The Bureaucratic Cruelty that is Modern Medicine
I’ve posted yet again with a picture of a frustrated person hunched over the computer. These days, two years into this pandemic, I am often that person. As I am writing my rant, a rapidly spreading COVID-19 variant called Omicron is THE Uninvited Guest™ this holiday season. I’d really hoped that the vaccine would have had more widespread acceptance and we wouldn’t be in this situation, but this is our unfortunate reality now. In addition, COVID-19 has metastasized the already inherent bureaucratic cruelty of the US medical system into death by a thousand slashes of red tape. I will explain why my past two years of practicing psychiatry in the US have been my worst yet.
“Bureaucratic cruelty” occurs when an institution cannot provide a safe (or at least neutral) space to manage trauma and the inevitable emotional turmoil that is human nature. Instead, the system focuses on perfection and endless productivity/monetization at all costs. This creates a hypercompetitive environment in which what is seen as “weakness” is not tolerated. Individuals in this system constantly feel pressured to fit into often confusing and fluctuating roles. Bureaucratic cruelty then creates a system where everyone throws each other under the bus.
The healthcare system itself is a Kafkaesque maze of forms, compliance metrics, and ceaseless documentation. Onerous documentation requirements, intending to ensure that safety metrics are followed, wrest more time away from patients and toward screens. More regulations from an alphabet soup of acronym obsessed handlers are piled upon clinicians yearly. The result? Systems then play an unspoken, intricate game of “pass the hot potato” to try and avoid being the one stuck with the lion’s share of documentation. Compassionate patient care is sidelined in the race to check endless boxes on the electronic health record. If you are wondering why your doctor is taking so long to see you, this is most likely the culprit.
Simply admitting a patient from the emergency room to a hospital room generates hours and hours of documentation. The admission is often accompanied by a turf battle between departments and specialties: an implicit game called “Proving the Patient Needs to be Here”. Sadly, it’s easier to send the patient home- this is the unwritten rule of the system. Patients are shuffled from department to department with no answers to their questions or worse: being told they are making up their problems. I’m sure you have seen it. One of the residents I trained with said one time, “we take better care of papers than patients.” She’s not far off. The ultimate “reward” for seeking healthcare in the United States, should the “Proving” game be successful, is a stratospheric bill.
This sick (pun intended) system plays out in all systems, but is especially tragic in profit centered healthcare, where the patients and those who care for them are the ultimate losers.
Patient care has become more complicated, but the ability to deliver care safely has waned. Due to accelerating COVID cases, I’m largely relegated to doing sessions with my patients over the telephone or over video chat. Most people are accepting of this despite its limitations. Yesterday though, I got an earful from a patient. This person educated me about the COVID “mass hysteria” going on, and, “why can’t I just bend the rules and do an in person appointment?’
“I’m really sorry,” I say, “but the county posts known COVID 19 exposures in our buildings and we can’t risk your safety.” It took cajoling and apologizing; even pleading (!) to get this patient to agree to a telephone appointment.
This is extra emotional labor I don’t need now. Just routine patient care (meaning paperwork) these days is overwhelming.
The patient’s workplace is typically bureaucratic cruelty gone wild. Workplaces love to trumpet that they accommodate FMLA (Family Medical Leave Act) or work leave for mental health reasons. Patients’ lived experiences are quite the opposite. Workplace “protocols” immediately jettison the patient into an endless loop of copious “leave” forms. This is bureaucratic cruelty at its worst: expecting an already ill patient to not rest and recover, but to prove they are sick. Many of these forms I can’t complete because they are highly intrusive at best, humiliating at worst.
Employers are not allowed to contact me directly unless the patients sign a release of information. This is for good reason. Some employers use paperwork as a passive aggressive excuse to shame and nitpick employees. Some work leave forms even ask me to specify exactly what tasks the patient should be doing each hour, as though I trained in their field! Other employers ask for excessively detailed clinical information on why the patient is sick. One employer even wanted me to ally with them and find reasons to dismiss their worker!
If any of you intrusive employers are reading this please note: we do not provide this information by law. We can only specify the patient has a ‘serious health condition’ and supply the dates we request that the patient be on full or part time leave. Don’t ask me for a mental health diagnosis again. I’m serious. If you really want this information, hire an occupational medication physician or QME (Qualified Medical Examiner) and pay them to do so. I will fill out the medical certificate forms, but I’m not going to do extra unpaid work for you. I am an advocate for my patient, not you.
Adding to the miserable burden, understaffing of pharmacies has caused a huge backlog in patients waiting for prescriptions or not getting the ones they need filled correctly. The pharmacies also usually let us know if a prescription is rejected and needs a “prior authorization.” This means that the medication is not covered under their insurance plan, or requires one of their approved formulary medications to be prescribed first. Unless the patient or pharmacy notifies me of a needed prior authorization, I have no way of knowing. With health insurance companies incessantly morphing and mutating their formularies and benefits, it is impossible to track every prescription. I’ve had patients report the same symptoms the next month, only to later discover the medication was never filled. I wish these corporate pharmacies would please pay their staff better and treat them kindly so they stay? I’ve also known of numerous staff who quit because they are verbally and even physically assaulted by patients. Being safe in your workplace is a basic human right…maybe…I think?
It is no surprise that more than 500,000 people have quit the healthcare industry since the start of the pandemic.
Losing a healthcare worker to any cause is a loss of enormous time and dedication. It takes years to learn the skills to practice competently, and then many more years to get the “experience” needed to bulldoze through all the bureaucratic cruelty these systems create. It is inevitable that the short sided policies of a profit driven system trickle down to those who treat patients, and of course eventually harm the patients themselves. The energy in these clinics and institutions is anything but healing. Go to any healthcare appointment and they shove a mountain of paperwork at you to fill out before they even ask your name.
In spite of this, I still like practicing medicine and connecting with my amazingly resilient patients. So…I send my apologies to those who sent me holiday wishes, cards, and presents this year and I just couldn’t get into any holiday “cheer.” I’m still just a frustrated person hunched over the computer, hoping to outwit some more bureaucratic cruelty for my patients today.
Disclaimers: any clinical dialogue herein has been modified to protect patient identity. Statements and opinions expressed in this article are those of the author and are not intended to malign any religion, ethnic group, club, organization, company or agency.
