The Covenant

by Danielle Ofri
Academic Medicine

Maimonides, Hippocrates—their oaths we know well. These are covenants that bind doctors to our patients. They are implicit declarations of trust or, rather, acknowledgments of the trust patients must place in their physicians. When people are sick, they often have no choice but to place their trust in the hands of physicians. We, in turn, pledge to honor that trust by promising to act in their best interest.

But what about the covenant between physicians and the medical profession? In a manner parallel to the trust patients place in their doctors, we doctors place a trust in our profession. We readily invest years of our lives in training. We willingly place our clinical responsibilities ahead of personal needs—missing children’s bedtime stories to take call, giving up weekends to round, answering the phone at 3 am, spending extra hours on the phone with insurance companies to do battle for our patients. This is not to say that all doctors are saints or that there aren’t ogres and opportunists among us. But the vast majority of doctors put in a good faith effort to place their patients’ needs front and center. The commitment to do the right thing for our patients remains the guiding—and treasured—principal for most doctors. When it comes to the relationship between doctors and the medical profession, though, it feels as though the profession has not been holding up its end of the bargain lately.

The increasing corporatization of medicine has profoundly changed the tenor of medical practice. We already know that the grafting of corporate leitmotifs such as “throughput” and “vertical integration” has reformulated the health care system into an assembly line–style factory. What’s really melting the covenant, though, is not that we doctors have been reduced to mill hands running an assembly line—that transmutation has already taken place—but that we are now being alloyed into the actual cogs. A few more blasts from the health care blowtorch and we’ll be fully ossified into crisp shiny gears, perfect for keeping the machine purring smoothly, efficiently, and profitably.

I know, I know—this sounds like the familiar histrionics of entitled doctors grumbling about the loss of autonomy and power. But I feel as though there is something deeper afoot than the mere griping over deteriorating working conditions. The steady bore of burnout within our profession has taken on a noticeable crescendo of late. The uptick in the slope of this dispiriting line marks a change that I believe reflects something more primal—the crumbling of the covenant between doctors and the medical profession itself.

When we recited those oaths upon entering the field, we committed ourselves to the ideals of medicine with the understanding that medicine would offer back the steady hand of a profession that would be not only fulfilling but also principled. We were promised an intellectually challenging career, a demanding one whose sacrifices would be exceeded by the immense privilege of being able to help our patients. We pledged ourselves to a career path that did not offer shortcuts or easy options but was worth the sweat equity. We placed our trust in this profession, and now that trust feels revoked. Somewhere along the line, the medical profession was ceded to the health care industry.

The unholy anastomosis of merger-avid, ranking-obsessed medical centers with Orwellian electronic medical records (EMRs) developed for billing rather than patient care, has created a system in which medical care has been commoditized down to a checkboxable item that fits neatly onto a spreadsheet. Or a quarterly stock report. Or an obscene paycheck for a health care executive who has never once palpated the pulse of a patient.

And no, I don’t pine for the days of the giants or bulging paper charts. No amount of polishing of rose-colored glasses would make me yearn for the good ol’ days of paternalism toward patients and the old boys’ club of medical leadership. We’re done and gone with that, and good riddance. The despair I see amongst our colleagues today, however, is more than just burnout. It is a betrayal of trust, the trust we gave to our own profession.

Physicians are forbidden from abandoning their patients. It is unethical—and also illegal—for a doctor to walk away from a patient in need. This prohibition on abandonment is so bedrock to the concept of trust between patients and doctors that we see mention of this even from Hippocrates. Indeed, this moral imperative is what motivates so many of us to keep at it, even in this discouraging climate.

Nowhere, though, do we hear anything about a prohibition on the profession abandoning its practitioners. There’s no code of ethics that outlines any moral duty of the medical profession toward those who carry forward its ideals and practices. Increasingly, we doctors feel alone in our efforts, abandoned by our profession.

When I talk to physicians about their current state, abandonment from the ideals of medicine is an overriding theme. The most common phrase I hear is, “This isn’t what I signed up for.” To a one, they say that they entered the profession because of a desire to help patients. They were attracted to a field that offered concrete tools, intellectual strategy, and human connection to achieve that. But now that medicine has been subsumed into industrial health care, they feel they have been subjugated into lonely automatons whose sole imperative is to click boxes in the EMR, a far cry from the heartfelt oath they took upon graduation from medical school. They are not burned out—they love patient care and couldn’t imagine doing anything else. Rather, they are heartbroken and, as a result, embittered.

Many of us no longer recognize the profession we entered. Hospitals now look like investment firms. Deans are now CEOs. Patients are customers. Physicians are providers, casually interchangeable. Salaries of upper-echelon administrators require scientific notation to express, while nursing is chronically understaffed. Medical care is a commodity whose profit margins are dissected more exhaustively than pathology specimens in the lab.

No, this is not what we signed up for. This is not where we placed our trust.

In response, the profession tells us that we should focus on wellness and resilience. On a good day, when I almost manage to keep my head a hair’s breadth above water during patient care sessions, these well-meaning encouragements strike me as ironic. On a bad day, when the impossible math of the system undercuts my ability to care for my patients and I see their health suffering as a result of this, these terms feel downright cynical.

Resilience? The doctors I see are among the most resilient people in existence. That they manage to soldier on in this soul-crushing system, mostly managing to take good care of their patients and not walk out en masse—that’s resilience! Wellness? That’s like a kindly offer of an ice pack from a mafioso after he’s kneecapped you with a baseball bat.

I don’t doubt that the emphasis on physician resilience and wellness arises from benevolent intentions. I’m sure the desire to make physicians less miserable is genuine. But they put the onus on the doctors to make themselves feel better—Take up yoga! Meditate during your (nonexistent) lunch break! Engage in mindfulness!—when it’s the system that has inflicted the pain and burnout. A system, I should add, that shows no intentions of making any fundamental changes.

It is a bitter irony indeed. Most doctors labor to earn the trust of their patients. Yet we feel as though the trust we placed in our own profession has crumbled away without so much as a fare-thee-well.

Corporate chromatography has stratified the medical profession into a sedimentary layer of clinicians topped by ever more abstruse layers of bureaucracy with commensurately tenuous connections to actual medical care. (Over 35 years, the ratio of administrators to doctors grew from about 1:1 to 10:1.¹)

If the profession wants to reearn the trust of its members, it might be time to shift the primacy of patient care out of mission statements and into actual facts on the clinical tarmac. Those who run health care systems from the C-suites ought to do 2 mornings of clinic per month or a few weeks of ward time each year. Besides helping out with the unremitting clinical backlog, it would provide an object lesson on how much time is needed to take care of a living, breathing patient. Administrators without medical or nursing degrees should regularly help staff the front desk and the call centers. This would surely be an eye-opening experience, and no doubt the extra hands answering the phones would be met with abounding appreciation from both staff and patients.

Everyone who has a role in health care needs to work directly with patients and experience how the system thwarts efforts to do the right thing. Regular contact with the clinical infantry will make it abundantly clear that doctors and nurses are not burned out by patient care but rather by their inability to give patient care the way they know it should be done. The decision makers need to see how this affects patients, who are not able to have their medical needs fully met.

An equally important necessity is an honest appraisal of the revenues reaped by these venerable nonprofit institutions. (Seven of the 10 most profitable hospitals in the United States fall into the “nonprofit” category.²) If the health care industry is as patient centered as it claims to be, then this money ought to be prioritized toward giving doctors sufficient time with their patients and fully staffing the nursing ranks. When it comes to the fundamentals of good patient care, most everything else is secondary.

I’m heartened that applications to medical school are at an all-time high and that spanking new medical schools are popping up to accommodate these eager students. I wouldn’t dissuade any of them. Medicine is still the most rewarding field, hands down. The covenant with the patient remains robust and indeed is the animating impulse for doctors. The covenant with the profession, however, remains in guarded condition—thready pulse, raggedy breaths, BP 60 over palp. As any practicing physician could tell you, it’s time to address the “goals of care.”

References

1. Cantelupe J. The rise (and rise) of the healthcare administrator. AthenaInsight. https://www.athenahealth.com/insight/expert-forum-rise-and-rise-healthcare-administrator. Published November 7,2017.

2. Bai G, Anderson GF. A more detailed understanding of factors associated with hospital profitability. Health Aff (Millwood). 2016;35:889–897.