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Bosses of Us: Doctors, Administrators, and the Profit Motive

When I was an intern, my program faced a total collapse of one of the non-teaching hospitalist groups that staffed our institution. As the census on the teaching service began to explode and both teaching and non-teaching attendings could not adequately handle the volume of patient care, the program proposed folding the neuro-intensive care unit (ICU) service in with the general ICU.

Intensivists and residents alike balked at the idea, arguing that the explosion in the overall ICU census would lead to poorer outcomes, unhappier staff, and was not the type of situation we had agreed to when we signed our contracts. The program directors trotted out our chief resident to have a town hall regarding our concerns. He had no answers for us. The program directors themselves were absent.

About a month later, I began my extra ICU rotation and ran into a Saturday where we had back-to-back admissions rolling into the unit the minute after we got sign-out. In the era of COVID-19, this scenario seems like a dream of easier years.

COVID drove the ire that residents and attendings alike have felt over the current situation in American medicine into a fever pitch — online forums have suddenly flooded with calls for unionization, work stoppages, improved safety standards. The virus is not the only villain of this story: the scapegoat gaining traction are the MBAs who forced their way into the art of medicine, bringing with them business and the cold logic of the profit model.

Certainly, administrative takeover in the name of big business has happened across medicine. But the idea of medicine as profit, the idea of medicine as lucrative and prestigious and a source of power, existed far before anyone with a business degree and no clinical experience crawled their way into a hospital boardroom. Residents from programs where their leadership — staffed by clinicians — has failed them know this all too well. In the last few months, we have been told by the clinicians leading us that the virus would be no worse than the flu, even as cases mounted. We have been asked to take off our masks. We have been exposed, quarantined and infected.

The struggle before us, the one that lies after this disease is vaccinated against or, hope-against-hope, disappears from the global scene as its predecessors SARS and MERS did, cannot simply be a call to remove people with business degrees from medicine, or for physicians to reclaim the great big piece of the pie they once had. The profit motive, the drive for reputation, glory, recognition, infect all of us. Clinicians are not exempt, clinician-leaders even less so. Residents have known intimately that they are cheap labor for hospital systems, trading promised education for the assurance that they will remain underpaid cogs in the medical billing machine. An entire medical organization has sprung up around this labor: program directors, attendings, mid-level providers and business administrators all benefit from their residents’ work.

It is not merely a shift in the administrative capacities of the hospital system we need: it is solidarity. The pain of this profession, indeed of all professions involved in the direct care of people suffering disease, binds us together. Attendings, residents, nurses, housekeepers, unit secretaries, patient transporters, technicians. Under the weight of a pandemic that kills so unceasingly, we workers are all suffering. That suffering, as much as it is the direct cause of a horrific lethal illness, is as much at the feet of those businessmen who neglected us as it is at the feet of the physicians who co-opted the health care system as a way to make a name for themselves, to secure finances, to become a bigger part of the mill of a system chewing up patients and care-givers in the name of making more and more money for an anonymous face in a boardroom. It is not a single group of people with the wrong degree, with the wrong understanding of power that have poisoned our art: it is the avarice within all of us, the greed and ambition that has turned our patients into human capital, and health care workers into movers of that capital.

The horror facing us during this pandemic makes it easy to seek a scapegoat in business administrators, but many housestaff have seen that both their hospitals’ business leaders and clinician-leaders are failing them. Unionization, a necessary step toward righting the labor struggle in medicine, is only a first step. Signing a portion of one’s paycheck to the union may give the union more names to a list to submit as proof of its support in contract negotiations, but it is not enough.

The pandemic points to an important lesson: a rejection of traditional leadership structures, at least those that feed into a profit-based medical system, may be necessary in order to create a different world. The union provides such a framework, vesting power in a collective of voices. But in order to succeed at the level of a union, physicians need to let their voices join that collective — they cannot expect a delegate or representative alone to do the entire job, just as we might expect a program director to guide us in the right direction.

The need for actual collectivity, actual mutual aid among physicians, runs antithetical to the training hierarchy of program director-attending-resident, or the hierarchal hospital structure where doctors issue orders for nurses to carry out. The struggle to drive a cultural shift among residents who are used to doing what they are told has been brewing within my own program. Even as our union begins to push for hazard pay, it remains enormously difficult to get the residents to publicly voice their demands or tell their stories. Short of those already ideologically aligned with the principles of united labor, even the angriest of housestaff are reticent to put their concerns into the world.

That the hierarchy has already carved its expectation of obedient silence into us is obvious. But there is no help coming for us unless we help each other by driving the narrative of this catastrophe with our collective voice, speaking the story of our collective suffering: the entire leadership class, clinician and politician and businessperson alike, has failed us by profiting off the healing art. Through speech, through protest, through constant and united pressure against those in power who refused to prepare even as Wuhan and Lombardy buckled under the weight of COVID, we stand a chance of one day speaking into being the kind of care-giving of which we dream. But we cannot do it with only a few of us.

We would do well to remember our suffering in the days after this disease abates. We would do well to let it join us in collective action against the drive to profit at the expense of patients, to ambition at the expense of our colleagues’ labor, to reputation at the expense of our personal ethics, to turn away from the great art of healing the sick. But we must do so with true unity, as a true union.

Image credit: University of Washington Housestaff Association on The Stranger

Michael Gallagher, MD Michael Gallagher, MD (1 Posts)

Resident Physician Contributing Writer

Rutgers-New Jersey Medical School/Kessler Institute of Rehabilitation

Michael Gallagher is a PGY-3 resident in physical medicine & rehabilitation at Rutgers-New Jersey Medical School/Kessler Institute of Rehabilitation interested in palliative care, the ethics of rehabilitation and physiotherapy, and health care labor relations. Outside of work he is a mediocre 400m sprinter, sci-fi writer, and amateur barista.