25 December 2019 — Left Voice
[The shape of things to come, here in the UK? WB]
A recently released report on horrifying conditions in one of New York City’s major hospitals revealed the way that profit-driven understaffing and overcrowding lead to patient death and deplorable conditions for healthcare workers. The Mount Sinai Hospital scandal is just one example of the dismal quality of care under capitalism.
Left Voice speaks with a physician who has worked for several years in hospitals throughout New York City. With the physician’s experience as a healthcare provider, they give a riveting account of everything that is wrong with the US healthcare system and how capitalism creates these conditions.
What do you make of the recent scandal involving the Mount Sinai Emergency Department?
As a physician who has worked countless hours in Mount Sinai Hospital’s (MSH) emergency department (ED), the term “war zone,” as recently used in the New York Post, cannot be more accurate—but is indicative of a larger problem beyond any one emergency room. This article along with the recently published article exposing a doctor’s sexual abuse of patients in the MSH ED raise questions around the quality of care in emergency rooms and hospitals in the US in general.
The conditions in Mount Sinai’s ED are commonplace in many locations and around the country. Chronic understaffing and overcrowding continues to plague hospitals, despite administrators’ efforts to make things look better when inspectors evaluate. I can recollect several patients who did not get the care they needed in a timely manner because nursing ratios were so pitiful. Any physician who has worked in a similar setting can attest to cases where they had to plead with an overworked nurse to get a patient a needed medication.
There is one case that has stuck in my mind in particular. I can remember working with an 80-year-old man with a gastrointestinal bleed and slowly downtrending hemoglobin. This, by all standards, is considered a medical emergency, which must be addressed. The man was told he would need a blood transfusion before being able to undergo a procedure to evaluate the cause. Despite orders being placed for blood, there was a delay in delivery. The man had not seen his nurse in well over an hour and was alone and scared. He started to become confused and began screaming, “Somebody come help me, somebody help me!” When I approached him, he asked, “What the hell do I have to do to get a little bit of care in this place?”
Often people come to hospitals with perceived emergencies believing it is the safest place for them. The problem is much larger than any one emergency room or any one hospital. Overcrowded, understaffed hospitals run by administrators that care more about profits than patient health, inside of a healthcare system that cares more about profits than health, can be extremely dangerous—for all of us.
Is this just a problem in the Emergency Department or are these issues more widespread?
After reading the recent New York Post articles, one might think the problems are strictly in the emergency room, as many patients only have contact there and then go home, rightfully disgusted, hoping to never return. For those who actually require admission, the speed and quality of their care often depends on their race, income, and who they know. Large hospitals around the country typically have special teams sometimes from Human Resources Departments or the hospital’s President’s Office who consistently visit either Emergency Departments or various hospital floors “advocating” for the “VIP” patients. What this really means is that the wealthy or connected patients often get treatment in a more efficient fashion. I have witnessed a wealthier patient with connections to people in high places kick another patient out of line for the same imaging exam. This dynamic is even more exacerbated if the patient is a person of color. Study after study reveals the suboptimal care people of color receive in our healthcare system. In the US, class and race often dictate that the well-being of one individual is more important than another.
Once one gets admitted to the hospital and moves from the ED to the floor, it does get a bit better, but I can personally tell you there are a number of concerning dynamics throughout the hospitals in NYC and the greater United States. Mount Sinai, New York Presbyterian, Northwell- you name the hospital—cover their buildings and surrounding cities or towns with signs welcoming patients and promising health as their highest priority. In my experience though, the highest priority of these institutions is financial–and more specifically, profit maximization.
Teaching hospitals, for example, obtain government funding to “train” “resident physicians” who do a great majority of the patient care while overseen by “attending physicians.” These resident physicians caring for individuals in teaching hospitals typically are forced to work upwards of 80-100 hours per week. The institution tasked with protecting them from being overworked, the Accreditation Council for Graduate Medical Education (ACGME), has determined a work week of 80 hours averaged over a 4-week period is fine.
This puts patients at risk of being cared for by an overworked physician. As studies have shown time and time again, physician exhaustion increases the rate of medical errors. It pains me to say that during residency, I would cringe each time a patient wanted to speak with me about their larger life situation that was affecting their health. Why? Because teaching hospitals make sure to use the cheap labor to their utmost advantage and, therefore, load up residents with extremely large numbers of patients to see each day. It is much more beneficial for hospitals to force the labor onto residents and call it “training” than to hire an adequate number of staff. However, regardless of whether a hospital has residents, in general, the physicians and nurses are understaffed and overworked. Hospital administrations are constantly trying to “cut the fat” and stretch the labor as much as possible. Hiring more staff means better individualized care, but it also means greater costs—that is why hospitals in New York City like Mount Sinai, NewYork-Presbyterian, and Montefiore pushed back so strongly when nurses threatened to strike over safer staffing ratios this past year.
Once it is decided that a patient will be admitted, there is constant pressure on the healthcare team to get you in and out as fast as possible. “Time is money,” as they say. Unfortunately, that often means poor care for patients. In order to admit people quickly, teams on hospital floors are forced to accept admission after admission…after admission. “Admitting” a patient to the hospital is a substantial amount of work. One must closely review a patient’s history of presenting illness, past medical history, labs, imaging, and other tests in a detailed manner to make sure nothing is lost and the best care is provided.
Our hospital system’s ruthless factory-like setting means it is not rare to find unstable patients that should be in an intensive care unit instead sent to a floor designed and staffed for lesser acuity. Often patients arrive to hospital floors from the ED without a comprehensive examination, or a clear diagnosis. When patients arrive to their admission floor without the labs and other exams they need, adequate care is delayed, which can be extremely dangerous.
What about the healthcare that is provided outside the hospital, in the “outpatient setting”?
One might think once you leave the frenetic hospital and get to the outpatient clinic, things would improve. Unfortunately, though, the factory-like conditions are not just found in hospitals and emergency rooms. The conditions in the overcrowded hospital ED’s are emblematic of the healthcare facilities in the US as a whole—whether public or private, not-for-profit or for profit. If you have ever gone to see a primary care doctor or clinic specialist and thought, “Wow, it seems like they are in some type of rush,” it is because they are in a rush.
In 15 minutes, an outpatient physician is expected to meet a patient, discuss their chief complaint, create a relationship, build trust, do a physical exam, come up with a diagnosis, and develop a plan of care. This is obviously impossible to do in 15 minutes, but almost any clinic you go to in the US will have this time pressure implemented.
Various committees have set “quality metrics” or “best practice advisories” for the outpatient setting in an attempt to ensure people receive needed health maintenance. One may think a set list of tasks could help clinicians complete important tasks more efficiently; however, there is not much non-industry funded data supporting their efficacy. Because clinics are run like a business, patients are treated like customers whom they want to see come back, and therefore “quality metrics” are paramount. As a consequence, clinicians are under pressure to take a “check the box” approach and convince themselves this is “providing good care,” regardless of the fact that these metrics have shown to have no effect on people’s health outcomes.
There is a staggering amount of data to show that the specific health interventions that can be done in a medical visit only account for a small percentage of a patient’s overall health or well being. A much greater percentage can be attributed to social or structural factors in society or “social determinants of health.” A physician’s job should be to care for the whole person, including helping an individual or community to address these “social determinants of health.” Unfortunately, it is impossible to detect and address these issues in a regular health care visit. Factory medicine takes precedence and sick patients get shuffled in and out of the outpatient health setting. Often they are sent right back into environments that are making them sick in the first place. The health system’s top priority is to have a body present so that a monetary value can be extracted and then remove that body from the office as quickly as possible so another can be funneled in.
From what you are saying, it seems that the quality of health care is almost an afterthought for these private institutions…
Whether it is the emergency department, hospital floor, or outpatient setting in US healthcare, the patient is turned into just another number from which money is extracted. Care is often substandard and many times dangerous for the reasons highlighted above. Healthcare in the United States is the most expensive in the entire world. The “medical industrial complex” or the conglomeration of hospital corporations, insurance companies, pharmaceutical companies, and device manufacturers govern how our system functions. On the one hand, the primary goal of pharmaceutical companies, hospital corporations, and device manufacturers is to “give as much care” as possible, even if the overtreatment leads to harm, as long as they can bill; whereas the primary goal of insurance companies is to deny care and raise prices to benefit their bottom line, which leads to extra bills for patients. This dynamic ultimately leads to poorer care and impossible financial situations for patients. Today in the US, two-thirds of individuals who file for bankruptcy site a medical issue as a primary contributing cause.
Recently, Jeremy Schahill of The Intercept interviewed Wendell Potter, former Vice President of Corporate Communications of CIGNA, a global health insurance company. In Potter’s words,
The problem is the basic structure of our healthcare system. We have a system that really is driven by and controlled by health insurance companies. They are the entities that are barriers to care or the gatekeepers if you will. They have figured out ways to profit handsomely from the status quo. They also do not control health care costs, nor do they really have any incentive to do that. […] More and more people are shifting to the category of uninsured or underinsured […] so they are resorting to sites like GoFundMe to get the care they need, but don’t have the money to pay for.
In a country where a $738 billion dollar Pentagon budget was just approved and the nation’s three richest men own more wealth than half of the country, this is truly a disgrace.
How do healthcare workers experience these conditions from inside the system?
Working inside of the US healthcare monstrosity takes its toll on clinicians and healthcare workers. Many individuals go through years of schooling and accrue hundreds of thousands of dollars in debt believing that entering this system will allow them to “help” people, only to learn that the system is not built with patient well being as a first priority. They feel disconnected from their work as they are exploited by health care institutions. This leads some to leave health care all together and others into deep despair. Depression and suicide are common among physicians and nurses, with rates up to two times greater than that of the general population. This system is harmful to the patients it purports to serve as well as the staff it employs.
Why is our healthcare system so dysfunctional?
An overcrowded emergency department is not an absurd exception. Instead, it just exposes how healthcare is provided in the US under capitalism. As Vincent Navarro, MD, DrPH defines it, capitalism is “a social formation in which a class—the capitalist class or bourgeoisie—has hegemonic dominance over the means of production, consumption, and legitimation.” The capitalist economic system allows a small number of extremely wealthy people–with vastly different material realities and choices than the majority of the population–determine how these healthcare institutions run. While those who provide care inside healthcare settings—the nurses, doctors, aides, researchers, technicians—are typically motivated by patient well being, these corporations and their executives simply are not.
The “war-zone” that is the MSH ED—or similar departments around New York City and the United States that have not yet made the news—is a natural outcome of this system. This same system is one which allows for the vast concentration of wealth in the hands of a few. It is one which allows for elderly patients in an emergency room to be screaming and begging for care, while at the same time the CEO of the same hospital to be making a salary of several million per year.
When a hospital or healthcare system is exposed in the press, what follows is a period of frenzied activity within the institution: inspections, tours by hospital executives and trustees, visits from the Department of Health, discussions of “what can be done?” Often, the outcome of this process is reduced to new plans for “adjusting workflows,” “optimizing” and “streamlining” various processes, staff trainings, etc.
Thankfully, a coalition of current and past physicians, public health practitioners, administrative assistants and project managers have filed a public complaint against Mount Sinai for sex, race, and age discrimination. There have been actions in front of the hospital on December 19, 20, and 21 demanding Mount Sinai “drop its profits-before-people approach and become accountable for employee and patient well being and safety.” While this is a step in the right direction, the group is asking community members to call and request changes in leadership at the institution. Unfortunately, this will not go far enough as it is not simply the leadership of these large institutions that are problematic, but the entire structure of how these institutions are governed.
There is never a larger discussion around the underlying exploitative nature of healthcare in the US. Never a discussion around who actually controls institutions within the medical industrial complex in the US and how the innate structure of organizations incubate opportunities for abuse. These conversations are much harder and much more dangerous. They would potentially threaten the profits of the rich and powerful and expand the conversation beyond one specific sector of the economy, so they must be avoided.
What is the relationship between healthcare in the US and capitalism?
I liken US healthcare to a gigantic steaming pile of shit covered in sprinkles. Healthcare institutions in the US have nice buildings, beautiful lobbies, moving mission statements, but it is all for show. It is to make the “customer” feel good when they enter, but they are rotten and dysfunctional to their core. Articles like the one published by the New York Post knock a couple sprinkles off of the pile and start to expose the underbelly that is US healthcare under capitalism. But instead of cleaning it up and making an actually humane system that truly cares about people’s health and addresses the actual drivers of poor health outcomes in society, a couple more sprinkles are added to the pile. This happens with all institutions within the US healthcare system, whenever their bottom line is threatened.
We must grapple with the fact that countless examples will continue to pop up around the country because this is what health care is under capitalism. The reason we do not have a sensical system that provides competent compassionate care to everyone without bankrupting them, as we could under a Medicare for All system, is because it would threaten the profits of the insurance, pharmaceutical, and hospital industries. The capitalist system in which the medical industrial complex functions is unable to address the true drivers of disease—structures such as poverty, inequality, racism, militarization, climate crisis—because these are all an inevitable byproduct of capitalist accumulation.
Capitalism is a cancer that has metastasized throughout the globe and continues to eat away at our planet and break down any life-sustaining fabric of society in pursuit of profit. Whatever capitalism touches–whether it is the food industry, energy, education, health care–the name of the game is profit-maximization and exploitation. Until we come to grips with that, we are going to continue seeing healthcare institutions putting profits over the lives of patients.