News trends come, and news trends go. The coronavirus disease (COVID-19) pandemic is a news topic that, for the time being, is here to stay. This pandemic has already revealed deeper issues within the culture of medicine here in the United States and focused young physicians on what really matters.
As this pandemic progresses, a debate will undoubtedly emerge in our system as to whether or not doctors may avoid treating patients with COVID-19. Some will take a leave of absence from work to avoid the issue. Some will quit. Others will wait for a locum tenens spot in a safer future. The debate has already sparked over whether resident physicians should be involved in the care of COVID-19 patients. These discussions reveal smoldering issues within the system.
What went wrong?
To start from the beginning, the medical education system is a broken, overpriced experiment, still following the train of thought that an overworked assistant professor reading from a PowerPoint presentation is somehow the ideal way to promote lifelong learning, while sheltering medical students from Medicare’s relative value unit (RVU) system that now dominates the national scene.
The RVU system proves to be a shock to a majority of young residents as it promotes a factory-like work environment that demands certain productivity benchmarks be reached come hell or high water. For graduating residents swimming in educational debt, the demands of the system must be met, leaving few with the option to work on a more reasonable or part-time basis, or biasing disinterested residents toward choosing more procedural specialties or sub-specialities with the theoretical goal of avoiding productivity pressure in the future. (Think of it: to study so hard for so long, only to do something you’d rather not!) Little wonder burnout is so high.
And residency opens one’s eyes to the inner workings of the insurance world, where the primary goal is to make money for the shareholders. Residents facing the bundled payment system, working on getting their patients out of the hospital, suddenly realize who’s truly in charge. (How were we so sheltered from this in medical school, when we were writing reflective essays on patient encounters that had no correlate to reality?)
And the practice of medicine as a vocation continues its long, slow decline. The ceremonial, knee-length white coat, formerly reserved only for attending physicians, and serving as a symbol for the purity of life and practice necessary to the practice of the art of medicine (despite being an obvious infectious vector), is now handed out at whim, with all due respect, to physical therapists, occupational therapists, dietitians, speech language pathologists, master degree students, nurse practitioners, and yes, even medical and nursing students. Imitation may be the sincerest form of flattery, but the symbol is now commonplace, nullified, irrelevant, and non-emblematic. All are now “providers.”
It’s in this context that burned-out physicians across the country may start to refuse to take risks for those impersonal companies out there ready to replace them at a moment’s notice. Can we really be surprised at the debate among some quarters as to whether or not to take the risk of treating COVID-19 patients? The joke’s on us, and on our patients.
The system will ultimately hold, thanks to the conscientiousness and goodwill of the vast majority of physicians across the country and our supportive departments that still dot the landscape. But how long will this last? And how can we improve the system going forward?
A reality check would be a start—no more chest-thumping about how we have the best health care system in the world. We have the most expensive health care system in the world. And the scene is dominated by big business and a practice design enslaved to unbridled capitalism, riding on the backs of physicians. This scheme is suspect at best. Treat us like cattle? Don’t expect heroes. The system needs reform.
But a quiet, subversive, bucking of the system is also in order. This will be the most effective action we can take, and will be accomplished through actions opposite the natural response expected in the current practice environment. As the Wendell Berry poem goes, “[E]very day do something that won’t compute/ Love the Lord. Love the world. Work for nothing./ Take all that you have and be poor./ Love someone who does not deserve it.” Or, as E.M. Forster wrote, “it all turns on affection.”
As many have noted (and I think in particular of the British physician Dr. Andrew Lees, who has written on this point with particular eloquence), the answers to the issues we face this year won’t be found in consumerism, fancier hospital buildings, and shorter wait times. The answers will be found in competent practice, small acts of right living, and affection for our patients.
Several fellow residents and I sat in the office recently, discussing the recent developments. All of us are disappointed at the prevailing headwinds within medicine here in the United States. But when the topic of COVID-19 surfaced, no one hesitated. “My wife and I have discussed this,” one of my colleagues commented: “This is why we went into medicine. This involves sacrifice. We took the Hippocratic Oath.”
The administrators and businessmen of medicine would do well to sit up, pay attention, and watch the oath-keeping that occurs in the days ahead. This is the art and practice of medicine. This is our vocation that, though denigrated and increasingly commodified, is still ennobling.
We won’t be working remotely.
Nicholas Brennecke is a neurologist.
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