By Eric Reinhart, M.D., Ph.D.
The New York Times, February 5, 2023
Doctors have long diagnosed many of our sickest patients with “demoralization syndrome,” a condition commonly associated with terminal illness that’s characterized by a sense of helplessness and loss of purpose. American physicians are now increasingly suffering from a similar condition, except our demoralization is not a reaction to a medical condition, but rather to the diseased systems for which we work.
The United States is the only large high-income nation that doesn’t provide universal health care to its citizens. Instead, it maintains a lucrative system of for-profit medicine. For decades, at least tens of thousands of preventable deaths have occurred each year because health care here is so expensive.
During the Covid-19 pandemic, the consequences of this policy choice have intensified. One study estimates at least 338,000 Covid deaths in the United States could have been prevented by universal health care. In the wake of this generational catastrophe, many health care workers have been left shaken.
“For me, doctoring in a broken place required a sustaining belief that the place would become less broken as a result of my efforts,” wrote Dr. Rachael Bedard about her decision to quit her job at New York City’s Rikers Island prison complex during the pandemic. “I couldn’t sustain that belief any longer.”
Thousands of U.S. doctors, not just at jails but also at wealthy hospitals, now appear to feel similarly. One report estimated that in 2021 alone, about 117,000 physicians left the work force, while fewer than 40,000 joined it. This has worsened a chronic physician shortage, leaving many hospitals and clinics struggling. And the situation is set to get worse. One in five doctors says he or she plans to leave practice in the coming years.
To try to explain this phenomenon, many people have leaned on a term from pop psychology for the consequences of overwork: burnout. Nearly two-thirds of physicians report they are experiencing its symptoms.
But the burnout rhetoric misses the larger issue in this case: What’s burning out health care workers is less the grueling conditions we practice under, and more our dwindling faith in the systems for which we work. What has been identified as occupational burnout is a symptom of a deeper collapse. We are witnessing the slow death of American medical ideology.
It’s revealing to look at the crisis among health care workers as at least in part a crisis of ideology — that is, a belief system made up of interlinking political, moral and cultural narratives upon which we depend to make sense of our social world. Faith in the traditional stories American medicine has told about itself, stories that have long sustained what should have been an unsustainable system, is now dissolving.
During the pandemic, physicians have witnessed our hospitals nearly fall apart as a result of underinvestment in public health systems and uneven distribution of medical infrastructure. Long-ignored inequalities in the standard of care available to rich and poor Americans became front-page news as bodies were stacked in empty hospital rooms and makeshift morgues. Many health care workers have been traumatized by the futility of their attempts to stem recurrent waves of death, with nearly one-fifth of physicians reporting they knew a colleague who had considered, attempted or died by suicide during the first year of the pandemic alone.
Resistance to self-criticism has long been a hallmark of U.S. medicine and the industry it has shaped. From at least the 1930s through today, doctors have organized efforts to ward off the specter of “socialized medicine.” We have repeatedly defended health care as a business venture against the threat that it might become a public institution oriented around rights rather than revenue.
This is in part because doctors were told that if health care were made a public service, we would lose our professional autonomy and make less money. For a profession that had fought for more than a century to achieve elite status, this resonated.
And so doctors learned to rationalize a deeply unequal health care system that emphasizes personal, rather than public, moral responsibility for protecting health. We sit at our patients’ bed sides and counsel them on their duty to counteract the risks of obesity, heart disease and diabetes, for example, while largely ignoring how those diseases are tied to poor access to quality food because of economic inequities. Or, more recently, we find ourselves advising patients on how to modulate their personal choices to reduce their Covid risk while working in jobs with dismal safety practices and labor protections.
Part of what draws us into this norm is that doctors learn by doing — that is, via apprenticeship — in which we repeat what’s modeled for us. This is, to a degree, a necessary aspect of training in an applied technical field. It is also a fundamentally conservative model for learning that teaches us to suppress critical thinking and trust the system, even with its perverse incentives.
It becomes difficult, then, to recognize the origins of much of what we do and whose interests it serves. For example, a system of billing codes invented by the American Medical Association as part of a political strategy to protect its vision of for-profit health care now dictates nearly every aspect of medical practice, producing not just endless administrative work, but also subtly shaping treatment choices.
Addressing the failures of the health care system will require uncomfortable reflection and bold action. Any illusion that medicine and politics are, or should be, separate spheres has been crushed under the weight of over 1.1 million Americans killed by a pandemic that was in many ways a preventable disaster. And many physicians are now finding it difficult to quash the suspicion that our institutions, and much of our work inside them, primarily serve a moneymaking machine.
Doctors can no longer be passive witnesses to these harms. We have a responsibility to use our collective power to insist on changes: for universal health care and paid sick leave but also investments in community health worker programs and essential housing and social welfare systems.
Neither major political party is making universal health care a priority right now, but doctors nonetheless hold considerable power to initiate reforms in health policy. We can begin to exercise it by following the example of colleagues at Montefiore Medical Center in the Bronx who, like thousands of doctors before them, recently took steps to unionize. If we can build an organizing network through doctors’ unions, then proposals to demand universal health care through use of collective civil disobedience via physicians’ control over health care documentation and billing, for example, could move from visions to genuinely actionable plans.
Regardless of whether we act through unions or other means, the fact remains that until doctors join together to call for a fundamental reorganization of our medical system, our work won’t do what we were promised it would do, nor will it prioritize the people we claim to prioritize. To be able to build the systems we need, we must face an unpleasant truth: Our health care institutions as they exist today are part of the problem rather than the solution.
Dr. Eric Reinhart (@_Eric_Reinhart) is a political anthropologist, psychoanalyst and physician at Northwestern University.