Recently, the CEO of the largest healthcare company in the US was gunned down on a sidewalk in New York City. There will be no comment of judgment on the murder, as taking a life is never a positive. As for the victim, regardless of our judgment of him as a person, the reality is that he was simply a player in the game of medicine and healthcare. These “service” industries, and especially the latter, which more closely resemble a government-mandated monopoly that has run amok, have left us, its financial supporters, in the dust. Hating the player while ignoring the game, is a common media-driven misstep these days (that same media that is weirdly scripted throughout the entire country, as they try to fuel anger, hate, and misdirection while avoiding approaching the real issues.
You may also have noticed that the CEO was being investigated for insider trading and fraud. There was also an antitrust investigation against his employer, United Healthcare. That’s getting a little closer to some of the real issues—and by this, I mean the inhumane, soulless, mandated journey one must take to climb the ranks in the bureaucratic big businesses that now comprise the healthcare “service” industry. This rite of passage, unfortunately, has infected healthcare as well, and some would argue it has been hit the hardest. Additionally, many of these fully for profit “service” companies are not-for-profit, yet ruthless with staff and more ruthless with cuts and overworking staff to make the budget appear favorable to the bean counters, only adding salt in the wound when it comes to the negative view of current medical systems. Blood boils.
In reality those “service” industries that are in place to serve society—whether we are talking about education, law, or medicine—have been overtaken by the impetus to serve themselves. The people they serve play second or third fiddle, yet the lives of those same people they no longer serve are dominated by them. In the prophetic words of John McKnight, in the book Disabling Professions, published almost 50 years ago:
“The politics of modernized societies will be the conflict between the irresistible resistance of the service business and the immovable object created by citizens who have experienced the disturbing help of privileged servicers who wear the mask of love.”
We are required to be clients now, as opposed to people who were served and whose problems were solved. The new problem is how to keep the financial books looking good for these companies, regardless of how our health or financial books are in reality. This goes for education and law as well, however, medicine and healthcare cut deeper to the core due to their invasive nature. Nuns, oblivious to profits, used to run many of the hospitals. We used to be born at home in front of family and friends within our local community. We died at home or grieved the death of a loved one with family and friends in our local communities. Now we are born in a hospital, grieve by being prescribed antidepressants, and die in a hospital or hospice facility. Our first view of the world is a sleep-deprived resident guiding us out of the womb or a scalpel dissecting our mother’s abdominal wall followed by a rubber glove pulling us out. Our departing view of the world is a nurse injecting us with narcotics and benzodiazepenes.
“The disabling effects are intrinsic to modernized professional service. Whatever benefits they might provide can only be assessed after we recognize them as essentially self-interested systems with inherently disabling effects.” – John McKnight
The road to serfdom is paved and short when it comes to healthcare
It reminds me of an example of a certain unnamed individual who worked for a nonprofit healthcare system in his hometown. They tracked his patient numbers, billing practices, and how often he prescribed very expensive procedures for his patients, whether warranted or not. This person specialized in breast cancer, which rarely requires very expensive procedures, so he was constantly receiving “feedback” about not overprescribing expensive and unnecessary types of radiation treatment. He eventually looked for another job due to the constant feeling of nausea for working for such cretinous beings whose intentions were poorly covered by their masks, but was unable to stay in the same city where his entire family lived for several generations because the nonprofit (i.e. by definition an organization that “exists for the good of the community”) mandates that their physicians sign non-competes so they cannot take a job at the only other healthcare facility for dozens of miles around Pittsburgh. Said person is a pretty good breast cancer specialist that has treated thousands of people in Pittsburgh, so it is unclear how forcing him to leave the area for several years is for the “good of the community” but such actions are standard operating procedure for healthcare facilities and companies in the present soulless state of service line medicine where physicians are referred to as providers. Everyone knows these issues, and yes, they make your blood boil.
This should be enough to open our eyes to the present issues of bureaucratic medicine, but the story goes on. The physician from above moved with his 6-month pregnant wife. His prior not-for-profit employer also owned a billions-in-profit insurance company that, as part of his road to serfdom, he was forced to purchase without option for his health insurance. He and his wife were still covered for a month after employment as he paid for this, but this insurer would not cover his wife’s OB appointments after moving south as they were now considered out of the coverage area. They were told they must drive over 16+ hours round trip (with a now 7-month pregnant wife) to see one of their docs, a ridiculous proposition that the person on the phone was somehow able to keep a straight face while suggesting. When he started his new position at an esteemed medical system and university, also not-for-profit and in the billions-in-profits range, he was told that his new insurance did not start until one month after his employment, leaving a gap with no care for his pregnant wife. He asked to pay cash for the routine 7-month appointment, but was told by a soulless robotic voice on the phone that their policy is to charge the entire cost of the pregnancy package upfront when paying with cash, thus over $12,000, even for just one routine appointment. When questioned about this, and the issue elevated to her robotic manager, he supplied a “sorry, that is the policy” routine that has become typical in large bureaucratic organizations that require removal of the soul as a part of employment. She ended up seeing the wife of one of his residents off hours for free, a luxury that the majority of the population doesn’t have access to. Two billion dollar not-for-profit healthcare companies “serving the community” where he spent countless hours providing care and was forced to pay for their insurance from his salary while making them countless profits, and neither would see his pregnant wife for a routine 20-minute visit and lab draw unless they drove 16 hours or paid $12,000. That my friends, is the game we are forced to play, a game that, yes, makes your blood boil. Both systems illustrated quite well to this doc that they were not providing service for him, but quite the opposite.
When things get large, they become inhuman. The brilliant E. F. Schumacher told us in his masterpiece that Small is Beautiful (Economics as if People Mattered), but we failed to listen—or perhaps we were simply forced to ignore the advice as we watched the major systems become massive and overbearing. And while it happens in every industry, it is certainly more palatable in those non-healthcare related for-profit companies who do not wear a mask and lead with the fact that their primary goal is making money. When countries get large, world wars start. Italy went thousands of years with ridiculous, almost laughable, skirmishes and land disputes between neighboring, family-run fiefdoms. If the Medici and the Florentine Republic tried to take over the world, they would have been quickly smacked back into reality by the time they reached nearby Siena. Only when Italy forced all the areas of the Italian Peninsula to unite, mostly against their will, did they become the massive kingdom of Italy, ushering in Mussolini, giant ugly concrete postmodern buildings, fascist cooperation between big business and the government, and yes, forcing its citizens to go to war to support the wrong side during World War II.
The same thing happens in bureaucracy. Normal, once humane, moral, ethical, and decent human beings join the grinding wheels and treat others like cogs. They use terms like “circle back” and “granular” and sit in meetings for countless hours discussing nothing of relevance. This cruel and unusual punishment is a type of dehumanizing training that further wipes their conscience of decency, and they begin to treat other human beings like nonhuman line-items: doctors are providers in service lines and patients are clients. They denigrate with terms that the Nazis used to dehumanize Jewish physicians and limit their ability to see non-Jewish patients. They discuss made-up irrational budgets at length, constantly speaking of “making budget.” Climbing the ranks upwards mandates a soul-expulsion spiral downwards in a Dante Inferno like manner. Budget and cutting costs are all that is heard even though we are supposed to be caring for patients. The nuns have been replaced by penny-pinching managers, and it ain’t pretty. The habits of yesteryear have been replaced by dunce caps. The managers, on the other hand, don’t quite understand what happened to their souls during their Dante-like descent up the corporate latter, but everyone around them is doing the same, so they have no choice but play along (until they can take no more and leave).
“It is becoming more and more evident that rather than producing “services” they are creating sensitive but frustrated professionals, unable to understand why their love, care and service does not re-form society, much less help individuals to function.” – John McKnight
This large bureaucratic mentality and workplace more so resembles a crowd, and history is ripe with examples of what humans do when part of a crowd. In his brilliant work The Crowd: A Study of the Popular Mind, Gustav Le Bon describes the crowd mentality that ripped through the French Revolution, particularly that “the substitution of the unconscious action of crowds for the conscious activity of individuals is one of the principal characteristics of the present age.” He wrote this in 1895, but it still stands as relevant particularly in most of our workplaces where our individuality is sacrificed for the good of the unstoppable machine.
And this is where the issues start. If this is what is required to climb the ranks in healthcare and medicine, what trickles down throughout the entire industry? How can an industry that requires soulless direction upwards provide compassionate and appropriate care downwards? Insensitive leadership does not promote sensitive, compassionate, and loving care, it promotes Sackler-like behavior always at risk of financial rationalization impeding compassionate care. We, the plebes are left with over a million dead and a ravaged Midwest from the Sacklers and their government collusion—who only got a slap on the wrist for causing casualties that eclipse more than 500 September 11s while the head of the FDA joined their company, Purdue Pharma, after letting their highly addictive drugs reign down upon the US. And yes, they were and are a “physician-founded and physician-led company” that remarkably still exists. The icing on the cake is that you can kill a million people and not even go out of business while small mom and pop shops get shut down for the tiniest regulatory oversight.
“Professionalized services communicate a world view that defines our lives and our societies as a series of technical problems. The technical definition is masked by symbols of care and love that obscure the economic interests of the servicers and the disabling characteristics of their practices. The sum of these disabling characteristics of their practices is an ideology that converts citizens to clients, communities to deficient individuals and politics to a self-serving debate by professionals over which service system should have a larger share of the Gross National Product.” – John McKnight
And of course, Purdue paid off a whole plethora of other big businesses who were in on it (along with marketing companies like McKinsey who just got fined). Healthcare often resembles more of a money grab, funded through tax dollars, forced upon employees, and showered upon us as the largest present-day monopoly. Insurance companies are the troops of an inherently flawed system where one is forced to pay to be told what they must do to be healthy, while those entrapped within this system know that the path to health lies in lifestyle, which is outside of its road to serfdom. Society deeply knows this and is tiring of it quickly and aggressively, while their “saviors” then respond by deepening their overreach to expand the cult of dependence in present society. This dependence always seems to promote the service industry while fueling societal outrage as it is apparent to all that the service industry is servicing themselves behind a mask of love.
See a pattern here? Still cheering on the killing of one CEO with a wife and kids who is nearly irrelevant in the giant picture? Your blood may be boiling, but it’s the game that is heating it up, not the player.
Perhaps the most ridiculous notion is that doctors and healthcare make us healthy. We, as a society, joined the cult of dependence with open arms. We now turn to our healthcare systems to lead us in all aspects of life, including a multitude of “medical” issues that used to be part of normal life and resolved with effort, fortitude, and the help of friends and family. We overeat, under exercise, over drive our lives and then turn to our medical systems to fix us. We feed our kids garbage and let them play video games in the basement and then stick them with diet drugs to lose weight. For those systems that exist purely to profit off our maladies, we sure make it easy for them. I am a doctor. I do not make you healthy. I fix issues that may be impairing your health, and then you take over. In the gym and our nutrition sessions, where I am a coach, motivator, smack-talker, and friend, that is where I can motivate you to be healthy, but it is still ultimately in your hands. This model, while novel and yielding incredible results is not even part of healthcare and I set it up tangentially because my employer had enough foresight to support such an idea (that will hopefully actually be considered healthcare one of these days).
“Visible social phenomena appear to be the result of an immense, unconscious working, that as a rule is beyond the reach of our analysis.” – Gustav Le Bon
The underlining existential issue of bureaucracy and medicine is the fact that these massive systems require soulless, unethical behavior that at times feels as though it is being pushed along by an invisible hand. People do not want to be treated like soulless, brainless drones at the workplace, and do not want to treat others like this either, and certainly not patients. As healthcare receivers, patients do not want this. The problem is that the cost to play the game is often a dumping of human decency at the door. The monster has taken over and admission to the game is unwanted by all but a few, but unstoppable by all as well. The real question, and I believe I know the answer, is that under the current large bureaucratic model, is this actually required? Is it part of the machine and unavoidable? We must question the underpinnings of these systems, as they will likely always produce the same outcomes. Until then, blood will boil each and every time.
“Whoever be the individuals that compose it, however like or unlike be their mode of life, their occupations, their character, or their intelligence, the fact that they have been transformed into a crowd puts them in possession of a sort of collective mind which makes them feel, think, and act in a manner quite different from that which each of them would feel, think, and act were he in a state of isolation.” – Gustav Le Bon
Human individuals are turned to inhumane robots in the current healthcare system. Individuality is destroyed for group think as bureaucratic layers provide an anonymity, shielding the conscious from any responsibility of the soulless behavior that would normally rattle an individual to his or her core, allowing them to make the soulless climb upwards. Nobody wants this but they do not know how to change it so they play the game and partition their lives from inside and outside of the work place often rationalizing their actions as “just part of the job.”
“In the collective mind the intellectual aptitudes of the individuals, and in consequence their individuality, are weakened…He will be the less disposed to check himself from the consideration that, a crowd being anonymous, and in consequence irresponsible, the sentiment of responsibility which always controls individuals disappears entirely.” – Gustav Le Bon
Late days and nights, meetings about nothing, inhuman words and responses that further rot us at our core become the norm as our personal interests must be eroded to climb the bureaucratic ladder and support the system. Individuals will openly discuss this in private, but never when the system is watching. The inhumane behavior then spreads throughout like an uncontrollable virus. The only way to avoid it is to exit the game—which many people do—even after decades of training to be part of it.
“Contagion is a phenomenon of which it is easy to establish the presence, but that it is not easy to explain…In a crowd every sentiment and act is contagious, and contagious to such a degree that an individual readily sacrifices his personal interest to the collective interest.” – Gustav Le Bon
The reality is nobody wants this, from top to bottom, but everyone feels stuck. Nobody wants the requirements to climb the ladder and nobody wants to be an inhuman automaton and treat other inhumanely, but the system requires it—and sometimes dollar signs, trailing zeros in bank accounts and compensation packages are sufficient to forgo individual thinking. Those who cry for more bureaucracy to save the system of too much bureaucracy are largely misguided, almost as much as those that think the system is working. Even the highest of leaders in the system agree that a degree of hypnotism is at play and they are forced to act in ways they never thought possible. While nobody knows a grand solution and easy fix to the problem, the first logical step is for us all to take health into our own hands and stop pretending it is granted to us from others, particularity bureaucratic institutions that are in the game for financial benefit, not for the love. If we continue to crawl to these institutions for health that they cannot grant, we will keep fueling the game.
“Removing the mask of love shows us the face of servicers who need income, and an economic system that needs growth. Within this framework, the client is less a person in need than a person who is needed.” – John McKnight
Until medicine returns to servicing the public and not themselves, the game will continue. Until patients take their health into their own hands and return to their communities for their psychosocial benefits, the game will continue. The reality is the game needs us more than we need it. Perhaps our first step is to stop playing it.
As Ivan Illich asked in 1979, “Why are there no rebellions against the coalescence of late industrial society into one huge disabling service delivery system?” Perhaps he is finally getting his answer.
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