The Moral Crisis of America’s Doctors

Corl decided he could not let that happen. Exchanging glances, he and the nurse unplugged the patient from the monitor, wheeled her stretcher down the hall, and pushed it out of the hospital. The blast of cold air when the door swung open caused Corl to shudder. A nurse called the police to come pick the patient up. (It turned out that she had an outstanding warrant and was arrested.) Later, after he returned to the E.R., Corl could not stop thinking about what he’d done, imagining how the medical-school version of himself would have judged his conduct. “He would have been horrified.”

Concerns about the corporate takeover of America’s medical system are hardly new. More than half a century ago, the writers Barbara and John Ehrenreich assailed the power of pharmaceutical companies and other large corporations in what they termed the “medical-industrial complex,” which, as the phrase suggests, was anything but a charitable enterprise. In the decades that followed, the official bodies of the medical profession seemed untroubled by this. To the contrary, the American Medical Association consistently opposed efforts to broaden access to health care after World War II, undertaking aggressive lobbying campaigns against proposals for a single-payer public system, which it saw as a threat to physicians’ autonomy.

But as the sociologist Paul Starr noted in “The Social Transformation of American Medicine,” physicians earned the public’s trust and derived much of their authority because they were perceived to be “above the market and pure commercialism.” And in fields like emergency medicine, an ethos of service and self-sacrifice prevailed. At academic training programs, Robert McNamara told me, students were taught that the needs of patients should always come first, and that doctors should never allow financial interests to interfere with how they did their jobs. Many of these programs were based in inner-city hospitals whose emergency rooms were often filled with indigent patients. Caring for people regardless of their financial means was both a legal obligation — codified in the Emergency Medical Treatment and Labor Act, a federal law passed in 1986 — and, in programs like the one McNamara ran at Temple, a point of pride. But he acknowledged that over time, these values increasingly clashed with the reality that residents encountered once they entered the work force. “We’re training people to put the patient first,” he says, “and they’re running into a buzz saw.”

Throughout the medical system, the insistence on revenue and profits has accelerated. This can be seen in the shuttering of pediatric units at many hospitals and regional medical centers, in part because treating children is less lucrative than treating adults, who order more elective surgeries and are less likely to be on Medicaid. It can be seen in emergency rooms that were understaffed because of budgetary constraints long before the pandemic began. And it can be seen in the push by multibillion-dollar companies like CVS and Walmart to buy or invest in primary-care practices, a rapidly consolidating field attractive to investors because many of the patients who seek such care are enrolled in the Medicare Advantage program, which pays out $400 billion to insurers annually. Over the past decade, meanwhile, private-equity investment in the health care industry has surged, a wave of acquisitions that has swept up physician practices, hospitals, outpatient clinics, home health agencies. McNamara estimates that the staffing in 30 percent of all emergency rooms is now overseen by private-equity-owned firms. Once in charge, these companies “start squeezing the doctors to see more patients per hour, cutting staff,” he says.

As the focus on revenue and the adoption of business metrics has grown more pervasive, young people embarking on careers in medicine are beginning to wonder if they are the beneficiaries of capitalism or just another exploited class. In 2021, the average medical student graduated with more than $200,000 in debt. In the past, one privilege conferred on physicians who made these sacrifices was the freedom to control their working conditions in independent practices. But today, 70 percent of doctors work as salaried employees of large hospital systems or corporate entities, taking orders from administrators and executives who do not always share their values or priorities.

Philip Sossenheimer, a 30-year-old medical resident at Stanford, told me that these changes had begun to precipitate a shift in self-perception among doctors. In the past, physicians “didn’t really see themselves as laborers,” he notes. “They viewed themselves as business owners or scientists, as a class above working people.” Sossenheimer feels that it is different for his generation, because younger doctors realize that they will have far less control over their working conditions than their elders did — that the prestige of their profession won’t spare them from the degradation experienced by workers in other sectors of the economy. “For our generation, millennials and below, our feeling is that there is a big power imbalance between employers and workers,” he says.

Last May, the medical residents at Stanford voted to form a union by a tally of 835 to 214, a campaign Sossenheimer enthusiastically supported. “We’ve seen a boom in unionization in many other industries,” he told me, “and we realize it can level the power dynamics, not just for other workers but within medicine.” One thing that drove this home to him was seeing the nurses at Stanford, who belong to a union, go on strike to advocate for safer staffing and better working conditions. Their outspokenness stood in striking contrast to the silence of residents, who risked being singled out and disciplined if they dared to say anything that might attract the notice of the administration or their superiors. “That’s a big reason that unionization is so important,” he says.