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Brian Lehrer: It's the Brian Lehrer Show on WNYC. Good morning again, everyone. We'll take calls from doctors now on the much-read New York Times magazine article describing that many doctors in this country experience themselves as being in a state of moral crisis. The crisis, according to the article, comes from the business model of medicine these days in which doctors are usually employees of healthcare companies being measured on their productivity like any other laborer and any other job, and having to not fully take care of their patients as a result.

Doctors who read the article and would like to call in and share your experiences, 212-433-WNYC, 212-433-9692. The article is called The Moral Crisis of America's Doctors, and with us now is the writer of the article, Eyal Press, journalist and author of several books, most recently, Dirty Work: Essential Jobs and the Hidden Toll of Inequality in America. Eyal, thanks for coming on. Welcome to WNYC for this.

Eyal Press: Thanks so much for inviting me on, Brian.

Brian Lehrer: Can you start by defining the terms moral crisis and moral injury as you use them?

Eyal Press: Sure. The term moral injury, if listeners have heard it, they've probably read about it in relation to military veterans. It's a term that psychiatrists in the VA started to use to describe a set of symptoms that didn't quite match PTSD, but that seemed equally, if not more troubling.

The definition there is that when someone witnesses or does something in the course of fulfilling their duties that transgresses their core values, so for a soldier watching a roadblock where civilians are adversely affected or seeing killing, and then having to live with having witnessed or participated in such an act.

Now, since it became widely used among VA psychiatrists, the term moral injury started to migrate until people started wondering, are there other professions where it's used? In fact, in my book, Dirty Work, I suggest that a lot of workers in low-status jobs who are exposed to violence, people, for example, who work in our prison system also experienced moral injury.

After my book appeared, I got a letter from a doctor who said, have you looked at physicians? That's really where this article began, and there is indeed a literature, a growing literature. I mentioned Wendy Dean, a psychiatrist who wrote an article back in 2018 suggesting that what doctors are really suffering from is moral injury, not burnout, the more common explanation.

What she posited in this article was that this was happening because their duty to their patients kept being compromised by their duty to answer to administrators, to have to hassle with insurers, to spend more time filling out electronic medical records than face-to-face with their patients, and basically that the whole business of medicine interfered with the caring side of medicine and that this caused moral injury.

This article appeared in Stat, a medical news website, not the most widely circulated publication in the country by any means, but it really struck a chord and it went viral, as I describe in my piece. I think the fact that my own piece has opted, as you said, a really strong reaction, I've heard from dozens of doctors and really read through the comments on the piece, suggests that these issues are really very pressing within the medical profession.

Brian Lehrer: Doctors in the audience right now, do you consider yourself suffering from anything you would call moral injury, let's say, as opposed to burnout as Eyal just framed it, or in any other way relating to the business model of medicine these days? 212-433-WNYC, 212-433-9692.

Connecting this to your book, Eyal, about dirty work as the title was, more the working class Americans, we came to call essential workers at the start of the pandemic, you write in the article, "Many physicians have found themselves subjected to practices more commonly associated with manual laborers in auto plants and Amazon warehouses like having their productivity tracked on an hourly basis and being pressured by management to work faster." Can you elaborate on that?

Eyal Press: Yes. I tell the story in the piece of an emergency physician who goes just by the letter A and that by the way is notable. Most of the doctors I spoke to didn't want to be identified because they feared that if they spoke out, they would face negative repercussions. They might get fired, they might be seen as troublemakers.

That really surprised me because I thought unlike the workers I wrote about in Dirty Work, physicians are respected, have prestige, have high salaries, have a voice in our society, but many of them, it turned out were very afraid. It gets to what you just said about 70% of doctors today work either in large hospital systems or for corporate entities.

In other words, they're not by and large setting their own terms of work and working in small private practices where they control how much time they spend with patients and so forth. They're getting directives on how much time to spend. This physician A talked about how she viewed the emergency room as really a sacred space and a place where if there was a patient who needed her to sit by the patient's side for hours and hours who was suffering a terminal illness, she would do that.

Well, this is impossible in the practice where she was working until recently because everything is about speed, it's about efficiency, it's about relative value units, a metric used to measure productivity, and also reimbursement. She just felt this profession that was about caring is all about the almighty dollar at this point.

Really just lost her love for the work, felt in conflict with the constant demands to really work in this kind of fashion where it's speed, it's quickness, it's move to the next person, and eventually took a break and left and is now contemplating what to do next. That story I heard over and over again in various permutations from physicians who just felt that the pull of an administrator or the time they have to spend getting pre-approval for a medication for a patient who really needs the medication, that this was what they spent their time doing, and it really led them to question, did I get into this for this?

Brian Lehrer: Let's take a phone call from a caller identifying herself as a doctor. Laura in Warren, New Jersey, you're on WNYC. Laura, thank you so much for calling in. Hi.

Laura: Oh, hi. Thank you. I'm an older general internist. I just recently retired and I've been so demoralized by the changes that I've seen over my lifetime in medicine which has been more than 40 years now. Two things are clearly true and are in conflict with each other. One is that our society spends way too much money on medical care, the American society particularly. We do need to figure out how to decrease the cost, but these healthcare companies are not interested in decreasing cost.

Every quarter we got, I called it our regular instruction on how to increase the cost of medicine without really trying, basically telling us how to bill more money. That's common. If you say these words, the hospital system and your billing will go up and you won't really change anything about the care of your patient. It's extremely cynical. The other thing is that honestly, a lot of people in medicine make too much money, more than our peers in other countries.

I was involved in medical education and when I first came out, which was in the '80s a primary care person like myself would make maybe half as much or a third as much as a very highly trained surgeon, like a cardiac surgeon or neurosurgeon. Now the difference in pay is maybe 10 or 20 times. It's enormous, and it has really changed the--

Brian Lehrer: Depleted the ranks of primary care physicians because there's no economic sense in going into that.

Laura: Yes. The people going into primary care, the people who don't have the test scores to go into something else very bluntly.

Brian Lehrer: Or have a certain commitment.

Laura: It's really a shame. Or have a serious commitment, that's a very small number. [laughs]

Brian Lehrer: Can I ask you a follow-up question about the tension that you laid out at the beginning of your phone call between the real problem of costs rising? You imply the need to control costs and the fact that these business practices that are making it harder for patients and harder for doctors are not really intended to control costs.

Laura: No, I don't think so.

Brian Lehrer: I was wondering, and I was going to ask Eyal and I will, after our phone call, if there's an underlying problem here that needs its own article, the rising total cost of medical care in this country, as more tests and treatment become available aimed at more medical conditions and diseases, plus the aging of the population leading to more total medical expenses. Wondering if hospitals and other medical companies implementing these productivity practices are, to some degree, playing defense to keep their existence economically sustainable, but you think that's too innocent in explanation, right?

Laura: They're trying to shift the cost to other people and improve their own profits. They don't care about the total societal cost of medicine. I can tell you that.

Brian Lehrer: Laura, thank you so much for your call. Eyal, anything on that, not even so much the total cost of medicine to the nation as an abstract or as a policy measure but to keep themselves economically sustainable?

Eyal Press: I think that's true but I think that the caller's point raises two things. One is that we treat healthcare as a commodity in this country. We don't treat it as a right that is universally provided to every citizen. In that sense, it is a business, has been for a long time, and as I say in the article, for decades the large medical associations, the AMA, and others seemed perfectly fine with that. I think it relates to one of the points the caller made in terms of why that was so, doctors profited handsomely, the system paid them well.

The system still pays many of them very well but I think it's notable that it is starting to adversely affect the people who were the supposed beneficiaries. That is a shift and I think it's coming about because of almost the hyper-corporatization of what had always been to Europeans, to people in Canada a healthcare system that was commercial.

Brian Lehrer: You cite a metric that hospitals and other medical employers are using now called RSVs. What does that stand for, RSV?

Eyal Press: I think you mean RVUs.

Brian Lehrer: Oh, RVUs I'm sorry. RVUs, of course.

Eyal Press: That's okay. Relative Value Units. This is a metric that it's been around for a long time. It's not new but to get back to Dr. A whose story I was describing before, she felt and others I spoke to felt what doesn't get measured there is talking to a patient, listening to a patient, spending time with a patient. That's not valued. What's valued is doing a procedure, doing an intervention, doing something that as the caller mentioned gets billed and counts financially.

Now, yes, the hospitals are under pressure to balance the budget to make money and the insurers are also in it to make money but it's this system in which there are various stakeholders who are in it not for care but for turning a profit, for generating revenue. Within that what gets lost I think a lot of doctors are coming to feel is the ability to care for patients in a humane way.

Brian Lehrer: On these RVUs, here's an email that has come in from a surgeon who writes, "I am speaking anonymously as I do believe I would suffer retribution from my institution if I spoke openly. So long as a physician's worth is measured in RVU, US doctors will do more unnecessary procedures and order more unnecessary tests in order to maximize their RVUs or suffer the financial consequences. What is required is for the people to realize that the insurers, pharmaceutical companies, medical device companies, malpractice attorneys, large hospital systems, and their enablers on Capitol Hill have duped them into believing the falsehood that we have the best healthcare system in the world and to demand better from their elected representatives. Until that happens, little will change." What's your reaction to that including this doctor's assertion that we've been duped into thinking we have the best medical system in the world or medical care?

Eyal Press: That's a version of what I kept hearing in the interviews I did, and strikingly the echo of I don't want to be identified because I'll suffer repercussions. Again, in Dirty Work, I was interviewing undocumented immigrants who would say that working in meat packing. I thought that of course, they're afraid because they don't know if they have any rights. They can be deported. They can be fired and replaced so easily, but it's doctors who feel this. That is really striking that they feel they can't even speak out lest they lose their jobs or be deemed troublemakers.

I will also say that I learned in the course of this article things that I found shocking for example, that at this point, close to a third of the emergency departments in our country are actually controlled. The practice is controlled by a private equity firm, firms like Envision and TeamHealth. You go to the hospital, you go to the ER, very few people have heard of these entities or know that this is the case but their presence is everywhere at this point and they are, again, according to the physicians I interviewed, doing things like once they take over, finding ways to save money by replacing physicians with PAs or increasing their hours or demanding more speed that people are treated more quickly.

Some of this is really hidden from patients. On the other hand, I think that as a country there is a lot of outcry about how broken our healthcare system is. I think we're at a moment when it ought to be all options ought to be on the table, including a total overhaul of a system that is more expensive and seems to provide us less quality care than other countries.

Brian Lehrer: Before we go to our next doctor caller, I want to follow up on what you just said about emergency rooms because was one of the things that made my eyes pop the furthest out of my head when I was reading your article. That ER doctors are at the forefront of these trends including a lot of outsourcing and the role of investment companies that you were just mentioning. How does a hospital outsource medical care in its own emergency room?

Eyal Press: What happens is there's a physician practice that they contract with to run the emergency department. Then that physician practice does a deal with TeamHealth and becomes part of, or Envision, one of these private equity firms. Now if you go online and read about these firms, that's not how they-- They describe themselves as providers of healthcare. The owners are the Blackstone Group and KKR. These are major, major private equity firms. There's a level of removal in terms of direct ownership but there is actually a very important lawsuit that I mentioned in the story in California where the American Academy of Emergency Physicians organization representing 8,000 emergency doctors across the country is suing to bar California from allowing hospitals to contract this out to corporate entities like Envision.

The doctors contend that even though on paper this is still a physician-owned emergency department, in reality it is controlled by a non-medical corporate entity that determines everything from who gets hired to their hours to the speed and measuring their productivity and so forth. That lawsuit was filed, I believe in 2021, maybe 2022. It is moving forward and there are a lot of eyes on it because states across the country do actually have laws that ban non-medical corporations from interfering and delivering emergency care. This is a way around it to say well, it's not the Blackstone group that is delivering this care. It's this physician's practice that happens to be part of us.

Brian Lehrer: We're talking with Eyal Press journalist and author of several books, most recently Dirty Work: Essential Jobs, and the Hidden Toll of Inequality in America. We're talking about his article being much read and much shared and much commented on in The New York Times Magazine called The Moral Crisis of America's Doctors. Here's another doctor calling in. Robert in Manhattan, you're on WNYC. Hi, Robert.

Robert: How are you doing? I've been doing radiology in New York for the last 50 years, and I've seen everything change. I think the major problem is the voluntary non-for-profit system. We transformed to the point where the CEO of the hospital is all-powerful and he's only responsible to a board of trustees. On that board of trustees, maybe there are one or two people who have a clue about anything going on in the hospital. The rest of them are on the board to just burnish their reputations.

There's no responsibility there. I spent 15 years on the board at the medical board at Beth Israel, and I saw everything transform. In my career, I've seen Beth Israel taken over by Mount Sinai. I was at Saint Vincent's Hospital, which went out of business. I was at Maimonides Hospital, which supposedly ran $150 million debt last year, so the system is just not working.

Brian Lehrer: That's so interesting in part because I was just going to ask Eyal about the New York context for this. He's talking about all this corporatization of medicine, all the examples that he gave, venture capital firms in the emergency room, running it, things like that. Here in New York, Robert, hospitals are required to be not-for-profit. Mount Sinai, New York Presbyterian, Northwell Health, these are all big chains at this point, as you point out, but they are not-for-profit organizations, not businesses. Robert, do you think that distinction doesn't matter very much today?

Robert: Well, I think it's part of the problem and the recompense for the CEOs of the hospitals is outrageous. The CEO of Mount Sinai makes $12 million a year, and it's probably comparable to all the other medical centers in New York. The biggest joke is where you've got a university with the medical center, the two largest earners who are salaried by the university are the CEO of the medical center and the football coach and the president of the university comes in a distant third. The whole model is out of whack.

Brian Lehrer: Robert, thank you. Eyal, comment on that call.

Eyal Press: The New York context that I recorded on, there's a scene in the piece where I talked to medical residents, people who are training to become physicians. They were promised anonymity for meeting with me. That's what they wanted, again, because they feared exposing themselves and being named could have adverse career repercussions. These were folks who were training in a city where as noted the hospitals are non-profits, but that's not what they sensed and saw. They felt the business model was very much what dictated things.

They actually used this term moral injury several times and talked about practices that they felt patients thought they were okay with and blamed them for that they found shameful and that they wanted to tell the patients, "We don't set these practices. We're residents." I asked, "What practices in particular?" They described-- This was during the pandemic that a hospital in a poor community, people in the local community would languish on the general floor while "VIP" patients were immediately given private rooms. They didn't have a say over this. They didn't want this to be the case. They felt tainted by it as they saw it happening. Of course, they look across the country and think, "Where will I go where this won't be the case if it's the case here in New York City."

Brian Lehrer: One more doctor call. Rose in Manhattan. You're on WNYC. Hi, Rose.

Rose: Oh, hi. Thank you very much for taking the call, and thank you, Eyal, for writing the article. I'm calling to give a little bit of a historical context because although I really agree with the moral injury and with what the commodification of medicine is doing this really predates it. I'm an internist and an endocrinologist who actually later went into health policy because of these issues. In the 1980s, I left academic medicine to practice endocrinology in a rural area in upstate New York that had no endocrinologist.

I started in private practice. Of course, my morality, I could not not treat anybody who needed endocrine care regardless of their ability to pay. I was very quickly working literally 24/7. After three years doing that, I could hardly even pay my own rent with what I was receiving in terms of compensation. I couldn't bill Medicaid because it cost me more to bill Medicaid than what they paid me.

Had very few people with private insurance and Medicare was paying almost nothing. If I were to have done procedures as the oncologist and gastroenterologist I was sharing office space with were doing, I would've been making $300,000 a year. I wrote an article for the American College of Physicians which was published and later went into after that to try to fix the system. I joined the newly created Physician Payment Review Commission, which was established in 1987 by Congress to try to reorient payment for Medicare.

That's when the RVUs that you were mentioning came into being. I don't think the problem is with the RVUs themselves. The problem is more with how we value the time that physicians really spend talking to patients. I did a lot of work doing surveys and practices and physician practices to try to address this problem. Those research were published in the New England Journal of Medicine.

Brian Lehrer: Rose, I'm going to jump in here because we're going to run out of time shortly, and I want to follow up on something that you said. If you worked in a congressional context back in the '80s, the latter part of Eyal's article is things that can be done about this situation. He points to unionization, he points to direct care practices that get around some of the corporatization, but that's not for everybody. He talks about other ways of pushing back. Do you think the answer to this is at the policy level?

Rose: Oh, I think it definitely is at the policy level. It's also I think a basic societal issue of what do we actually value. Do we value the time that physicians spend talking to patients? Do we see that as something of value? If we do, we need to pay for it. That's a policy decision, and that's something that's not being done. I don't think potentially a union could push for something like that but it's going to get a lot of pushback also from physicians that do a lot of procedural work.

Brian Lehrer: Rose, thank you so much for your insight into this. I'm going to read one more text message that puts another individual human face on this. Very sadly, unfortunately. It says, "I am a close-to-retirement pediatrician. Every doctor I know of my vintage has said they are grateful that we went into medicine when we did because we would not want to be starting out in this environment. I left my hospital job when I was told by a director, everyone would get rid of pediatrics if they could because it makes no money. No consideration at all of the value to our underserved community." Writes this pediatrician. Eyal, we have time for one more answer from you, and maybe we should follow up on Rose's call and ask, what are the solutions to this?

Eyal Press: Well, I asked all the doctors I spoke with that question, and the answers ranged, but Keith Corl, an emergency physician I profile in the piece has come to conclude that we just need to take the profit motive out of medicine. We need a single-payer system. We need to treat it as a right. We need to not commodify care. There were other doctors who did not echo that, who said the direct care model is the right one. Although, as you noted, and as I say in the piece, you have to pay to be eligible for direct care and not everyone can. It's not a solution for everyone. I definitely agree though that these are political questions.

These are questions that affect all of us, but that need to be resolved outside of just the medical sphere. They're also questions of values and who we are as a society if we're willing to countenance a system where the caller felt taking the time to treat a patient, to talk to them not to do a procedure because maybe that's not the best thing for them, that that's punished or that's somehow not what should be rewarded. I think we really have to question where we're going when that's the case.

Brian Lehrer: Eyal Press, journalist and author of several books, most recently, Dirty Work: Essential Jobs, and the Hidden Toll of Inequality in America. His much-read and much being shared, New York Times magazine piece is The Moral Crisis of America's Doctors. Thank you so much.

Eyal Press: Thank you so much, Brian.

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