Have Doctors Joined the Working Class?

Marx und Engels Alexsander Platz Berlin

On September 28, 1864, exactly 150 years ago this weekend, the first meeting of the International Workingmen’s Association (IWA) was convened at St. Martin’s Hall, London.  Among the attendees was a relatively obscure German journalist by the name of Karl Marx.  Though Marx did not speak during the meeting, he soon began playing a crucial role in the life of the organization, in part because he was assigned the task of drafting its founding documents.

The work of the IWA and Marx is increasingly relevant to the practice of medicine today, largely because of the rapidly shrinking percentage of US physicians who own their own practices.  This moves physicians into the category of what Marx and his associates called, “working people.”  According to data from the American Medical Association, in 1983 76% of physicians were self-employed, a number that had fallen in 2012 to 53%.  And the trend is accelerating.  It is estimated that in 2014, 3 in 4 newly hired physicians will go to work for hospitals and health systems.

To put this change in Marx’s terms, the rapid fall in physician self-employment means that a shrinking percentage of physicians own what he called the means of production.  In his view, this alienates workers – in this case physicians – from other physicians, themselves, the work they do, and from patients.  Whether we agree with Marx on every point, his writings on this topic provides a provocative perspective from which to survey the changing landscape of contemporary medicine.

As applied to medicine, the first form of alienation Marx highlights takes place between members of the medical profession itself.  When physicians are paid by someone else, working in someone else’s facility and using someone else’s equipment, they begin functioning more and more as instruments of production, like workers on an assembly line.  Before long, many tend to see each other largely as commercial competitors, overlooking any mutual professional interests they might otherwise share in common.

When fewer and fewer physicians are self-employed, those who employ them often begin to treat them like any other commodities that can be traded in a competitive market.  When employers talk about hiring, they may do so in terms of FTEs (full-time equivalents), as though physicians were just undifferentiated units of labor.  On more than one occasion, I have heard executives talk about the number of physician “bodies” they will need to adequately staff a facility.

The second form of alienation Marx predicted occurs within physicians themselves.  Physicians are not just units of work – they are also human beings.  When physicians are self-employed, they enjoy many opportunities to find personal fulfillment by helping their patients and communities from their own volition.  Once they become employed, however, they often become objectified, merely carrying out tasks prescribed to them by someone else.

As a result, employed physicians find themselves spending less and less time thinking about the choices they can make to serve their patients and community, instead simply carrying out – and often resenting – the demands of those they work for.  For example, when quality initiatives are imposed on physicians by employers and payers, the pursuit of quality may take on the character of an external demand, as opposed to something physicians freely choose because they believe in it.

A third form of alienation takes place between the worker and the act of working.  As physicians lose control of the means of production, both physicians and the work they do often becomes commoditized.  Decisions about what patients to care for, how to care for them, whose aid to seek in doing so, where such care should be provided, and how to determine the quality of the care delivered all tend to shift from the physician to the physician’s employer.

As the evaluation of physicians’ work becomes increasingly tied to compliance with externally imposed policies and procedures, physicians themselves derive less and less intrinsic psychological fulfillment from caring well for patients.  This trend can be exacerbated by the widespread tendency of employers to use physician compensation as a way to influence and control the practice of medicine.  Before long, some physicians may think more about their wages than about the patients they care for.

The final and perhaps most pernicious form of alienation occurs between workers and the product of their labors – in this case, between physicians and their patients.  The commoditization of medicine promotes an attitude of mutual suspicion, often encapsulated as “Buyer beware.”  Relationships between physicians and patients become superficial, transient, and largely commercial, which tends to erode trust, compassion, and the commitment to excellence in patient care for its own sake.

With time, physicians learn to think of themselves as healthcare providers, their work as healthcare delivery, and their patients as consumers or customers.  The physician, in other words, becomes a mere vendor and the patient a mere purchaser.  Seeing physicians and patients in this light leaves little room for the virtues of character and trust.  It is difficult for physicians to take themselves seriously as professionals if patients treat them with the same suspicion as snake oil salesmen.

The signs of the alienation Marx describes might take many forms.  One would be decreasing job satisfaction and increasing job turnover, which have been shown to have substantial effects on quality of care.  Another would be increasing rates of burnout, depression, substance abuse, and even suicide attempts, which again affect the care patients receive.  One simple indicator is the frequency with which physicians smile and express fulfillment and pride in their work.

Even if we do not agree with Marx on every point, it is difficult not to see in his 150-year-old writings provocative and in many cases prescient warnings regarding the present plight of the profession of medicine.  If he is right, as the gap between physicians and what he calls the means of production widens, physicians will tend to become increasingly alienated from colleagues, themselves, their work, and above all their patients.

What remedy would Marx offer?  Extrapolating from his 1864 IWA “Inaugural Address,” he would call on physicians to unite.  He would encourage physicians to secure medicine’s means of production, through the ownership of their own practices.  His objective would not be to secure higher wages or enhanced job security.  Instead it would be to decrease alienation and promote conditions under which both patients and physicians are most likely to thrive.

19 replies »

  1. When doctors leave their private establishments to work for hospitals, it creates a new billing system for patients, and the cost of even the simplest primary care procedures will increase. With agencies and physician staffing services, a complete shortage of physicians in primary care will likely never come to pass.

  2. HI Rich,
    Great blog and expected of a man with liberal arts training from Wabash!
    Glad to see Philosophy courses influence and contribute to your ongoing thinking.

    This is provocative –
    Physicians need to unite to form an alliance – large clinically integrated network, and sell our product into the marketplace!
    Hospital beds become the commodity – and we bid on the best value hospital to support our network; the health system that offers our patient members the best service and quality for a lower price.

    Come on docs – let’s begin the movement, the CI network would empower us to maintain the ‘art’ of medicine and to continue to have the fire and passion that drove us into medicine to care for our patients!

    Phil D

  3. Physicians ARE paid by someone else, they ARE working in someone else’s facility (hospitals) and they ARE using someone else’s equipment (hospital owned resources)…..And through this process they are producing volumes and volumes of excessive, wasteful and possibly harm interventions.

  4. Taking back medicine…a post with a group of doctors who read my blog and correspond…vdeos say a lot…threre are 38 government agencies a physician’s practice has to respond to that can fine or close a practice.


    We are stuck with an HHS and CMS that no longer seems to write their own policy and we get stuck with the Center for American Progesss where folks who want to die like Zeke Emanuel hang out, again writing policy for our HHS/CMS system. Look up Zeek on the web as he’s w walking/talking commercial for Untied Healthcare and that’s another issue in itself with the strong mentorship that has existed with HHS/CMS since Hillary Clinton hired Lois Quam years ago from United. She has survived there and opened the door for many more. You will also find many more old United Cronies over at CAP who too are involved in writing policy as it’s one of those political think tanks.

    That will help explain some of how we got to where we are now. It’s a too big to fail health insurance world and here’s a link from that might be an eye opener if you want to explore the subsidiaries of a health insurer today as it’s where all the action takes place. Through use of subsidiary companies insurers can hide in plain site and take over more and more of the business of healthcare.


  5. Challenging socio-political-economic environment

    It is increasingly challenging to practice medicine. With the Medicare Trust Fund slated to go bust in 2019, the Center for Medicare and Medicare Service (CMS) is increasingly resorting to cutting physician reimbursements and implementing capitation and bundled value based medical payments models. The medical reimbursement effects of the PP-ACA are not yet fully discerned; but appear to continue the decline in compensation.

    And, to illustrate this potential governmental control, in what other industry can participants debate the simple question, “who is the customer?”

    Dr. David Edward Marcinko MBA

  6. This strikes me as a reasonable view of the path we are pursuing in the US today. But the problem seems to me to be the increasing administrative work associated with insurance companies, Medicare, Medicaid, etc. That paper pushing moved us from a world of individual practitioners, to a world of group practices where the increasing cost of administrative overhead could be shared, to the point now where only big organizations can interface with big organizations. I’ve read different guesses on how much the administrative overhead costs add to the overall cost of healthcare and the numbers are 15% to 30% in most analyses. This is intolerable to physicians and to the healthcare system as a whole, not to mention to the public-patients. Wouldn’t universal healthcare make sense? The only people who would NOT benefit would be the insurance companies and the 1% who now benefit from their monstrous profits. Universal healthcare, or even single payer healthcare, would accomplish the same thing as a physician union with a lot less paperwork!

  7. so we’re’ on the way toward “to each physician according to his need . . .? ”

    yeah, where’s that union address again? I want to join up. maybe Eric Holder won’t put me in jail, since it’s AGAINST THE LAW for physicians to unionize . . .

  8. What good Idea.If all doctors will bring together for a common purpose they will make a good result in the field of medical care than ever before.

  9. Doctors need a union – oh wait, they already have one. Marx would be very proud.

  10. Doctor – welcome to the working class.

    We got some things to talk about