榴莲视频

In this exclusive video, Eric Reinhart, MD, a political anthropologist, psychoanalyst, and medical resident at Northwestern University in Chicago, discusses his in the New York Times about the demoralization of doctors within the U.S. healthcare system. Reinhart explains that the virtuous ideology doctors are fed throughout their training may not actually stand up in practice, and that providers are leaving the profession as a result.

The following is a transcript of his remarks:

In the , I referenced the end of American medical ideology -- what I see as a historical current that we are in the middle of right now.

When I talk about American medical ideology, I'm talking about the stories that medicine has told about itself. The stories that doctors have been trained to tell about themselves. It's how they understand their relationships to their patients, how they fit into systems, what their role in society is, and how they understand their moral integrity within this world.

Historically in the U.S., physicians have been spoon-fed from the time we're in college, through medical school and through all of our training, that we're part of a virtuous moral profession that cares for others. That is why we joined the field. That's why we pursue this. And this is a very captivating narrative of ourselves. There are lots of incentives for us to believe this.

This narrative doesn't really hold up that well if you look at the history of American medicine. The American medical profession has been part of a cartel, more or less. It's been a trade union that has sought to protect its own economic interest, very often at the cost of patient well-being. Medical bankruptcy is the in the U.S. We are part of that. That destroys people's lives.

From the 1930s onwards, doctors have been part of political organizing to prevent what was regarded a little bit later as socialized medicine -- the idea that medical care might become a matter of rights rather than something governed by a revenue interest. The AMA [American Medical Association] was largely formed to do this, to advocate for doctor's interests, their financial interests, and also their desire for autonomy to not have any kind of interference from government.

Eventually the AMA realized this wasn't going to hold, especially around the passage of Medicare and Medicaid in 1965. There was a kind of compromise that they made to work hand-in-hand with the government, but [also] to use the government like a private insurer. So it more or less continued the for-profit model of healthcare that we've always had, and Obamacare doubled down on this yet again.

So in this context, the idea of medical ideology is a framework to help us think about how the narratives we have told about ourselves are now disintegrating as the structure of the American healthcare industry is really becoming too pernicious to avoid seeing. We have wanted not to see how we fit into this. And I think now doctors are increasingly confronting the reality that our stories of ourselves aren't as flattering as we might like them to be.

I think we have been able to sustain as a profession being overworked and being exploited for a very long time because we believed in what we did. I think increasingly people cannot maintain that belief. It doesn't feel valuable in the way that it once was imagined to be. It feels increasingly like I might just be serving the bottom line of the hospital as I'm turning over patients almost on an assembly line and sending them back out to communities where they don't get the follow-up care they need. They don't have access to basic social services, and their healthcare outcomes are abysmal. As a consequence, U.S. mortality rates are really, really bad compared to peer nations.

This is in large part because of our healthcare system and also because of the way that this healthcare system has cannibalized public health. It has really taken over public health and taken away from the basic social investments that we need to make.

I think we need big structural changes. I don't think moral lessons in medical school are going to cut it. I don't think cultural competency is going to cut it. And I really don't think traditional healthcare reform, like another version of Obamacare, a little bit bigger, et cetera, is really going to cut it. It's important. We need to cover everyone with healthcare insofar as we can right now and use whatever means possible to do that because people die without it. That matters. I don't mean to dismiss that as irrelevant.

But it won't solve the fundamental issue that we have, which is that this is a healthcare system, even in nonprofit centers, that is predicated on for-profit incentives. We see what executives at academic medical centers, for example, are paid. That's not an accident. They're run like businesses, and they will continue to be running like businesses until we have a fundamental shift in how we organize healthcare and health systems in the U.S.

I think the most important part of that actually is not going to happen within healthcare -- it has to happen in or through investments in community-based care systems that allow for prevention, that allow for better aftercare, that allow for trust. We don't have that right now, and U.S. public health is abysmal as a consequence.

An admittedly too simplistic formulation of what I'm saying is something like: we need to shrink healthcare in order to build health.

Healthcare is generally reactive -- it responds after disease has already arisen. Public health is oriented around prevention. Social welfare systems allow for prevention. You can't have public health without robust social welfare systems that are publicly funded. Charity isn't enough. We have to invest in people's rights, not in just somebody's generosity.

I think in order to really make advances for health in the U.S. we need to take a backseat as doctors. We have often led a lot of things politically within public health that, frankly, we probably shouldn't be leading.

People with lived experience of being excluded from these systems who know how you need to design the systems from the bottom up to serve the people who are most suffering right now -- those are people who need to be advancing in these systems and put in positions of leadership. Along with historians, labor historians, medical historians in particular, sociologists, anthropologists, environmental scientists, people who have relevant knowledge that's really, really important for public health that has largely been marginalized.

I think there's a certain kind of epistemic humility that we need to operationalize within medicine, to realize that there are limits to our knowledge and we shouldn't necessarily be running all the things that we currently are empowered to run.

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