Health Care Under the Knife

Moving Beyond Capitalism for Our Health

Howard Waitzkin

• Editorial: Monthly Review Press
• Año: 2018
• ISBN:
  9781583676769
• Categoría: Economics
• Categoría: Economic Policy

“I’ve still got my health so what do I care?” goes a lyric in an old Cole Porter song. Most of us, in fact, assume we can’t live full lives, or take on life’s challenges, without also assuming that we’re basically healthy and will be for the foreseeable future. But these days, our health and well-being are sorted through an ever-expanding, profit-seeking financial complex that monitors, controls, and commodifies our very existence. Given that our access to competent, affordable health care grows more precarious each day, the arrival of Health Care Under the Knife could not be more timely. In this empowering book, noted health-care professionals, scholars, and activists—including editor Howard Waitzkin—impart their inside knowledge of the medical system: what’s wrong, how it got this way, and what we can do to heal it. The book is comprised of individual essays addressing the “medical industrial complex,” the impact of privatization and cutbacks under neoliberalism, the nature of health-care work, and the intersections between health care and imperialism, both historically and at present. We see how the health of our bodies in “developed” countries is tied to the health of the bodies of the labor force in the Global South, and how the World Bank and the International Monetary Fund are linked strangely, inextricably, to our physical well-being. But this analysis would not be complete without the book’s final section, which delivers invaluable guidance for how to change this system. Recounting case studies and successful efforts for creating a more humane community, this book ultimately gives us hope that our health-care system can be rescued and made an integral part of a new and radically different society.

PART ONE

Social Class and Medical Work

1—Disobedience: Doctor Workers, Unite!

Howard Waitzkin

A person can become free through acts of disobedience by learning to say no to power. . . . At this point in history the capacity to doubt, to criticize and to disobey may be all that stands between a future for mankind and the end of civilization.

—ERICH FROMM, “ON DISOBEDIENCE”

I confess: I am a disobedient doctor.¹

After a career in academic medicine and public health, I decided to work part-time in a rural health program. There I began to understand the loss of control over the conditions of medical practice that has affected so many doctors. Administrative demands multiplied and constrained my ability to care for my patients in the ways I thought best.

So I decided to disobey. A seemingly minor training requirement, the International Classification of Diseases, 10th edition (ICD-10), which Medicare and other insurers started to require for medical billing as of October 1, 2015, became yet another administrative demand that pushed me over the line to disobedience. But the struggle might have involved many other arenas of clinical medicine, where the requirements of employers infringe on a doctor’s freedom to practice according to his or her professional judgment.

PROLETARIANIZATION

Intrinsically I have nothing against being a proletarian. Everyone in my immediate family was one, and I supported much of my education by working as a wage laborer in, for instance, a tire factory, where I learned firsthand about life as a worker in our capitalist society. Throughout my medical career, I have befriended secretaries, nursing assistants, janitors, and other “non-professional” health workers—wonderful people whose services on behalf of patients and doctors usually go underappreciated. Such people spend most of their waking lives doing tasks assigned by supervisors, and they enjoy little or no control over the conditions and rhythm of their work.

Medicine, I thought, would provide a way to seize control of my own work process and creativity by organizing at least a large part of the work week as I preferred. A position in academic medicine actually did allow me that liberty, despite the challenges of university bureaucracies, budget cuts, fund raising, and academic politics. Even in academia, the ability to control my activities started to erode, usually linked to financial shortfalls and measures of productivity.

However, entering the world of a non-academic medical employee revealed the awesome scope of proletarianization, a sharp change in a doctor’s previous social-class position.² Until the 1980s, doctors for the most part owned and/or controlled their means of production and conditions of practice. Although their work often was challenging, they could decide their hours of work, the staff members who worked with them, how much time to spend with patients, what to write about their visits in medical records, and how much to charge for their services.

Now, the corporations for which doctors work as employees usually control those decisions. Loss of control over the conditions of work has caused much unhappiness and burnout in the profession. Early on, an esteemed clinician and mentor described medical proletarianization when it was first emerging as “working on the factory floor.”³ Most doctors have become employees of hospital and health system corporations,⁴ and around half of doctors report feeling burned out due to the stresses of their work as employees.^{5, 6} Due to the mystique of professionalism and relatively high salaries, doctors often do not realize that their discontent reflects in large part their changing social-class position.

DECIDING TO DISOBEY

As a doctor worker, I got into trouble by expressing concerns about the training that our health network (hereafter, OHN) was requiring for all practitioners before the implementation of ICD-10. Until then, I had not received significant adverse feedback from the administration, had received multiple expressions of praise and gratitude, and recently had obtained reappointment to the active medical staff.

OHN had contracted with a corporation (hereafter, “$Corp”) to help cope with the transition to ICD-10. This corporation was one of hundreds that have emerged to sell consulting services to health care organizations facing the challenges of information technology (IT) required by the private insurance industry, Medicare, Medicaid, and various certifying and regulatory agencies. Such challenges include electronic medical records (EMRs), meaningful use, quality assurance, accountable care, medical homes, and similar arenas. These arenas all involve “metrics” that try to make quality quantifiable, a goal that has generated wide skepticism, debate, and worry in the medical profession, as well as the broader society (for instance, in the debate about standardized testing in schools).

$Corp’s training for ICD-10 took multiple hours of unpaid time observing narrated slide shows and taking proficiency tests, and I decided to disobey the requirement. One reason involved a close friend who was dying from metastatic gastroesophageal cancer. His dying process and my desire to spend time with him had made me even more aware that each moment of life is too precious to waste, especially on activities whose purpose isn’t clear.

After I previewed the $Corp training, I concluded that its educational quality was abysmal, conflicts of interest were not disclosed, most recommendations were not evidence based, and the narrator’s comments implicitly encouraged “up-coding” diagnoses to higher levels of severity and more comorbid conditions, so billing codes could generate more payments for OHN. The federal government’s prohibitions against up-coding were not mentioned. The training also didn’t explain how to use ICD-10 on our particular EMR software. Brief discussions with other practitioners confirmed universal contempt for the training, as well as universal compliance with it because people felt they had no choice. I compared time wasted on the training program to time spent with my dying friend and decided to protest the training.

WORK REQUIREMENTS AND THE SLIPPERY SLOPE TO FASCISM

My subsequent interactions with OHN administrators surprised me, despite my knowledge about physicians’ changing social class position. The Chief Medical Information Officer (CMIO) at OHN wrote that “practitioners with incomplete ICD-10 coursework at midnight on 10/7/15 will be suspended until the coursework is completed.” In response, I sent an email message asking him to explain the rationale for the training requirement. Copying the Chief Executive Officer (CEO), the CMIO pasted his responses in the text of my original message:

1. Please provide evidence that additional training in ICD-10 . . . improves any measurable patient outcomes, costs, or collections.

• Not a debatable point. This is a requirement by OHN, so, sorry to say, whether you agree with it or not, it must be done.

2. Please provide the costs to OHN for the training.

• Not relevant, as this is a requirement.

3. Please provide quantitative estimates of the financial benefits of the training for OHN.

• Not relevant, as this is a requirement.

4. Please give a concrete description of the process by which you concluded that “completion of this training allows us to achieve both appropriate care and remain fiscally responsible—part of OHN stewardship.”

• Not relevant, as this is a requirement.

This response pressed one of my alarm buttons, which I might call the fascism button. I responded that my dear grandfather, who was a farmer and then a housepainter after he lost the farm, taught me not to comply with requirements when I didn’t understand the reasons for them. Doctors, I wrote, are complying with an ever-increasing burden of unjustified requirements that take the joy out of practice and cause many of us to leave medicine prematurely. Citing Arendt’s classic book on Adolf Eichmann,⁷ I explained the slippery slope to fascism, when people do what they are ordered in their jobs without understanding why. Such unjustified requirements, I argued, deserve our conscientious questioning and sometimes non-compliance—a very modest act of “civil disobedience.”

Unimpressed, the CMIO replied: “Everyone must complete the training. We all make choices and I hope you will make the right one for you and your patients.”

STANDARDIZATION

If an argument about incipient fascism in the workplace didn’t work, I thought, maybe I could appeal to practicality. I proposed coming to the office, unpaid, and practicing ICD-10 within our EMR program, supervised by an IT staff person who then could attest to my competence. But the CMIO did not budge: “OHN’s Transformation is a movement to ensure process consistency and standardization. . . . Therefore, your request for an ‘exception’ is outside the organization’s expectation.”

Again, the CMIO’s reply pressed an alarm button, in this case the Henry Fordism button. Not only must I as a doctor worker accept orders without questioning them, but I also must behave at work like an automaton in a medical assembly line governed by “process consistency and standardization.”⁸ Without space for individual variation and creativity, the organization’s “transformation” became what my mentor foresaw: “working on the factory floor.”

I then requested details about what my forthcoming suspension would entail; the contractual authority for the suspension; a plan of coverage for my patients; an external review of OHN’s interference with my professional judgment; and recognition of my rights under whistle-blower laws and regulations. I repeated my concerns about authoritarianism in the medical workplace and commented on the extensive evidence that standardization actually may reduce quality, creativity, and productivity. I also reiterated a request for a face-to-face meeting.

PUNISHMENT

My moral predicament deteriorated quickly. On the next morning, the CEO sent an email providing none of the information I had requested and asking for my resignation effective within one week, despite packed schedules including many unstable patients. Then, five days before the deadline for suspension, I received a letter by overnight mail from the CEO stating that I was in breach of contract. A second letter stated that the meeting I had requested had been canceled, and my office hours with patients also had been canceled until further notice. Because I needed to respond to lab results and urgent messages about patients from nurses, I tried to connect with the EMR system but found that I had been cut off. I also could not connect to email or even to the ICD-10 training.

I now faced the apparent abandonment of hundreds of my patients, who had not received any alternative plan of care. I knew and previously had taught medical students and residents that medical abandonment is unethical according to the AMA Code of Ethics⁹ and other sources, and also is illegal in many states. For that reason, I contacted the chief of the medical staff and the chair of the physicians’ council, who intervened with the CEO to get me reconnected to the EMR system, so I could manage acute problems for my unstable patients.

Because I was not willing to abandon my patients, I also persuaded an administrator to get me reconnected to the ICD-10 training, which I completed under protest late the next night, after spending time with my dying friend. On the following morning, a Sunday, I received an email from the CEO thanking me for completing the training and stating that my breach of contract had been “cured.”

The nursing staff reconstructed my canceled schedule for the next day so I could see most of the patients. Nurses said patients had approached them in supermarkets and called them at home, asking what was going to happen now that I was gone. One patient asked if I had died.

REDEMPTION

As a doctor worker, I faced a challenging ethical situation that included loss of professional autonomy, authoritarian practices in the workplace, and apparent abandonment of patients. My first suspension in over forty years of practice also raised concerns: Would a report about the suspension from OHN to the National Practitioner Data Bank lead to effects on my medical licenses or ability to practice in other settings? Was it my responsibility to blow the whistle on OHN’s practices to licensing, accreditation, and insurance agencies?

My small act of conscientious disobedience eventually led to some unexpected responses. My contract and state law required that OHN convene an external review based on my claim of interference with my professional judgment. The coordinator of the state agency that licenses health facilities expressed willingness to investigate this issue and the abandonment of patients. Facing the probability of external review, the CEO finally agreed to meet with me. At the meeting, I proposed a formal mediation process. Instead, the CEO composed a document that included an apology, a statement that information about breach of contract would be removed from my personnel file, a commitment to consider individual physicians’ preferences in meeting future training requirements, and a promise to meet individually with a physician when a suspension is considered so patient care would not be disrupted.

Where is the path toward a non-corporatized vision of what we know medicine can be at its best? I don’t think that path involves our continuing acquiescence. I confess that I have decided to approach these problems through personal acts of disobedience. For me, closer to the end of my medical career than the beginning, such acts don’t risk much. For others, overcoming the risk will require a more organized approach to disobedience.¹⁰ Dare I en...