I’m a doctor who treats patients with Covid-19 in the emergency department and the intensive care unit. So it’s no surprise that people often ask me how I’m doing these days.
I’m a lot of things. I’m honored that patients trust me with their lives. I’m ready to give them the best chance at surviving Covid-19 if they fall critically ill.
I’m scared of contracting the coronavirus and bringing it home to infect my family. And despite donning personal protective equipment, disrobing at my back door, and taking two or more showers a day, I may have done so already. A few nights ago, my 8-year-old daughter developed a fever, headache, and a dry cough.
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I am also really, really angry. I hear the phrase “we’ve got this” used to rally doctors and nurses. The words sound like they were focus-group tested by a team of marketers and destined to wind up on a silicone bracelet. They capture a distinctly American blend of overconfidence and naivete. What, exactly, do we have? America has the most confirmed cases of Covid-19 in the world and a health care system that is ill-equipped to care for its citizens and failing to protect its health care workers.
How did it come to this?
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The doctor-patient relationship and practicing high-quality medicine were once cherished principles of our health care system. But in recent years, a new guiding principle has been made clear to the doctors, nurses, and others who care for patients: In America, health care is a for-profit enterprise. The practice of medicine has been captured by the men in business suits with MBAs, and they have written the rules. Health care systems spend millions on massive marketing campaigns that sell the public on their commitment to patient care, but their actions make it clear that their priority is the bottom line.
For years the U.S. health care system has strained doctors and nurses with demands that place financial interests above patient care, making the practice of medicine unbearable. Electronic medical records are maximized to capture billable procedures, surgeries, and “patient encounters” rather than communicate meaningful information between providers. The fact that they pull doctors and nurses away from their patients, leading some doctors to spend only 13% of their day face to face with patients is regrettable, but it’s the cost of doing business.
I knew firsthand that staffing in many emergency departments was too thin even before Covid-19 emerged. Too few doctors and nurses were routinely asked to see too many patients. This is a management decision designed to maximize profit. It’s also a decision that makes seeing patients thoughtfully and safely a continual struggle.
Walking the knife’s edge is the business model.
The devotion to profit, marketing, and metrics has supplanted the devotion to quality medical care. Doctors are being taught that the real priorities are door-to-doctor times, patients per hour, patient satisfaction surveys, and generating the most relative value units (a common way of billing). Practicing good medicine and the patient’s well-being were pushed further down the list.
Here’s a small example: Last week, with the Covid-19 pandemic in full swing, a community hospital where I have worked emailed me to let me know it had revoked my privileges. I couldn’t see patients in the ED until I helped the billing department determine if it could boost revenue on the cases I’d seen. Whether the person who wrote this email stopped to consider that this action was sidelining a physician during a pandemic or not serves as a reminder that, in the current framework of American health care, money always comes first.
With a system co-opted to generate revenue first and caring for the sick comes second, the U.S. spends nearly twice what other developed countries do on health care. Although we have our share of some dramatic and expensive victories for individual patients, from a public health perspective America’s patient centered outcomes are mediocre at best. They are even worse for racial and ethnic minorities. That was true before Covid-19, and early data suggest that the pandemic is further widening these health care disparities.
Caught between a health care system built to maximize profit and their devotion to their patients, doctors, nurses, respiratory therapists, physical therapists, and other clinicians are suffering moral injury. A post on a physicians’ private social media forum recently asked, “After we get through the coronavirus pandemic, who else is done with medicine?”
I, like many other health care workers, am sympathetic to the author’s frustration. For decades, doctors and nurses have known of the perverse financial pressures in the American health care system. To get through the day, they either try to ignore these forces or they build elaborate work-arounds to manage them.
As the wave of Covid-19 patients flood the nation’s hospitals, the venality of our system is on full display.
Health care workers are being asked to fight Covid-19 with insufficient personal protective equipment. Pictures of American doctors in flimsy surgical masks and disposable gowns that expose wrists, necks, and hair look shockingly inadequate next to those of Italian and Chinese doctors covered head to toe in layers of personal protective equipment. Not surprisingly, health care workers are being infected with SARS-CoV-2, the virus that causes Covid-19. As I write this, at least 37 nurses and 26 doctors have already lost their lives due to Covid-19 in the U.S. More of us will follow.
There has, of course, been a public outcry by health care workers for hospitals to improve protections for their employees while battling the pandemic. Movements like #GetMePPE have gained national attention.
The responses from hospital administrations range from the pragmatic “we’re doing the best we can with limited supplies,” to the dangerous and threatening. In New York City, nurses were denied coronavirus testing unless their symptoms were severe enough to need admission to the hospital, so that they could continue to work their shifts. That kind of response is not only callous to sick nurses but risks infecting every patient they care for and every staff member they interact with.
Equally troubling, clinicians have been silenced from speaking out about the risks. In Washington state, an emergency department physician was fired by a Bellingham hospital for speaking publicly about its failure to protect its staff and patients from Covid-19.
The observation by the American engineer and management guru W. Edwards Deming that “every system is perfectly designed to get the results it gets,” rings true. Our health care system has perfected the business of medicine: extracting profit from the sick.
But patients and clinicians must ask, “Is this is the health care we want?”
The cataclysm of Covid-19 offers an opportunity to reshape health care in ways that may not have seemed possible just a few months ago. Will we have the collective will to make public health, social justice, equity, workplace safety and the practice of medicine greater priorities than financial success?
Keith Corl, M.D., practices both emergency and critical care medicine and is an assistant professor of medicine in the Division of Pulmonary Critical Care at the Warren Alpert Medical School of Brown University, in Providence, R.I. The views express here are those of the author. He would like to acknowledge Dr. Wendy Dean for her collaboration and contribution to this article.
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April 23, 2020 at 04:03PM
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Reshaping health care in the aftermath of Covid-19 - STAT
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