The U.S. healthcare “system” is completely and utterly broken. According to the World Health Organization (WHO), the U.S. system ranks 37th in the world, all while spending dramatically more on healthcare than other wealthy countries. Tens of millions remain without any health insurance coverage. For many, medical bills can mean economic ruin—some surveys show that up to 66.5% of all bankruptcies in the U.S. are a result of medical expenses. On the front lines of this system are nurses and physicians—individuals who, by and large, decided to go into the profession to help patients and communities—are becoming more frustrated by their inability to do just that, sometimes even causing providers to leave the profession. While many inside the U.S. medical-industrial complex have had enough, nurses throughout New York City (NYC) are putting their collective foot down and showing us the way to fight for better outcomes for patients and better working conditions for providers.
In March, members of the New York State Nurses Association (NYSNA) at New York’s “big four” hospitals (Montefiore, Mount Sinai, New York Presbyterian-Columbia and Mount Sinai West/St. Luke’s) voted by an overwhelming 97% margin to authorize a strike. The nurses’ fight centers around conditions for patient care, including safer staffing ratios inside hospitals so that nurses can adequately care for each patient. Throughout NYC, nurses are forced to work long shifts and are chronically understaffed. The nurses who recently threatened to strike recognize that these working conditions are part of hospital executives’ push to squeeze greater and greater profits out of workers at the expense of patient health—and they have had enough. New York nurses are fighting just as teachers across the country did earlier this year—including the tens of thousands of Los Angeles teachers who struck last January for better conditions for in schools. They are discussing the strike option just as more than 8,000 Stop & Shop workers in New England recently authorized a strike against cuts to healthcare benefits and pensions and the CAMBA Legal Services workers voted to walk off the job if their demands are not met. The nurses are also taking up the example of healthcare workers around the world, including the 40,000 Irish nurses who recently struck. Nurses are recognizing they have the power to fight and win better patient care. But while nurses across New York are standing up for themselves and their patients, a big question remains: Where are the doctors and why are they not threatening to strike together with nurses?
Why Are The Physicians on the Sidelines?
Physicians see first hand every day how our dysfunctional healthcare system is simply not built to adequately address patient and community health. For many doctors, these frustrations manifest in burnout and dissatisfaction within a field they once loved. Today there is an epidemic of burnout among physicians, with some studies suggesting burnout affects up to half of all physicians. After training for years with the desire to help others, doctors come to experience medical system that values profit over all else and rarely gives them the tools to make a difference in the communities where they work. This can leave doctors feeling hopeless, and combined with other factors, can lead to depression or even suicide. Today physicians are committing suicide at two times the rate of the population as a whole. Yet, even at this moment of frustration and anger, they continue to keep their heads down, providing validity to this broken system. We see nowhere, among doctors, a resistance like that now being organized by nurses.
In order to analyze why doctors are not throwing down their stethoscopes and finally saying enough is enough, a review of the U.S. medical education process is in order. As longtime public educator John Taylor Gatto highlights in his book, The Underground History of American Education, the education system is built to create “tools for industry.” Gatto points out that this system conditions those who pass through it to take direction well and to not question authority. At the same time, education aims to instill the importance of profit and continually reinforces the legitimacy of the capitalist system. Health care education is not excluded from this. The fact that the medical industrial complex “serves” suffering human beings gives the system the guise of moral superiority, but both patient and community health remains secondary to profit maximization nonetheless.
Data has shown that physicians typically come from the upper classes in the US. It is not hard to see why. Medical school exams and applications alone can cost thousands of dollars and this doesn’t even account for the cost of exam preparation courses or materials. Overall, the admissions system selects for a particular type of upper middle-class to bourgeois candidate—some reports show the median family income for a matriculating medical student is around $100,000 per year. At a time when close to half the American people do not earn enough afford an unexpected $400 expense, the cost of becoming a physician is prohibitive for the vast majority. Students with families that can bear such costs tend to come from environments that have conditioned them from a young age to respect systems of authority and not question their legitimacy. After all, if the parents have benefited economically from doing so, why would their children act any differently? This rule is then reinforced throughout the experiences of undergraduate school, medical school — as I have written about in the past — and residency education. The young medical student or resident learns that getting close to and appealing to authority figures leads to better outcomes—whether that means higher test scores, letters of recommendation, or better employment opportunities. This makes the physician less and less likely to challenge, much less disrupt, the medical system he will soon be working within.
Within the hospital, doctors typically adopt an individualist mentality in which they consider only how they can personally make an impact on their patients’ health, while ignoring the need for systemic change. The direct work with individual patients can be personally rewarding, but this method of practice does little to impact the larger factors that lead a patient to become sick in the first place. A physician sees a patient in a clinical setting, and treats him without ever actually discussing or addressing the social conditions which have caused his illness. They then send the patient directly back into the environment that is harming him. This method of practice ultimately helps to uphold the exact structures making patients ill, but no physician could accept this fact, so instead they tell themselves they are doing important work and making a positive impact. Over time, operating within the system of factory line health delivery—the norm in the U.S.— teaches the physician that change occurs on an individual basis.
If a physician ever thinks of organizing collectively to withhold her labor in order to demand better conditions for her patients, employers declare that doctors are “abandoning” those in need of care. The hippocratic oath taken by physicians to “do no harm” is cited. This argument obviously disregards the fact that it is the employer and ownership class which is directly harming patients every day in pursuit of profit—denying care, pushing individuals into bankruptcy, pursuing unnecessary treatments, neglecting systemic causes of illness, etc. It also ignores the fact that by continuing to focus the treatment on narrow individualistic explanations for disease and illness, the physician helps to redirect the patient’s attention away from the larger issues that are truly causing his or her suffering.
It is clear why few physicians would think about striking after being psychologically conditioned in this way. Many simply believe the work they are doing is adequate and having a meaningful impact on patient and community health. Although many may work under a boss, doctors also often have more autonomy over their work than those in other professions. Their distinct petty bourgeois positions, which allows them the possibility of “being their own employers,” reinforces their individualist, conservative mentality—though it is important to note, physician control is ever decreasing as healthcare becomes more corporatized.
The individualist mindset created through medical and residency education is completely antithetical to the consciousness necessary to take action against an employer—whether protesting, organizing work “slow downs,” or using the most powerful weapon, the strike. Those who organize collectively to strike, such as the New York nurses, believe that change comes from masses of individuals standing together against the status quo. This runs counter to the ideology continually drilled into the physician. Subtle psychological methods of coercion keep physicians in line and unknowingly supporting their own oppression and the continual harm of their patients. This is combined with strong material conditions of coercion which we will discuss in the next section.
The Material Conditions of Doctors
Physicians experience the truly sickening state of the U.S. medical system day after day. They see first hand how the profits of health insurance companies, hospitals, pharmaceutical companies, device manufacturers and other health care corporations are placed above patient health. For those who truly wish to help the patients they work with, this can be extremely frustrating and could even push the physician to want to resist these oppressive systems, even after undergoing the multiple levels of psychological conditioning. This is where the material conditions of the physician come into play: to ensure doctors stay in line.
In general, American physicians are more economically well off than the majority of the population. The exorbitantly high pay that physicians find themselves earning after residency serves to support the status quo for the healthcare industry. Physicians become comfortable with their lifestyle and their positions of power in hospitals. They begin to develop a stake in maintaining the system. Though the physician may see various ways the medical industrial complex damages patients, he will be reluctant to put his comfortable position at risk by questioning the current state of affairs. It is much easier for a physician to accept the lifestyle this system provides her than to accept she is being used as a cog inside of the medical industrial machine where the health of patients is only a secondary concern.
Even before graduating from residency training, the material conditioning of the physician begins. Becoming a physician is expensive. Physicians typically undergo a 4-year university education in addition to their four years of medical school. This can easily leave a new physician entering residency— a 3 to 8-year period of training after medical school — with hundreds of thousands of dollars of debt. This debt, which is part of the over $1.5 trillion of overall student loan debt in the US, puts the physician in a precarious position in the workplace at the beginning of her career. Indebtedness makes the resident physician less likely to do anything to jeopardize her standing during residency — where she is often used as cheap labor for hospitals and clinics — since it could affect job opportunities later in her career.
The enormous debt facing a resident — a term coined from the days when they would literally live or “reside” in the hospital — then forces him to work exorbitant hours for little pay. His workweek can extend to upwards of 80 hours. When a residents’ pay is broken down to an hourly wage he often finds himself making just over $10/hour. It is now a fad for hospitals to pretend to care about physician wellness. One group tasked to structure residency programs, the Accreditation Council for Graduate Medical Education (ACGME), has attempted to improve resident wellness by putting work limits in place for residents. These have been set at 80 hours per week, averaged over four consecutive weeks, meaning that a resident could potentially work as many as 100 hours in a given week. In this scenario, overwork and exhaustion make physician organizing and resistance even less likely.
We Must Organize
Physicians are key actors in the medical industrial complex today. They serve as conduits for profit extraction from sick and injured people. Until physicians begin to put individual endeavors aside and begin to organize collectively, they will continue to see their patients harmed by the “healthcare” system. How can physicians advance their collective organization? They can start by pushing for unionization in all healthcare settings—even if that means going against anti-union contracts that hospitals and clinics often require doctors to sign. Change in this system will not come from hospital administrations, device manufacturers, health insurance companies, or medical academies like as the American Medical Association (AMA). All of these groups benefit from the existing system focused on endless profit maximization. Change will only come through collective action and resistance by healthcare workers.
Physicians around the world have organized and withheld their labor for better conditions around patient care in the past. In a system that continues to directly harm patients, strikes or various other forms of work stoppages or slowdowns, are an ethical imperative. Whether it is teachers in Virginia or nurses in New York, withholding one’s labor and threatening profit production is, by far, the greatest tool any worker has against an employer. These efforts by teachers have improved educational environments for children in schools. In hospitals, strikes have the potential to provide better staffing ratios, and ultimately better care, for patients. The nurses who give their time and efforts to organize — even while risking their own jobs — are showing what it means to truly care for patient and community health. Physicians have much to learn from the nurses’ example.
Mike Pappas is a resident physician practicing Family Medicine in New York City. He can be contacted at firstname.lastname@example.org