As We Continue to Drift Into a Totalitarian Medical System: A View of a Country Boy

Even from my relatively sheltered rural existence somewhere in the United States, I can sense, I can observe, how the medical world around us (I talk about the United States but it may apply to other countries as well) is steadily drifting into a “totalitarian-capitalistic mode.” Or let us call it: totalitarian medical system (TMS).

Obviously, the medical system around here has been always grossly capitalistic, enslaved to the mighty dollar. However, one could have described the past system as sort of a benign, enlighten conservative capitalism. However, the system, we have been drifting into represents another mode of capitalism: that of a harsh, rigid, disciplined, controlled, and cruel capitalism conducted along classical totalitarian-dictatorial lines. Think about the United States in the late 1990s; now think about China of today. Get the idea?

In such emerging system, we doctors, the engine which is moving the medical machine, have almost nothing to say; we have been reduced to peons. Of course, the patients, those for whom the machine actually exists, had never much to say, were forever peons. They were always led as herds to the water; the ignorant greedily buying the prevailing propaganda that “this is the best medical system in the world”; the wealthy (who by natural selection are a little more informed) understood, they still do, that money buys the best care. That it is if you are informed and lucky.

The drift into totalitarian medicine has been slow and gradual. And thus, the peons, the slaves of the medical industry, either fail to sense it, to realize the shift, or they prefer to ignore it, and anyway, they tend to say: What can we do about it? We have no choice.

But if you look carefully around you, within your own environment or your neighborhood; if you talk to your colleagues; if you question your patients; if you follow the media; if you stop and look beyond your own so much desired salary check and the constant glare of the electronic medical record (EMR); and if you try to ignore the barrage of propaganda produced by your employers, only then you appreciate the shift I’m talking about.

And here, below in brief are the major components of our TMS. Brief because even if each item deserves a whole book, I guess that your attention span is quite limited and only a few of you will bother to finish reading this little piece.

Hospitals

Hospitals have become monsters, industrial monsters, growing bigger and bigger and gaining power from merger to merger. Terms like “non-profit” have become meaningless; profit is the key word!

Managed by armies of administrators, managers, and hordes of non-medical parasites with a myriad of ridiculous titles printed on their name tags, they function like mammoth factories in China—albeit much less efficient. In fact, the hospitals’ pyramid has been now inverted: the supporting staff greatly outnumbers those who come in touch with the patients. In many smaller hospitals on any given day, there are more administrators in the hospital than patients.

Lip service to alleged excellence is the religion d’jour. We are the best, we are the center of excellence, we have the best doctors, the best technology, and we are the national leaders. And this optimistic message (ala’ the forced optimism prevailing in Soviet Russia of the 1920s) is pushed forward by trained masters of propaganda—look at the size of public relationship department in even small hospitals. Glossy brochures by mail, colorful internal newspapers in any small hospital, group pictures of smiling, satisfied nurses, letters from extremely satisfied patients, and “major news,” glorifying the new Vice President of Finance or broadcasting the important speech our CEO gave in the national meeting of hospitals managers. Like North Korea. Doctors have little significant role, if any, in the conduct of the hospital. Sorry, the term doctors has become a misnomer. Doctors are now “providers” (see below). They are employees – hired and fired. They are hired for their monetary value to the system. The emphasis is on recruitment: a process in which myriad of recruitment agencies benefit. Once they are hired and trapped in a contract, the emphasis on retention is non-existent. If they do not “produce,” if they stray out of the propaganda lines, then they become not useful. Let them go.

There is no much place for dissent. You are not happy with what you see, you see problems, you want to openly discuss areas of dysfunction or misconduct, then very soon you are marked as a “problem maker.” An enemy of the system. Your fate is decided behind closed doors. The “open” process is brief and unilateral. It is easy to manufacture accusations against you: doctor, you have been disruptive, didn’t you complain against the management? The head nurse in the emergency room (ER) reported hearing your ranting? Didn’t you tell a sexist joke in the operating room (OR), it has been reported. The “assistant managers,” trotting around the hospitals on their little heels, often have the task of actively soliciting such information (i.e. denunciations) against you. It may be useful one day.

And once they decide to get rid of you, you have not many options. They always tell you: either you resign immediately or we will have to fire you. In that case, we will have to report you to the National Practitioner Data Bank (NPDB). Now, who would choose to be tattooed with such a permanent stain on one’s record? Who would want to embark on a costly and (usually futile) legal fight with the mighty hospital? Better sign the resignation, find another job, and move on. Doing so, you sign a secrecy term that you will never disclose to anyone why you left. You will never share the problems you have observed. Now after you signed, they may even pay you 3 months’ salary. That is, if they are generous.

The role of whistle-blowers in today’s hospitals can be compared to that of suicide bombers. If you wish to report on any misconduct in your hospital, be it malpractice or corruption, you do not have a chance to survive. These days, most hospitals ask you to sign a “non-disclosure” form: you agree not to disclose or discuss anything about anything pertaining to the hospital outside its walls. Any query, any issue has to be brought to the management. In most cases, to be ignored.

Secrecy has always been a crucial weapon of totalitarian systems. This is how they rule the plebs!

Insurance Companies and Hospital Billing

These companies are a critical component of the TMS. In some places, those companies belong to or cooperate with the hospital groups, sharing profit. Together they band to enrich their CEOs and shareholders. And again, the rule of the game is to bill more and pay less, confuse, hide, and cheat, both the patients and the peons.

The pricing system of hospitals is absolutely opaque. They simply bill as much as they want to. So, for example, a hospital in one State can bill 50,000 bucks for some ortho-prosthesis operation while on the other end of the country another hospital would charge for the same procedure 15,000 bucks. Why? Because they can. No explanation provided.

Anyone who needed hospital services and is erudite enough to examine the itemized bill (one has to beg for the itemized list) would not fail noting the multiple and habitual attempts to over bill on almost anything. And if you complain—first you are ignored, and then you are brushed off. If you persist, write, call, and write again—they may decrease your bill. Never admitting any wrong doing and never apologizing. Remember: dictatorial systems never apologize.

It is the same with the insurance companies. Their main rule is “first deny.” Next, find reasons not to pay out or pay less. Their motto is: bill as much as you can. BTW: the EMR is a tool which allows a constant billing fraud which prevails all over the country and is encouraged by the TMS. The “copy paste” of pre-prepared text in order to document the complexity of the case, and thus a higher level billing is an ubiquitous phenomenon, a fraud.

Also here secrecy is a key factor! Like in mafia system.

Providers

Yes, we doctors have now become “providers.” In many places, our services are performed or duplicated (so the TMS believes) by “allied providers”: nurse-practitioners/physician-assistants. This obviously benefits the TMS: first, allied providers are much cheaper to maintain; second, they are less confident, and thus tend to order numerous extensive investigations (great for the system!); third, they are easier to discipline and keep in line.

This is not new: emerging totalitarian systems always start with eliminating the elite, the intelligentsia. People who are able to think freely are perceived as enemies. Chop off their wings. In such system, there is only one higher class: that of the dictators and their cronies. All the rest are to feel non-significant and in constant fear.

Experience and seniority lost any meaning. You are a specialist with 30 years of experience. It means nothing within the TMS: the guy who just has completed his residency is clearly more valuable to the system; he operates on anything that you treat conservatively. And he always agrees with us.

Looking at Today’s Doctors I See Two Major Groups

The younger generation of docs did not know better times. They, the Nintendo kids, grew up in a politically correct environment, groomed to succeed. And they know how to succeed within the TMS (they do not know any other system): obey the rules, forge happiness, and be useful. They are used to be constantly monitored by the “big brother.” They do not have a problem being evaluated/scored by faulty and biased and costly and contra productive commercial systems aimed at showing what patients think about them. Remember: for children born after the Soviet revolution, life under Lenin/Stalin was the norm … they even spied on their parents.

Trained in 8 or 12 h shifts, they do not comprehend the importance of continuity of care. For them medicine (surgery) is just a job. Quality of life: money and free time, this is what matters. Loyalty to their peers is minimal. Turn over high: “Oh, I was offered 25,000 more in Texas. Goodbye.” Obviously this “technologically advanced but intellectually challenged” generation lives in comfortable symbiosis with the TMS. They know how to satisfy the masters: for example, adopting any new technology as long as it benefits the budget.

The Older Generation

There is no need to elaborate as most of you readers are old farts (the youngsters won’t waste time). You know how you feel. Some are disgusted enough to seek early retirement. Most put on their blinders (like the good old work horses): they learn to plod through the EMR of the day (softwares changed according to the whims of the leadership) and carry on. Adding a few more feathers to the nest before retirement. After all, most of us, no more belong to the top 1% (i.e. gross earning >450,000/year).

And, as usual, there are docs who move over, becoming the politruks or apparatchiks for the TMS. We all know those types: once they are allowed to sit along the long conference oak table, once they are made privy to the systems’ secrets, they are charmed to become collaborators, forgetting the interests of their old buddies. Alleged power and the sensation of self-importance are addictive for some. Isn’t it better to be fed from the hands of the oligarchs than suffer with the plebs?

Academia

The era of the big academic leaders in medicine has come to the end. The solid educators and clinical role models who used to lead exemplary departments in the ivory towers were gradually replaced with doctors–managers, hired and replaced by the TMS, based on their skills to manage profitable departments. Departmental traditions are dying.

So are academic journals. Diluted with numerous obscure online publications (most not peer reviewed or where the review process is a hoax or a joke) respect to the written word has declined. Even the old traditional journals seem to be declining. There are no more great editors like the late Claude Organ (Arch Surg) or John Farndon (Br J Surg). Instead, we have multi-tasking “busy-bodies” who collect memberships in numerous editorial boards like medals on the chest of leaders in some banana republics. The standard of manuscript being submitted to even reputable journals is appalling, unreadable, and possibly non-credible. Sketchy editorial process allows many of such papers to be published, often in duplications or even more.

Along what we see elsewhere, much what is being published in medicine could be “fake news” or biased. You cannot believe anything anymore. You don’t know what has been faked or implanted by the industry-sponsored pseudo research and what is real. The dollar and the TMS control the information.

The Parasites

Army of parasites are supporting the monster. Each skimming its share of the huge amount of money (the highest in the world) spent of “health care.” For example: consultants in hospital management travel around to advice hospitals on how to be more efficient (i.e. more ruthlessly totalitarian). A 2 days visit, a few brief interviews, a cliché-ridden PowerPoint presentation, and a brief summary of banal recommendations (fire, hire, and consolidate)—50,000 bucks wasted by the CEO who a few months later resigns a hospital in shambles to move on to “save…spearhead” yet another hospital.

External human resources agencies take over administrative roles in remote control. Dictators prefer to outsource. Isn’t it safer for them to hire missionaries rather than depend on their own soldiers?

Numerous doctors, providers, and recruitment agencies control the move and hiring of anybody. You want a locum surgeon for the weekend, you pay 1500 bucks/day, and 500 bucks goes to the agency.

No need to dwell about the industrial–medical complex Goliath. You know what it does.

And so, the TMS has become the most wasteful medical system in the world, more and more so each year. I mean wasteful to society and the plebs. Not to the dictators/oligarchs who lead it.

Patients/Quality of Care

Patients: Who cares about them? 20 million not insured? Soon, 50 million not insured? Who cares—just repeal that flawed Obama care!

And who cares about the real quality of care (the real one) beyond the prevailing fake propaganda. But if you care and you look around and talk to the patients, you won’t fail to note the decline: the absence of leadership, the fragmentation, and the chaos masked by the pretentious pose of excellence. You are sick. Your “provider” is not available. You go to the ER, where you are over investigated and shipped away to the ivory tower, where you are treated by an ever changing team of “hospitalists” working on shift. You are discharged prematurely (as decided by one of the nurse-administrators or nurse “navigators”). Next day, you are back to see your allied provider who doesn’t know what to do with you and sends you back to the ER … and so it goes. Modern cutting edge medicine.

This all may sound to you superficial, crazy, subversive, exaggerated, and overly dark. Well, perhaps I have exaggerated a little. And of course out there are still islands or reserves of good medicine. We all know surgeons and doctors and even administrators (and hospitals) who keep the light glowing against the background of the darkening sky.

Also, for many of us, it is difficult to appreciate the decline while we are still doing relatively well, yes, not within the “one percent” but almost so. And the stock exchange is still smiling on us.

But wait a few more years.

By then, our own generation will enter the ranks of the elderly patient-population, a scary proposition.

One may ask: what is the point of complaining and criticizing without suggesting a remedy. In my mind, there is no partial remedy for the system. No method of palliation would eradicate the cancer. Only radical resection: replacing the system with a single payer system would have a chance to work. But this is a wishful thinking. It would never be allowed to happen in this country. The TMS and its friends are too strong.

A general surgeon (I am not going to sign this document. I still need my job for a few years …)