Summary: Eric Reinhart brilliantly issues a call for physicians – long a conservative force in health care – to expand their political horizon from their own recent labor awakening to join the progressive movement to transform our desperately ailing health system.
The Political Education of US Physicians
JAMA Network Open
June 27, 2023
By Eric Reinhart
Since the beginning of Ronald Reagan’s presidency, the proportion of workers in the United States who belong to a union has declined by approximately 50%, while income inequality has increased by approximately 20%. Today, just 10% of all US workers are employed in unionized positions. But following the recession that started in 2007 and 2008 and then the temporary resurgence of a social democracy during a pandemic that exposed neoliberal policy as a public health disaster, labor organizing against exploitation and public abandonment has been increasing. Amid growing concern about workforce attrition associated with the demoralization of nurses and physicians in a flailing medical industry shaped by profit rather than ethics, health care workers have become increasingly involved in this revival of labor politics.
A wave of nurses’ strikes and house staff unionization has put this ideological shift front and center in contemporary health care politics. There are now approximately 70 000 physician union members in the US, representing 7% of physicians—a nearly 30% increase relative to a decade ago. …
It is into this context that the analysis of housing affordability and housing-related benefits for house staff by Brewster et al interjects. Using data from the 2022 to 2023 academic year, Brewster et al found that compensation levels at 60% of 855 institutions administering residency programs imposed rent-burdened status on their resident physicians (ie, they required residents to devote >30% of monthly income to rent). Brewster et al also found that while inflation-adjusted rental prices increased by 18% between 2000 and 2022, inflation-adjusted first-year resident salaries decreased by 0.2% during that same period. Concluding with a call for more equitable compensation, Brewster et al note that resident labor unions have been associated with improved access to housing stipends.
This adds to what should be already clear rationale for physicians, nurses, and other health care workers to unionize to protect their own interests and to protect patient safety by improving working conditions. But there is another intertwined and more fundamental issue at stake: the political education of the most influential workers in what may be the most powerful industry in the US.
Worst-among-peer-nations life expectancy, alongside globally unparalleled health care spending and rapidly declining trust in medicine, public health, and government, make undeniable that the US is in need of a basic reorganization of its health systems. After allowing health care over the last half century to be dominated by private entities motivated by profit and enabled by depoliticized concepts of charity as substitutes for rights guaranteed by public systems, to achieve meaningful change will require a repoliticization of care. This must be linked with mass movements to demand public investment in universal health care and, even more importantly for public health, infrastructures for everyday nonmedical care that are essential for preventing disease and shrinking the currently elephantine footprint of reactive US medicine.
Comment by: Ana Malinow
In a fiery “Invited Commentary”, Eric Reinhart responded to a concurrent article on lopsided housing affordability and resident salaries in JAMA Network Open. Reinhart blasts medical training exploitation for its “high medical-education costs, undercompensation, excessive work hours, and an infantilizing hierarchical culture characterized by intensive personality policing under the veneer of racist, misogynistic, and classist professionalism norms and their self-defensive moralisms.”
The effort Reinhart believes would best achieve the “political education of US physicians” is the unionization movement currently taking hold in many institutions training residents today. He rightly maintains that by unionizing, residents have a chance to better their own working conditions, with spillover effects into better patient care.
But the goal of unionizing residents goes further to open the eyes of future doctors, who for too long have been blind to the paradox that is their training and the health care system in which they work.
For the last 100 years, Reinhart rightly asserts, the medical education of doctors has been political, but not in the way that raises awareness, but one that is “overwhelmingly conservative, profoundly uncritical, and reflexively protective of an ethically bankrupt field that has spent a century building up a capitalist health care industry.” It has been an anti-solidarity education that lulls doctors with the expectation of lucrative salaries and social position into complicity, working silently and thus propping up a health care system that immorally puts profits over patients. US physicians “have been professionalized into a convenient political nihilism” instead of questioning the paradox under which they labor. They accept, buttress, and uplift the for-profit, market-driven, repulsive health capitalism we call the U.S. health care system.
“Medical trainees deserve an explicitly political education,” Reinhart concludes, that “must be linked with mass movements.” This call must be heeded now more than ever, as for-profit insurance companies, private equity, venture capitalists, and corporations such as Amazon and Best Buy devour what is left of our public programs (Medicare and Medicaid especially), hospice, emergency departments, independent physician practices, and community and rural hospitals. An Obama-era scheme called “value-based payment” (VBP) is spreading across our health care system like wildfire, buttressing the profit-takers and, like wildfires, leaving widespread destruction behind. With the collusion of the Centers for Medicare and Medicaid Services, VBP and its corporations will soon take over the last bastions of non-corporate care provision and truly public financing, traditional Medicare and the Veterans Health Administration.
Through unionization, physicians begin to understand that extending care beyond the clinic into the community “hinges on power and policy” and beyond that, leads to “political organizing and struggle.” As physicians, we must join and amplify grassroots organizations that are fighting to end privatization of our public programs through local organizing, mobilization, and direct action. This grows the mass movement we need to achieve national single payer and end the paradox we serve. It would be a profoundly valuable use of physicians’ high incomes and social standing.
Reinhart’s is an incisive, impressive, and important essay, which I implore every physician to read. It’s a critical piece of our medical education.