doctor networks, and to turn them into salaried employees of hospitals and health plans. The aim, is to control service utilization and make health care delivery more coordinated and efficient.

This change would not necessarily be all negative. Consolidating doctors will help to deliver more efficient services at a lower cost. Doing so may provide security and peace of mind to doctors in the current challenging financial and regulatory environment. However, this change is coming at a steep price for providers and patients. Physicians need to be cognizant that they are trading away autonomy, control over decision-making, and at times their ability to influence the work process. Giving up autonomy and means of production results in alienation of physicians from each other, alienation from the work being done, alienation from their patients, and ultimately alienation from themselves.

To meet the complex nature of service delivery, health systems have created inflated bureaucracies, with numerous administrators and middle managers to manage the system of production. This has led to two parallel sets of workers in a system, often with broken lines of communication. Over time, a distinctively antagonistic relationship has developed between physicians and the bureaucracy that controls them.  A hierarchical bureaucracy now controls the daily work of physicians, and management’s  power is based on the concentration of decision-making authority and information needed in planning and controlling the system. The oppression of the physician working class is a result of their exclusion from the decision-making process.

There have been increasing complaints about the concentration of money and power among the managers of health systems, coupled with the increasing tendency to fill the ranks of administrators and hospital CEOs with people lacking clinical background. The official explanation for this trend is that systems are becoming increasingly complex, and that managing the business of health care necessitates control by business minded people.  This has created a clear split between administrators vs. doctors and nurses regarding dealing with clinical protocols and procedures.

In this challenging environment, physicians’ identities are increasingly being changed and molded to fit the chain of production. Physicians are described as a collection of FTEs (full-time equivalents). They are referred to as providers or prescribers, and they are increasingly viewed as workers whose job it is to deliver health care to costumers or consumers. The physician-patient relationship is seen as a business transaction between vendors and purchasers. “It is difficult for physicians to take themselves seriously as professionals if patients treat them with the same suspicion as snake oil salesmen.”  In this system, the ability to work becomes commodified and sold in the marketplace in 15-minute units., and physicians perceive their work as simply executing the checklists and demands that are coming from their employer.  In time, there is a sense that patient consultations are closer to mundane processes in a long production line, rather than a fulfilling system for improved health.

Given the nature of this situation, it is no wonder that so many patient safety and quality improvement initiatives, checklists, and “practice improvement” campaigns fail. They fail because often these campaigns are perceived as external demand, as opposed to something physicians freely choose because they believe in it.” As a result, physicians are increasingly alienated from their work. Decisions regarding who to take care of, when, where, and what therapy should be administered at what cost are increasingly determined by the employer or the insurer – and not the practicing physician. With the quality of the work delivered increasingly determined by process measures that are imposed externally, physicians will eventually be less satisfied by and fulfilled by their work.

In order to deal with the frustration of physicians, the employer provides two different types of solutions. The first is based in offering  R&R, relaxation workshops, and personal growth retreats to offset the negative impact of the alienation caused by the existing unpleasant work environment. The second to ask physicians to do more training. The CME (continuing medical education) industry is growing at a fast pace especially after the introduction of the maintenance of certification (MOC) requirements, which has encountered much resistance from the medical profession.

All of the forgoing suggests that doctors need to identify the problems they face in clear terms, and need to embrace their working class identity. Only then will they be able to identify possible solutions and create a practical plan of action.

Andres Barkil-Oteo is a psychiatrist and can be reached on Twitter @andre06511.

Image credit: Shutterstock.com

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