Declining Trust in Medicine: Implications of Managerial Revolution

Declining Trust in Medicine: Implications of Managerial Revolution

Declining Public Trust in Medical Scientists and the Healthcare System

According to research conducted by Pew, the percentage of US adults who trust medical scientists to act in the public's best interest has dropped from 40% in 2020 to 29% in 2022. Similarly, a 2021 survey by the American Board of Internal Medicine revealed that one in six people, including physicians, have lost their faith in doctors. Furthermore, one in three people do not trust the healthcare system. It appears that almost half of the population does not believe that our public health agencies are acting in our best interests.

Physician Shortage and the Managerial Revolution in Medicine

The medical profession is experiencing an exodus of doctors, leading to concerns about a worsening physician shortage. Data from the American Medical Association indicates that one in five doctors plan to leave medicine within the next two years. Additionally, one in three doctors plan to reduce their working hours in the coming year. The question arises, why is the field of medicine failing its brightest students and pushing seasoned practitioners into early retirement? The answer is multifaceted, but a significant contributing factor is the managerial revolution in medicine. Since World War II, medicine, like many other institutions, has fallen prey to managerialism. This is the misguided belief that everything can be engineered and managed from the top down. Managerialism is causing the deterioration of good medicine.

The Tenets of Managerialist Ideology

The managerialist ideology is composed of several core beliefs, as outlined by N.S. Lyons. The first is Technocratic Scientism, which posits that everything, including society and human nature, can and should be fully understood and controlled through scientific and technical means. In medicine, this is evident in the proliferation of top-down "guidelines" imposed on physicians to dictate the management of various illnesses. These guidelines are often dictated by professional medical societies, state and federal regulatory authorities, and public health agencies. These "guidelines" are essentially a means to control physicians' behavior by tying payments and reimbursements to specific metrics. In 1990, there were 70 available guidelines; by 2012, this number had ballooned to over 7,500. In this managerial regime, physicians' clinical discretion is sacrificed for unthinking checklists. However, as every physician knows, each patient is unique and cannot be adequately managed by a diagnostic-based algorithm or treated by an iPad.

Flaws in the Model of Evidence-Based Medicine

Technocratic Scientism has also driven the push for "evidence-based medicine" – the application of expert knowledge, typically gleaned from controlled clinical trials, to individual clinical cases. While this seems like a sound approach, it has serious flaws that have been exploited by Big Pharma. Studies yield statistical averages, which apply to populations but say nothing about individuals. Yet, Technocratic Scientism treats bodies as interchangeable. Yale epidemiologist Harvey Risch has argued that "evidence-based medicine" (EBM) is a sham. EBM proponents claim we should only use the "best available evidence" to make clinical judgments. However, this is deceptive. We should use all available evidence, not just that deemed "best" by self-appointed "experts." The term "evidence-based" is used to assert that double-blinded, randomized, placebo-controlled trials (RCTs) are the best form of evidence and therefore the gold standard for medical knowledge.

Impact of Utopian Progressivism and Liberationism on Medicine

The second tenet of managerial ideology is Utopian Progressivism, the belief that a perfect society can be achieved through the perfect application of scientific and technical knowledge. This belief sets up physicians for failure and patients for disappointment when promised miracles fail to materialize. The third feature of managerialist ideology is Liberationism, the belief that individuals and societies are held back from progress by the rules, restraints, relationships, historical institutions, communities, and traditions of the past. However, at its core, medicine is a relationship based on trust between a patient made vulnerable by illness and a doctor who pledges to use his knowledge and skills for health and healing. This fundamental aspect of medicine will never change.

Homogenizing Universalism and the Impact on Medicine

The fourth feature of the managerial revolution is Homogenizing Universalism, the belief that all human beings are fundamentally interchangeable units of a single universal group. This belief has led to the explosion of so-called quality metrics for medical providers and organizations. These measures cost each physician at least $40,000 annually to manage, costs that are passed on to patients. These measures often worsen medical outcomes by enforcing a one-size-fits-all approach to clinical care. This compromises physicians' appropriate clinical judgment and discretionary latitude. Doctors are pressured to hit metrics on measurements like blood pressure, even if this does not improve meaningful outcomes like heart attacks or strokes.

Bottom Line

What primarily ails medicine is not just technical problems or economic challenges, but philosophical issues fueled by ideologies that distort the nature and purpose of medicine. The only solution, it seems, is the development of parallel medical institutions—entirely new models of clinical care and reimbursement—started by physicians who opt out of this perverse system entirely. The question remains: will we recognize that the managerialist ideology undermines medicine’s goals of health, and summon the will necessary to cut through all obstacles and cut away the excrescences that undermine the ability of physicians to heal? What are your thoughts on this matter? Share this article with your friends and sign up for the Daily Briefing, which is every day at 6 pm.

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Some articles will contain credit or partial credit to other authors even if we do not repost the article and are only inspired by the original content.