Why Are Doctors Quitting? A Physician Weighs In

SARA SIDNER, SENIOR CORRESPONDENT: Now, turning to a crisis plaguing health care here in the United States, where a number of physicians is dwindling drastically. In 2021 alone, around 117,000 left the workforce. And one in five doctors say that they plan to leave in the coming years. In his recent opinion for “The New York Times”, political anthropologist and physician Dr. Eric Reinhart explains the fatal flaws of the country’s health system. And he joins Michel Martin to discuss the potential solutions to this’s worrying trend.

(BEGIN VIDEO CLIP)

MICHEL MARTIN, CONTRIBUTOR: Dr. Eric Reinhart, thank so much for talking to us today.

DR. ERIC REINHART, POLITICAL ANTHROPOLOGIST AND PHYSICIAN, NORTHWESTERN UNIVERSITY: My pleasure. Thank you.

MARTIN: We’re talking to you about a really powerful, and I would have to say disturbing, essay that you — that was published in “The New York Times”. An opinion essay. Will you say that, you know, we talk a lot about how doctors and other medical personnel are burned out. But you say they’re not burned out, they’re demoralized. Talk a little bit about that. Why do you say that?

DR. REINHART: You know, doctors have worked hard for a very long time in the U.S. They have been overworked. They have been exploited by medical systems. Nothing about that is particularly new. In fact, over the last couple of decades, doctors work hours have declined. We have better working conditions than we used to have. But the pandemic disrupted our impression of the system for which we work. I think one of the most demoralizing things, the things that leads to what has been referred to as burnout is when the system that you work is not serving the ends that it claims to serve. We, as doctors, want to serve our patients. I really believe that about the colleagues with whom I work, and we are constantly failing them. Not through any lack of effort on our part but because our health systems and our welfare systems are not set up to allow us to succeed. And doctors have played a very large part in producing that reality over a long historical period. We have, in some sense, allowed ourself to be paid off. We have highest in the world compensation for physicians, and we work in the least effective health care system in the world among wealthy nations. We have dramatically poor mortality, for example, then peer nations.

MARTIN: So, it’s — in a way, it’s like you’re saying that there is, like, a big lie, you know, at the heart of the profession. I mean, we’ve talked a lot about how, you know, nurses and other medical personnel are leaving the field. Nurses in particular, we gotten a lot of attention in part because the COVID pandemic. But you’re saying that physicians are also leaving the field. And if they haven’t, they’re talking about it. Why do you think that is, like, why now?

DR. REINHART: I think why all of these groups are now unable to sustain the belief that they used to have in the systems or at least some marginal belief, is because the pandemic accelerated death. Bureaucratically ordained death that didn’t have to be. Put it at a rate that we had never seen before. There was a study in the proceedings at the National Academy of Sciences, a top science journal, that estimated 338,000 lives could’ve been saved had we had a universal health care system in the U.S. like every other industrialization in the world has. When you’re working as a doctor or a nurse or a staff member at a nursing home, and you are seeing death after death that did not have to happen, and your reading about it constantly in the news. “The New York Times” has been publishing expose after expose of the corruption in the health care system and who is profiting from, who is deliberative designing the systems to produce these outcomes. This set is — has led to what I call in the SA collapse of American medical ideology. That is the stories that we have told ourselves about ourselves for so long. That have sustained our motivation despite poor working conditions, despite the fact that trainees and nurses and doctors, even senior doctors are exploited by this system. We have been able to sustain some belief that our work mattered. That it was virtuous. It was part of a moral enterprise. I think that a vision of ourselves is collapsing now.

MARTIN: Well, you call it corruption. Why do you use that worried? I mean, you — it sounds to me like this is the way it’s designed to work in a way except for the fact that it’s now collapsing.

DR. REINHART: I don’t mean corruption in legal terms, per se. But I think what you have is a field that is entirely inconsistent with the ethical values that it holds up. If you go through medical schools right now in the U.S., you will hear in every single medical school that you might attend, long speeches about health equity, health justice, how this is what our institution is designed to serve. And then you go work in the hospitals. I’ve had experiences like this. And you that — actually the policies that dictate who comes into this hospital, what kind of care they get, what kind of aftercare they don’t get is not guided by the ideas of health equity or health justice or even care. It’s guided by a goal of maximizing revenue, and in many cases profit.

MARTIN: So, you — so, let’s just say at the core of it you say is the for-profit model. At the core of it is that American health care is primarily delivered through for-profit mechanisms, even institutions that are ostensibly not- for-profit, right? They’re still operating under a profit motive, right? And so, your argument is that this leads to fundamentally terrible outcomes that patients get inferior care and that the medical personnel, doctors included, just can’t basically kind of keep up. They can’t fulfill their ethical obligation to care for people because of that. Tell me why you’re so convinced that that is at the root of the problem.

DR. REINHART: You know, there is a tradition that I come out of, it’s called social medicine. It’s founded by this pathologist in Germany, Rudolf Virchow. He went to steady an epidemic in Upper Silesia, a typhus epidemic. And he’s a specialist in pathology. And the first thing that he realized when he got there and he was studying this epidemic was that it wasn’t his pathological knowledge that mattered, it was housing, it was labor conditions. These were the determinants of health. In the U.S., those things are determined by policy. They are the political determinants of health. The U.S. medical profession has fashioned itself for well over a half century around suppressing its awareness. That what we do is the product of policy decisions. And if we do not engage in political struggle to try to advance of quality of life for our patients, we cannot fulfill our ethical obligations. This, in my view, is a — an obvious reality. This is true everywhere in the world. U.S. doctors, historically, have refused this. They say medicine is a scientific enterprise. It is not a political enterprise. Why are you trying to bring politics into this? And I think that has, overtime, hollowed out the ethical claims of the field. In my view, ethics in medicine in any scene in life has to be accountable to its effects. If you are ethical framework is producing effects that kill people who do not need to die simply because they have been deprived of care because they cannot pay, that in my view, is not an ethical system. Ethics without a paired politics to advance the ideals you claim to subscribe to is largely meaningless. It’s many ways, it’s worse than nothing.

MARTIN: But why are you so convinced that that is at the core of the problem as opposed to, I don’t know, decoupling, say, health insurance from your job or something like that. Well, I guess by some center that would be universal health care. I mean — so, people do think we — they’re, by some measure, we have universal health care now because we do have the Affordable Care Act that people have access to health care who didn’t have it before. Millions of people do. Why, in your view, has that not fixed the problem?

DR. REINHART: Just to clarify for that last point. You’re right that Affordable Care Act dramatically expanded health care access, this is extraordinarily important. But there are still over 30 million Americans who do not have health insurance and do not have continuous health care access. They can only get access only through emergency departments. And it’s very substandard care. It’s broken off. It’s very ineffective. It leads a lot to medical errors. And there’s also the fact that people who do insurance are underinsured. I work at a hospital where I can’t treat a lot of patients who come in with certain kinds of insurance. I have to refer them out. Sometimes it takes days for them to be transferred from our emergency department to another hospital. And that’s not unique to my hospital. I’m not a fan of that policy. But that’s true at countless hospitals around the country. So, simply the fact of insurance coverage does not insure good care. And I think the fundamental group of what determines care structures and all of these contexts is around motivation. And that is imbricated with for-profit pharma system, a for-profit insurance system. The Affordable Care Act expanded health care access, which is very important, but it also more deeply entrenched the insurance structure. Do you have private insurance that are making money off of this. So, it also enhanced insurance company profit substantially. What you’ve seen during the pandemic, for example, as hundreds of thousands of people have died unnecessarily are record profits in many hospitals, in the pharmaceutical industry, and the insurance industry. What we have is a fundamental decoupling of health care, of actual care and health outcomes with — and the goals of the system.

MARTIN: And you really point the finger at doctors for this. You don’t really come right out and say this. But I think that your argument is at its core that doctors are really to blame for this. Because of their need, desire for status and money. Is that fair?

DR. REINHART: Yes and no. So, it’s a very complex issue with a lot of different actors. The reason I start with doctors is because I, myself, am doctor. I’m speaking from within the medical institution and I believe that once first ethical accountability when you’re a part of any powerful institution is to hold it accountable to its ideals. So, I’m going to call out my colleagues because I think we can do something about this. There is an excellent essay in “The New Yorker” that a senior physician, Eric Topol, published a few years ago. It’s called, “Why Doctors Should Organize.” And part of what he says in this essay is that doctors are often resistant to the idea that we should be politically organizing for care and such, that’s not our domain. He says, actually, doctors have been organizing for decades, we’ve just been organizing to enhance our income, enhance our political power. We have not been organizing on behalf of the patients. And this is true. If you study the history of U.S. medicine, you can see from the 1930s and ’40s in California that it becomes — it passes to the EMA. They become a very powerful institution. They’re less powerful now in some ways but they’re a historical momentum in terms the system they have put in place persists. And those systems were put in place to protect American doctors against the specter of socialized medicine. Even as the people who were saying that we need to keep away from this recognize that it would lead to improve patient outcomes and patient care, but their concern was that it would reduce doctor’s income, it would reduce their status. It might make them secondary actors rather than primary actors in the health care field. What we see now is a consequence of that for our health care system but also for health systems, not just health care. The most important part of health in any context, in a national context is not health care, it’s the preventative systems that supply the basis for public health. Those are fundamentally interwoven with basic social services like housing, et cetera. What you have is a medical profession that is advocated it’s — for itself for so long and has obtained so much power and wealth in the process that it has cannibalized public health. Doctors have been leading in public health. They are, in fact, not necessarily expressly in public health. Medical interventions constitute only 10 to 20 percent of the determinants of health. 80 to 90 percent of the relevant knowledge for public health is not within the medical field, it’s in labor history, sociology, communications, environmental science. Why are these people — and it’s also in the knowledge that communities who are excluded from our current system have about the obstacles they face. They know how to design systems from the bottom up, which is how you always have to design public health system for them to be effective.

MARTIN: You know, there is a group of doctors that have been saying this for a very long time, they’re black doctors. OK. Black doctors, like in the National Medical Association, which was formed because the AMA, the American Medical Association, would not allow black doctors to join, and in some cases, they excluded them from privileges at white hospitals. Black doctors have been saying this for quite some time, in fact, you know, for decades. Why haven’t the other folks in the profession listened to them?

DR. REINHART: This could be an important point. I think whenever you design any system, you have to design it from the bottom up. So, not just public health, but if you’re talking about health care profession, to make it be ethical and accountable to its members, it should always be looking at those who have historically been most excluded and empowering them to lead the field forward. So, it has to be less exclusive than it has been, to be better than it has been. I think black doctors in the U.S. have a very important position, and they are leveraging it. A colleague of mine, Alicia Maibing (ph), he’s actually working for the AMA to try to promote health equity. There are limits to working within such powerful institutions whose intrinsic motivations are not necessarily in line with this. I think this is what a lot of black doctors and other progressive doctors around the country have faced. We can I advocate for these things, but if we are working within an extremely powerful systems and the majority of physicians around us do not very actively join us, it’s very hard to upend the power structures. It’s much easier, frankly, for those power structures to absorb dissidents into positions of leadership and in the process, silence them. And I don’t mean that the doctors themselves have bad motivations, we realize this is happening. This is a structural force, and we see this all the time.

MARTIN: But that’s why you advocate for doctors unionizing. And I’m just trying to figure out, you know, that’s one of the things that you suggest in your piece is that doctors should unionize. But I’m just trying to understand how that actually works. And frankly, I am just curious how you overcome this sort of cultural resistance that the people who are currently in the field have to this, they are just not used to thinking of themselves in that way. So, I’m just curious like why you think unionizing solves this problem?

DR. REINHART: Yes, I don’t. I think it’s an important step. I think doctors need to learn to organize together and organize beyond their field, need to organize with other health care workers, with techs, with nurses, and beyond that, they need to organize with their patients. We need to organize with our communities and ground ourselves in those, not in the values of these powerful very wealthy health care institutions for which we work. I think one step that is immediately achievable that doctors can take towards that is to begin to organize together.

MARTIN: Are you convinced that most of your colleagues agree with you on the problem, if not the solutions?

DR. REINHART: I think the doctors of my generation, younger generations, by and large, yes. They agree. I think the doctors who have been in this system and have been rewarded for loyalty to the system for a very longest time, and I think they’re wonderful human beings, many of them. I don’t mean that they’re bad people, but there is a structural determination of how they see the world. This part of medical ideology, the thing that’s collapsing, the story that we have told ourselves has been so core to their identity, their moral identity in the world, their ethical identity, their political identity. So, for them to be able to do an about-face and recognize that there is some level of responsibility for enormous harm that has been done, I think it’s very difficult. And I think we need to figure out how to bring these people in in a way that’s gentle, in some kind of way, but also being very hard about the reality that we have to face and that we need to do this not just for our own moral integrity but because people are dying, literally every single day, that refused to confront this.

MARTIN: Dr. Reinhart, doctor shows are a staple of television. Doctor shows on television are just filled with these kinds of storylines.

DR. REINHART: Yes.

MARTIN: You know, they are filled with the idealistic young doctor who comes in and says, well, this isn’t right, you know, this person needs health care and I can’t do it, and they fight the system and then, they go down in flames. It’s just interesting that, as a culture, we kind of accept that story but we don’t do anything about it. You know, I’m just curious like what do you think of that, if you think about that.

DR. REINHART: I think about this all the time, and I think that’s a really, really important point. And I think a lot of young doctors have — they still hold on to these ideals of equity, of justice, they hate it when they have to exclude patients from care, when we see our patients suffer for preventable reasons. And there’s a dedication to this idea of the great doctor, the great humanitarian who is going to sacrifice themselves for this. And this is part of why we’re so easily exploited. Many people in the field are very idealistic. They are happy to work 120 hours a week if they think that it matters. I mean, I often work over 120 hours a week because I think it matters. I don’t know how that’s clinical. But the problem with that is something that Che Guevara pointed out, a physician that’s part of the social medicine tradition. He gave a speech in about 1960, we called “On Revolutionary Medicine.” He described it in his own biography. He said, you know, I trained as a doctor and I had this vision of myself as the heroic doctor who would redeem the world in front of me. And overtime, I’ve realized that that fantasy is part of the problem. It’s not individual heroes who are going to be able to do the work that we need to do. We have to bind together at the collective, and not just as a collective of doctors, as a collective — you know, well beyond that. In terms (ph) of our rights (ph) about the entire population working on itself, that would be caring for itself. That would be revolutionary medicine. You can have revolutionary medicine from a single doctor or single group of doctors or a single hospital, it has to be a collective mobilization.

MARTIN: Is there any part of you that’s kind of burned out or demoralized? And if so, what do you say to yourself to get up in the morning?

DR. REINHART: It’s those relationships with people who are working every day to address the problems that I’m thinking about all the time even as I work in a hospital, I can’t address them. It’s my relationships from my long — my decade (ph) ethnographic work from the south (ph) in Westsides of Chicago of people who are suffering from health care exclusion, who can’t get access to housing. I leave the hospital and I am demoralized, very often. I’m frustrated that I couldn’t do better by my patients. I don’t have the resources to do it. But then I get a call from somebody who wants me to come visit them, because they are having a difficult day, that is what gives me a sense of meaning and continuation. So, I think that’s how we counter demoralization. We bond together in relationships and in collective movements to make things better.

MARTIN: Dr. Eric Reinhart, thank you so much for talking with us today.

DR. REINHART: Thank you for your time.