Reviews | Doctors are not exhausted by overwork. We are demoralized by our health care system.

Although Covid deaths have slowed, “disillusionment among health workers” has only increased. Recent talks have further laid bare the structural perversity of our institutions‌‌. For example, according to a New York Times investigation, ostensibly nonprofit charitable hospitals illegally indebted poor indebted patients for receiving care to which they were entitled at no cost and exploited tax incentives designed to promote care for the poor. poor communities. . Hospitals are deliberately understaffed and cutting patient care while sitting on billions of dollars in cash reserves. Not much is new, but doctors’ sense of our complicity in putting profits before people has become harder to ignore.

Resistance to self-criticism has long been a feature of American medicine and the industry it has shaped. From at least the 1930s until today, physicians have organized efforts to ward off the specter of “socialized medicine.” We have repeatedly defended health care as a commercial enterprise against the threat that it could become a public institution focused on rights rather than revenues.

This is partly because doctors were told that if health care became a public service, we would lose our professional autonomy and earn less money. For a profession that had struggled for more than a century to achieve elite status, this resonated.

“And so doctors have learned to rationalize a deeply unequal health care system that emphasizes personal rather than public moral responsibility to protect health. We sit by the bedside of our patients and advise them on their duty to counter the risks of obesity, heart disease and diabetes, for example, while largely ignoring how these diseases are linked to poor access to quality food. because of economic inequality. 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 to this standard is that physicians learn by doing – that is, through learning – in which we repeat what is modeled for us. It is, to some extent, a necessary aspect of training in an applied technical field. It’s also a fundamentally conservative model of learning that teaches us to suppress critical thinking and trust the system, even with its perverse incentives.

It then becomes difficult 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 almost every aspect of medical practice, producing not only endless administrative work, but also subtly shaping treatment choices.

Fixing the failings of the health care system will require uncomfortable thinking and bold action. Any illusions that medicine and politics are, or should be, separate spheres have been crushed under the weight of more than ‌‌1.1 million Americans killed by a pandemic that was in many ways a preventable disaster. And many doctors now find it hard to dismiss the suspicion that our institutions, and much of our work within them, serve primarily as a money-making machine.