By Maureen Miller
Occupy, an OWS-inspired Gazette, Nov. 10, 2011
In 1970, Stephen Bergman, then a Harvard medical student, missed his renal block exam to protest Kent State. He was one of many medical students who were transformed by the antiwar movement, and he went on to ask if we could transform physician training.
In 1978, Bergman published the satire “The House of God,” loosely based on his experiences an internal medicine intern at Beth Israel Deaconess Medical Center, under the pseudonym Samuel Shem.
“The House of God” is best known for popularizing medical students’ passive-aggressive argot. (“Gomer” is short for “get out of my emergency room”; “NAD” means “no acute distress.”) But its enduring accomplishment is that it brought to light an attitudinal shift among American physicians.
While doctors have been perfecting their gallows humor for centuries, Bergman concluded that his colleagues used theirs as a defense against the depersonalization they experienced as part of what is now often described as the “medical-industrial complex.”
The first authors to use the term “medical-industrial complex,” John and Barbara Ehrenreich, were with Health-PAC, a universal health care advocacy group. Their “American Health Empire: Power, Profits, and Politics” (1971) came to the attention of physicians nationwide after Arnold Relman, editor of the New England Journal of Medicine, wrote about it in 1980.
The Ehrenreichs argued that structural inequalities in health care undermine medical professionalism, and that health care corporations and consulting groups cannot exist without these inequalities—and that therefore we cannot work with them.
The Ehrenreichs and others continue to insist that we have trouble relating to our patients because we are ambivalent about our own roles as guardians (or gatekeepers) of an unjust distribution system. So the rise of the medical-industrial complex has been paralleled by the rise of a consciousness movement, “mindful medicine,” which encourages physicians to pursue activities such as narrative medicine, meditation practice, and exercise in order to cultivate a more introspective medical practice even within the complex.
At the same time, real political reforms have taken place. Student-driven curriculum reform has brought HIV-AIDS prevention, global health internships and electives, health care disparities, topics in LGBTQ health care, and primary care recruitments to medical schools.
A more outward-looking movement, the American Medical Student Association’s PharmFree campaign, which aims to diminish the pharmaceutical industry’s influence on medical practice, has been featured in the New York Times, Newsweek, and CNN.
Harvard Medical School even invited Bergman to address students at its commencement in 2009. He told them, “You are about to enter a disaster area: the health care industry. The system is broken. It is worse for doctors, worse for patients, and better only for the insurance industry.”
As a medical student, I get to ask tons of stupid and naïve questions, so here’s one: What if we tried to change the system?
A 2011 study by the American Medical Students Association found that about 95 percent of medical students believe their patients are underinsured, and that 80 percent don’t think the Affordable Care Act went far enough in narrowing that gap.
Their elders tend to agree. A 2009 study by the New England Journal found that 78 percent of physicians believe they have a professional obligation to address societal health policy issues, and 67 percent are willing to accept limits on their reimbursements in order to expand access to basic health care.
Although we may not seem like likely protesters, medical residents and many doctors with decades of practice behind them are the 99 percent, and we treat the 99 percent. We are part of the same system as our patients, and it also causes us distress. And when we speak, people listen.
An October 23 speak-out at Zuccotti Park by Health care for the 99 percent, a coalition of health care professionals, attracted more attention than any other teach-in so far.
What would it take to recruit more medical students and physicians to try to collectively change American health care? The challenge will be overcoming a decades-long tradition of isolation and resignation within a dysfunctional system.
Half a decade ago, the New England Journal published an article called “White Coat, Mood Indigo,” which noted that medical students become depressed as they enter their clinical training. These years are the first time most students interact with the American health care system as physicians, and what we see can be deeply discouraging.
We begin to infer that the best way to manage patients is to answer their questions on a need-to-know basis. We learn to order tests in sequences that are not always evidence-based or clinically sound partly because these tests can be expensive. Everyone in the industry is constantly working around the cost problem, and the complexity and dysfunction of these efforts make us increasingly depressed as we go about our first rounds.
Yet medical students do have an opportunity to learn another way. We learn it from colleagues who speak out. In my experience, most medical student advocates come into the health care reform movement after some nudging from a clinical or academic mentor. Many students I know (I’m a third-year medical student at NYU) have gotten into global health activism after reading “Mountains Beyond Mountains,” Tracy Kidder’s book about Partners in Health founder Paul Farmer.
More broadly, one of the best-known medical activist organizations is Physicians for Human Rights, which organizes medical professionals against violations of the Hippocratic Oath, such as torture.
There is also a national organization specifically devoted to ensuring that everyone has access to high-quality, comprehensive health care, Physicians for a National Health Program (PNHP), which has over 18,000 members across the country. For us to have a real impact, a large proportion of practicing physicians will have to coalesce behind groups like this one. We need organization almost on the scale of the global health projects.
PNHP advocates for an improved Medicare for All, shorthand for a single-payer American health care system that would cover every person under a federal insurance program. It is analogous to the universal health care legislation Vermont passed in May 2011, which will guarantee every resident state-financed health insurance, and it is a more expansive vision of the public option that multiple polls found the majority of American supported during the 2009 health care reform debate.
The public option, which would have allowed the federal government to provide Medicare-like insurance coverage to all Americans as a price competitor to private insurers, was viewed by many as a stepping stone to a federal single-payer program.
Right now there is some internal debate within PNHP about whether we should promote reform on a state-by-state level, as in Vermont, or continue to advocate for reforms on the national level. In any case, we believe that single-payer is “ambitious but feasible” for America.
And there is a lot we can learn from the ambitious project going on right now in Zuccotti Park. Medics attend to the occupiers around the clock; full-time practitioners moonlight with them. The time I spend at the park is what I can offer between clinical commitments — which, granted, is not much. But I am hoping to pick up some habits from the Occupy Movement to take to my classmates.
The last time I went to the park, on Oct. 23, I put it this way on a dorm-style dry erase board:
I am a med student.
t Medicare for All.
I am studying for my surgery clerkship, yet I am here.
Do I need a CT scan?
I was standing next to a Yippie pie-thrower who saw my sign. He asked me about how better to manage his myriad chronic medical conditions, and I had to tell him I didn’t know.
Soon I was no longer alone, and I felt more comfortable in the crowd. I was standing with my medical school classmate Josh Klindienst. Josh and I have been in school together for three years, but I can’t remember us having a conversation about health care reform before then.
I talk about health care reform a fair amount at my medical school — I am the campus contact for Physicians for a National Health Program — but everyone always tells me they don’t know enough about health care reform to join. Perhaps with the question of knowing enough, Josh suggested I simplify my message. I tried:
Medical Students for Medicare for All: Health care is a Human Right!
The new iteration got a better response than my previous sign. Flavio Casoy, a psychiatry resident from San Francisco, approached us.
“Why Medicare for All?” he asked.
“It makes more sense to most people than ‘VA-for-All.’”
He wanted us to make sure we knew why we believed it. Casoy was in town to attend a national conference of the Committee of Interns and Residents (CIR), a member organization of the SEIU. I’d never heard of it, but apparently Bellevue Hospital, the public teaching hospital where I train, has had a CIR chapter for 20 years. Within two days I noticed two CIR flyers in one of the hospital call rooms.
What do we need to do, to for lack of a better expression, put our colleagues on call?
Introspection is critical to thoughtful medical practice, but an outward turn, to the advancement of health care as a human right, is essential if we are to defend our professionalism and retain our peace of mind.
Turning outward is a habit of mind to which we devote much of our training. If you work in a health care system, you must learn how to work well in teams. An embrace of the communal work ethic — coordinated care, collaborative interviews with family members, and faculty consults — is really the only way for us to get anything done.
The Occupy Movement reminds us that simply talking to one another about our problems with the system would at least make us feel less isolated. Whatever our ideological or strategic differences about the best way to change the system, being willing to participate in these conversations would remove the barrier of feeling that we’re each in this alone.
Maureen Miller is a medical student in New York City and is a member of Physicians for a National Health Program (www.pnhp.org). The text above is a slightly revised version of her article titled “Check Up,” which can be found on pages 32-34 of the following issue of Occupy: http://www.nplusonemag.com/GAZETTE-2.pdf.