Monday, July 11, 2016

Medical proletarianization

I confess: I am a disobedient doctor.

After a career in academic medicine and public health, I decided to work part-time in a rural health program. There I began to understand the loss of control over the conditions of medical practice that has affected so many doctors. Administrative demands multiplied and constrained my ability to care for my patients in the ways I thought best.

So I decided to disobey. A seemingly minor training requirement for the International Classification of Diseases, 10th edition (ICD-10), became the administrative demand that pushed me over the line to disobedience. But the struggle might have involved any other segment of clinical medicine, where employer mandates infringe on a doctor's freedom to practice…

However, entering the world of a nonacademic medical employee revealed the awesome scope of proletarianization—a change in doctors' previous social class position. Until the 1980s, doctors for the most part owned or controlled their means of production and conditions of practice. Although their work often was challenging, they could decide their hours of work, the staff members who worked with them, how much time to spend with patients, what to write about their visits in medical records, and how much to charge for their services.

Now the corporations for which doctors work as employees usually control those decisions. Loss of control over the conditions of work has caused much unhappiness in the profession. Early on, an esteemed clinician and mentor described medical proletarianization when it was first emerging as "working on the factory floor."  Most doctors have become highly paid employees of hospital and health system corporations, and around one half of doctors report feeling burned out.[4,5] Owing to the mystique of professionalism and their relatively high salaries, doctors often do not realize that their discontent reflects in large part their changing social class position…

As a doctor-worker, I got into trouble by expressing concerns about the training that our health network (hereafter, referred to as "OHN") was requiring for ICD-10 implementation. Until then, I had received praise and little negative feedback, and had just been reappointed.

OHN had contracted with a corporation (hereafter, "$Corp") to help cope with the transition to ICD-10. This corporation was one of hundreds that have emerged to sell consulting services to healthcare organizations facing the challenges of information technology…

After I previewed the $Corp training, I concluded that its educational quality was poor and that it implicitly encouraged "upcoding," which could generate more payments for OHN. Brief discussions with other practitioners confirmed universal contempt for the training, as well as disgruntled universal compliance. I decided to protest the training…

My subsequent interactions with OHN administrators surprised me, despite my knowledge about medical proletarianization. The chief medical information officer (CMIO) at OHN wrote that "Practitioners with incomplete ICD-10 coursework at midnight on 10/7/15 will be suspended until the coursework is completed." In response, I sent an email message asking him to explain the rationale for the training requirement. Copying the chief executive officer (CEO), the CMIO pasted his responses into the text of my original message:

Please provide evidence that additional training in ICD-10...improves any measurable patient outcomes, costs, or collections.

Not a debatable point. This is a requirement by OHN, so, sorry to say, whether you agree with it or not, it must be done.

Please provide the costs to OHN for the training.

Not relevant, as this is a requirement.

Please provide quantitative estimates of the financial benefits of the training for OHN.

Not relevant, as this is a requirement.

Please give a concrete description of the process by which you concluded that "completion of this training allows us to achieve both appropriate care and remain fiscally responsible—part of OHN stewardship."

Not relevant, as this is a requirement.

This response pressed one of my alarm buttons, which I might call the "fascism button." In my response, I explained the slippery slope to fascism,  when people do what they are ordered in their jobs without understanding why. Such unjustified requirements, I argued, deserve our conscientious questioning and sometimes noncompliance…

The CMIO was unimpressed with my argument about incipient fascism in the workplace, so I next appealed to practicality. I proposed coming to the office, unpaid, and practicing ICD-10 within our EHR. His reply? "OHN's transformation is a movement to ensure process consistency and standardization.... Therefore, your request for an 'exception' is outside the organization's expectation."

I now faced the apparent abandonment of hundreds of my patients, many of them unstable, who had not received any alternative plan of care. Medical abandonment is unethical according to the American Medical Association Code of Ethics and is illegal in many states. I contacted the chief of the medical staff, who got me reconnected to the EHR so that I could manage acute problems for my unstable patients.

Because I was not willing to abandon my patients, I also persuaded an administrator to get me reconnected to the ICD-10 training, which I completed under protest late the next night. On the following morning, a Sunday, I received an email message from the CEO thanking me for completing the training and stating that my breach of contract had been "cured."

As a doctor-worker, I faced a challenging ethical situation that included loss of professional autonomy, authoritarian practices in the workplace, and apparent abandonment of patients. My first suspension in more than 40 years of practice also raised concerns, such as: Would a report about the suspension from OHN to the National Practitioner Data Bank affect my medical licenses or ability to practice in other settings? Was it my responsibility to blow the whistle on OHN's practices to licensing, accreditation, and insurance agencies?

My small act of conscientious disobedience eventually led to some unexpected responses. My contract and state law required that OHN convene an external review to examine possible interference with my professional judgment, and the coordinator of the state agency that licenses health facilities expressed willingness to investigate this issue and the abandonment of patients.

Facing the probability of external review, the CEO finally met with me in person, and I proposed a formal mediation process. Instead, the CEO composed a document that included an apology, a statement that information about breach of contract would be removed from my personnel file, a commitment to consider individual physicians' preferences in meeting future training requirements, and a promise to meet individually with a physician when a suspension is considered so that patient care would not be disrupted.

Where is the path toward a noncorporatized vision of what we know medicine can be at its best? I don't think that path involves our continuing acquiescence. I confess that I have decided to approach these problems through personal acts of disobedience. For a person like me, closer to the end of my medical career than the beginning, such acts don't risk much. For others, overcoming the risk will require a more organized approach to disobedience.

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