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A Noble Profession Tries to Get Paid: The Historical Roots of a Modern Healthcare Crisis · Cut & Tell

• 0:00
  Hey there and welcome to Cut and Tell.
• 0:01
  I'm Liz Malphrus.
• 0:02
  I'm a newly minted plastic surgeon in Philadelphia.
• 0:05
  And this season is all about arming you with the health policy knowledge that you need to be an advocate for your patients and just as importantly, for yourself in this crazy healthcare system.
• 0:21
  Okay, y', all, it's time to get down to business with this learning health policy thing that we're going to do together.
• 0:25
  Okay?
• 0:25
  And this first episode is actually, it's one of my.
• 0:29
  One of my least favorite things, honestly, is history.
• 0:31
  But I got to tell you, you.
• 0:32
  The history that I'm going to share with you in this episode, I once I learned about it, I think about it all the time.
• 0:38
  Like, I think about this stuff at least once a week because I truly believe that the history that we're going to talk about today, this is the root of the problem.
• 0:47
  Like, this is where it all began.
• 0:49
  These are like the core issues that we, I think, as a profession have never really dealt with.
• 0:54
  It's like our, it's our professional deep seated trauma that we've forgotten about that we are never going to move past unless we talk about it.
• 1:04
  Okay?
• 1:05
  And so despite this, I'm not a dates person, not a places person.
• 1:09
  Could not tell you dates of world wars.
• 1:11
  Like, I literally, this is just stuff that doesn't go in my brain.
• 1:14
  But this stuff, I promise you it's gonna be interesting, it's gonna be important and it's gonna shed some major light on why our system is so broken, how we got here.
• 1:22
  The big thing that I mean when I talk about the history being so important is that this history is how the culture of our profession was established.
• 1:30
  And it goes way back.
• 1:32
  And while culture in this way, it's harder and to measure than so much of what we do in healthcare and think about in healthcare today.
• 1:40
  But I really think that it's the most powerful force in this story and something we need to pay more attention to.
• 1:47
  A lot of what I'm going to talk about today comes from one book that I really think is so important.
• 1:51
  I've recommended it before.
• 1:52
  It's the Social Transformation of American Medicine by Paul Starr.
• 1:56
  I would encourage everyone to read it.
• 1:58
  And I think this episode today will give you an idea of like, sort of why I think this book is powerful.
• 2:03
  And it's really about connecting the culture of medicine today with what happened in the past.
• 2:09
  So let's start with a question.
• 2:11
  What is doctoring anyway?
• 2:13
  Is it a calling?
• 2:15
  Is it a trade?
• 2:16
  Is it a job?
• 2:17
  Is it a public service?
• 2:20
  This is kind of a silly question, but when you go back and look at the origins of our profession, these are the questions that they were dealing with, trying to sort out.
• 2:27
  And the reality is medicine is kind of its own thing.
• 2:31
  Like, it's kind of a little bit of all of those things.
• 2:33
  And that is a lot of where the tension, I think, in terms of how medicine works in our society comes from.
• 2:38
  So if we go back to 19th century American medicine, this is like very early roots, not an organized system yet at all.
• 2:46
  And there also really wasn't much like real medicine to be had.
• 2:49
  You know, like, we're talking about leeches and bloodletting and like, you know, like poultices.
• 2:54
  This is not.
• 2:54
  This is definitely before we had any defensible ground to stand on, that we were actually helping people in a meaningful way, but we were trying.
• 3:03
  In 19th century American medicine, there were no fixed prices.
• 3:07
  The way that any kind of compensation tended to work for health care would basically be bartering.
• 3:13
  So, like, you know, you go help the farmer and they give you some eggs, or like, you know, you go help the lawyer and they like, you know, get you out of your ticket for parking your carriage in
• 3:22
  the wrong place or something.
• 3:23
  I don't know.
• 3:23
  It also tended to be based on this idea of ability to pay.
• 3:27
  So if you're someone with resources, you were kind of expected to be, to be able to pay more.
• 3:32
  You probably got a higher level of service.
• 3:34
  Like, you know, you think back to the doctors you see in period pieces of pop culture, like say Downton Abbey or like Deadwood or something.
• 3:42
  That guy coming over to see you, like, you know, you know, they're, they're tossing him a tip of some kind.
• 3:46
  Most healthcare at that point was not happening in clinics or hospitals like we think of it today.
• 3:52
  Healthcare was happening in people's homes, at least if you were a person of means.
• 3:55
  The only people who were getting healthcare in those early days in any kind of institution were people who had no other options.
• 4:02
  We're talking people with like, like truly the very bottom of our society.
• 4:06
  People who just had nothing else, nowhere else to go, no, no one else to care for them, no family, no money.
• 4:12
  Like that is who was getting care in any kind of facility.
• 4:16
  And often that was under the auspices of a church or a charity.
• 4:20
  Some of this persists today.
• 4:21
  Like, we certainly do have some, you know, hospital systems that are associated with the Catholic Church or with other religious institutions, but doctoring in those institutions was very much about an act of service.
• 4:32
  So if doctors were working in institutions in those time period, it was much more about an act of service.
• 4:38
  Like, you were doing it because you felt called to help these people and you were not expecting much in return.
• 4:44
  In fairness, though, medicine really did not have much to offer people in those days.
• 4:49
  Like, again, if we call back, like, think about whatever period drama you've watched from this time period, like, like, this is how it goes.
• 4:56
  The, the poor woman in the corset, she passes out, she takes to her bed, and then they call the doctor and like, she almost always dies, okay?
• 5:04
  And like, that is probably pretty acc.
• 5:07
  Calling a doctor in that time was sort of like calling a priest.
• 5:10
  Like, you probably called a priest around the same time, because you weren't really getting doctors involved until things were really dire.
• 5:16
  And once you had them involved, like, the odds of anything, anyone getting better were very low.
• 5:22
  And like, people kind of knew that that just was how society worked.
• 5:26
  And it's not like the person, the doctor who would come to your house was like a learned professional necessarily.
• 5:31
  A lot of times these people had had some kind of apprenticeship.
• 5:34
  Like, maybe they're a botanist.
• 5:36
  Like, this is like, not in no way a standardized profession.
• 5:39
  You did not know what you were going to get.
• 5:41
  Basically, you got a person who would come to your house who said that they might be able to help, and you tried.
• 5:46
  You.
• 5:46
  You gave them the chance to help, and that's really about it.
• 5:48
  And while I think through a lot of American history, we think of doctors having been like a trusted part of society in these early days, doctors were not necessarily a trusted group.
• 5:59
  Honestly, a lot of grifters in the mix.
• 6:01
  They also, they just did not have much esteem in our society.
• 6:04
  So, like, if you look at wages at the time, like in the early 1800s, doctors at that time were earning like, a little bit more than an unskilled laborer.
• 6:12
  Like, this was definitely not a prestige profession.
• 6:15
  And the kind of respect that society had for doctors, though, it's sort of reflects that.
• 6:21
  When we're talking about prestige, it's always worth looking at what the Ivy Leagues were up to, because Ivy Leagues were around at this time.
• 6:26
  So if you look at Ivy League graduates From this early 1800s period, only about 8% of people chose to go into medicine.
• 6:34
  That's relative to 25% going into law and 25% going into clergy.
• 6:40
  And so if you think about it this, you know, I think nowadays we think of medicine and law as being on, like, sort of closer to equal footing in terms of societal, like, esteem or like, how these professions
• 6:50
  are perceived.
• 6:50
  That was not the case back then.
• 6:53
  So how do we pull ourselves out of that?
• 6:54
  Like, how did we go from being this, like, kind of lowly profession with not a lot to offer to this period of time where doctors really became leaders in society.
• 7:03
  So imagine you're one of these early, like, quote, unquote, doctors of the time, and you, you think you deserve more.
• 7:09
  Okay, you look around, say you look at the lawyers, look at the clergy.
• 7:12
  Both of these groups are achieving a better position in society, but through very different means.
• 7:18
  So think about clergy.
• 7:19
  They got like, you know, garments.
• 7:21
  They have this like, authority from on high.
• 7:23
  They don't necessarily get paid that much, but people do respect them and they're con.
• 7:26
  They're really a part of people's lives.
• 7:28
  Law, on the other hand, this was a totally different thing.
• 7:31
  Law, very much that profession approached this as like, we are tradesmen.
• 7:35
  Like, we lawyers, we provide a service.
• 7:38
  We are paid for that service, and we do it very well, you know, and these were two really very different kind of examples that were existing in the time that doctors could potentially follow.
• 7:48
  And I would argue this is one of the main, like, forks in the road that has led to a lot of the kind of downstream effects that we even see today.
• 7:56
  Because doctors, they chose that clergy route.
• 7:58
  They didn't follow the lawyers.
• 8:01
  Think about it.
• 8:02
  We got, we got robes, we got a noble calling, we got laying on of hands.
• 8:07
  We have a lot, honestly of the same features of clergy.
• 8:10
  And maybe this is like a little bit dark, but kind of like clergy medicine didn't have a predictable thing that it could offer you at that time, and the outcomes were much less predictable, you know, and that's a
• 8:23
  little bit similar to clergy in that, you know, they provide these intangible benefits primarily.
• 8:29
  I don't want to make this about religion, but just, you understand me, right?
• 8:32
  Like, there's a little bit of a magicalness to both of these in those early days.
• 8:36
  So I would argue, and I, I think I see this argument and Starr's book as well, that this early move towards becoming a noble profession, kind of like clergy, was really a coping mechanism for a profession that wanted
• 8:49
  to gain social status but really didn't have that much of a leg to stand on.
• 8:54
  It was kind of a big old fake it till you make it scheme.
• 8:56
  And while I think I'm certainly a big fan of the fake it till you make it strategy, but it really has a different flavor when you look back on it in this context.
• 9:03
  Because if you thought that Doctors were like, out there early.
• 9:06
  Doctors were like healing people and like doing science and like, that's why people respected them because of their results.
• 9:14
  That is very much not true.
• 9:15
  If you look at the timeline, a lot of that kind of respect and like moral authority preceded any kind of actual tangible societal benefit that they were offering.
• 9:25
  So I just want to pause for a second here because this is something that I, I've even like mentioned this before, I think, on the podcast.
• 9:30
  Like, let's just do, as a thought experiment, what if doctors had tried to model themselves at this point after lawyers instead of after clergy?
• 9:40
  Lawyers at the time had a very clear scheme with a lot of transparency.
• 9:44
  You, you pay them for their time and their attention and they defend you in a court of law.
• 9:49
  And it was much more cut and dry than what doctors were doing.
• 9:52
  I don't think anybody questions today in society that a lawyer's time has a dollar value.
• 9:57
  In fact, if you talk to lawyers today, this is only intensified, like every single minute, or at least every 15 minute increment of a lawyer's time is tracked.
• 10:06
  And it has a certain price to it.
• 10:10
  I definitely, I, this is a little bit my personal, my personal feeling about it, but I, I would say that lawyers are still a respected part of our society.
• 10:17
  Maybe you would say a little bit less so than doctors, but again, I think that's kind of a judgment call.
• 10:22
  But I will say that the benefit of this, the fact that lawyers position themselves as providing a service in an economy, as being part of an economy, it has led to them being much more successful in protecting their
• 10:34
  profession.
• 10:35
  And I'm going to come back to this topic several times.
• 10:37
  I think the lawyer comparison is very informative and sort of highlights how some of these very early moves in terms of how medicine developed as a kind of institution and a culture, really have all these ramifications that we
• 10:49
  still see today.
• 10:51
  Okay, so to kind of like sum up where we are right now, if you read Starr's book, one of his major arguments is that medicine as a profession built its authority, which he calls professional sovereignty.
• 11:03
  They did that by building themselves as something distinct from commerce.
• 11:08
  Medicine is a calling.
• 11:10
  Medicine is an act of service.
• 11:12
  Medicine from this lens from these early days was very much not a business.
• 11:16
  In fact, it was kind of positioning itself as anti business.
• 11:20
  It's about taking care of people.
• 11:21
  Like the clergy is taking care of your soul.
• 11:23
  You're taking care of the body.
• 11:24
  That was the sort of like initial way that we approached this.
• 11:29
  And doctors used in those early days that professional Sovereignty, to have respect and authority in society.
• 11:36
  And that is where the power comes from, not from the money.
• 11:38
  So for me, I really think that Star is onto something and that this is where.
• 11:43
  This is me, like, taking a leap kind of beyond what he said.
• 11:45
  But stick with me.
• 11:46
  This, I think, is where the seeds were laid for a lot of our problems that we have today.
• 11:51
  There's this uneasy kind of, like, root of all of this that boils down to that.
• 11:56
  We as a society, I think, on both sides, both in medicine and just from a patient perspective, we're not comfortable with the concept of paying for healthcare.
• 12:08
  Doctors don't want to have to charge people because, again, we're in this profession of, like, you know, we're here to, like, help you.
• 12:13
  We're here to, like, make you whole.
• 12:15
  And who could.
• 12:16
  How could you put a price on that?
• 12:17
  And they also don't want to be like, especially early doctors, it's hard to say that you're doing something out of the goodness of your heart and then also track somebody down if they don't pay you.
• 12:26
  You just kind of can't have it both ways.
• 12:28
  Patience on the other side, I think if you're offering them something akin to salvation, if you're saying, I can make you whole again, I don't think most people feel like they should have to pay for that.
• 12:38
  Like, if you can save their life, how dare you not?
• 12:42
  You know?
• 12:42
  So I think there's this really deep discomfort on both sides with this being an economic transaction.
• 12:48
  Like, think about it.
• 12:49
  Like, there's an interesting history here, too, that I'm not going to dive into.
• 12:51
  But, like, imagine like, a fire truck comes to your house because your house is on fire, and they stop and they're like, hey, lady, like, until you pay us, we're gonna just let it burn like that.
• 13:00
  That's not gonna work in our society.
• 13:02
  And I think in general, our society views doctors kind of like that.
• 13:04
  Like, we're more like the firemen.
• 13:06
  We're not the lawyers.
• 13:08
  The problem is that today medicine is big business, y'.
• 13:12
  All.
• 13:12
  Medicine is a fifth of our gdp.
• 13:15
  It is.
• 13:15
  It's a huge.
• 13:16
  It's so much money.
• 13:18
  And this core problem we have never dealt with.
• 13:21
  We're uncomfortable exchanging money for healthcare.
• 13:23
  And a lot of the complexity.
• 13:25
  We're gonna talk about a lot of all these things, systems that we've put in place around healthcare that, like, make it, honestly, so challenging and difficult and onerous.
• 13:33
  It's all a route, I think, about hiding the fact that doctors are getting paid to treat patients, because that's an idea that makes both sides uncomfortable.
• 13:42
  To try to allow doctors and patients to both live in this kind of fantasy world that they're not in an economy.
• 13:50
  So I think a lot of this complexity comes down more or less to this.
• 13:54
  This discomfort we have with this paradox at the center of the healthcare system where everybody is uncomfortable with the idea that they're going to pay for healthcare and doctors are uncomfortable as well getting paid for healthcare.
• 14:08
  But as we'll see in future episodes, this just makes us very vulnerable to anyone who wants to come in and try to make that money that nobody else feels comfortable taking off the table.
• 14:20
  But okay, I also want to talk a little bit about, like, obviously we have these roots where medicine was not respected, but we had a long period in American history where doctors absolutely were respected.
• 14:29
  Doctors were members of Congress.
• 14:31
  They were like major players in our society, very well respected and often very wealthy.
• 14:36
  So like, how did we do this thing where for a while, I think early doctors found a way to have their cake and eat it too on this question.
• 14:45
  They got to be revered for their selflessness and their acts of courage and acts of service, but also got to be paid kind of like the cultural elites that they basically lift as.
• 14:54
  One of the earliest, biggest, like concrete successes in this space was credentialing.
• 14:58
  And credentialing use now just, I just like to remind everybody, credentialing is essentially just another term for gatekeeping.
• 15:05
  That's what this is about.
• 15:07
  Our first attempt as a nation at setting up a system for credentialing failed miserably.
• 15:12
  So very early on, like 18, early 1800s, 18, 10, 80, 20, we had gotten some momentum for this early kind of rudimentary credentialing system for doctors to set some kind of standards for what a doctor actually was.
• 15:24
  That ended up falling apart in the 30s and 40s.
• 15:27
  And basically that was like political context at the time was Jacksonian anti elitist sentiment.
• 15:32
  So doctors had kind of started to gather a little bit of this elite like reputation.
• 15:37
  And this was just a moment in our society where that was not cool anymore.
• 15:41
  And there are also were these really successful alternative medicine groups.
• 15:45
  So at some point we're going to do like a side history on alternative medicine because it's fascinating.
• 15:50
  But that was kind of just like we have that today that was going on back then too.
• 15:54
  And those groups are pretty successful at kind of challenging this idea that doctors got to own medicine and healthcare.
• 16:03
  So there's this point like in the 1840s or so where like, only about four or five states even had anything pretending to be credentialing.
• 16:10
  So during that time, you could just say you were a doctor, like, there was no one would stop you.
• 16:15
  And really anyone could just have whatever training or no training at all.
• 16:19
  So like an Ivy League trained, you know, doctor of the time could just had no additional standing, no further, like, kind of signals that they were a legitimate doctor than, like just a guy on the street.
• 16:31
  And mostly this worked because there were no consequences.
• 16:34
  Like, if there's no credentialing, if there's no enforcement mechanism, like if there's no rules, there's also no consequences.
• 16:41
  So people were really getting away with it.
• 16:42
  And as you can imagine, that led to some significant erosion at the time in that early trust that people had started to establish between doctors and patients.
• 16:51
  Because suddenly what the doctor and how are you as a patient to know who to trust?
• 16:58
  So this situation, this, like, kind of dissolution of our first attempt at credentialing set up a good argument for doctors at the time to seize on, actually make a really big move.
• 17:07
  So that set up this argument that we needed credentialing, we needed some kind of gatekeeping mechanism in order to protect people's safety.
• 17:16
  So this is the big move here.
• 17:17
  The American Medical association, an organization you're probably familiar with that I would argue operates very differently today than it did in the past.
• 17:25
  The AMA was actually a huge player in a lot of early moves around this, our profession, and kind of how it got established and I think is much less significant, much less powerful today.
• 17:34
  But back then, the AMA got to that, got together in 1847 and adopted a code of ethics.
• 17:42
  Note that this was the first code of ethics of any profession in American society ever.
• 17:48
  Like, if you look back, the.
• 17:49
  Like the American Board association, like the lawyers equivalent of the ama, they didn't get a code of ethics till, like, the 1880s.
• 17:56
  So, like, 40 years later, then when I say code of ethics, let me guess, you're probably thinking like, yeah, the Hippocratic oath, like all of those principles that we are all familiar with from med school, kind of.
• 18:07
  So like that, yes, that was part of it.
• 18:10
  But if you go back and look and I've gone and seen it, it's like, kind of interesting to read.
• 18:13
  This first 1847 code of ethics for doctors was much closer to a man guide, I would say, for how physicians should conduct themselves in our society.
• 18:24
  And to a lesser extent, was it about, like, how you should conduct yourself in the treatment of patients.
• 18:29
  So a lot of what was in there was actually more about how doctors should interact with other doctors.
• 18:35
  Because while, you know, safety is, I think the argument they used and kind of the justification for this at a societal level, the reality is that a lot of the motivation for these individuals was this really intense infighting
• 18:47
  among doctors over, like, who gets which patient.
• 18:51
  So think about this at the.
• 18:52
  At the time we're talking, like, this is a time of, like, country doctor.
• 18:55
  You got, like some little town.
• 18:57
  They got one doctor.
• 18:58
  Imagine that a second doctor moves into town, or worse yet, some guy who says he's a doctor, and you went to, like, you know, Columbia, and they went nowhere.
• 19:07
  Like, this is a problem.
• 19:08
  You can imagine how that could.
• 19:10
  That situation could quickly become a big problem, especially for the people in that group who viewed themselves as like, the right ones, as the.
• 19:18
  The doctor, like the real doctors, you know.
• 19:20
  So a lot of it like this, this early one included a prohibition on advertising that actually held basically until, like, the 1980s.
• 19:28
  And that was, again, that was that, like, country doctor who had someone moving in on their turf and taking all their patients away.
• 19:35
  It even included rules about, like, physicians having to, like, take care of each other and each other's families as, like, an ethical obligation.
• 19:43
  It also was, and this is, I mean, this is partly just the times, but very paternalistic.
• 19:47
  A lot of the ideas in this document as well are very much focused on, like, this doctor knows best idea.
• 19:53
  Like, this whole, like, movement that we've had now today towards, like, patient centered care, towards patients having rights.
• 19:59
  Like, they did not have that in the early days.
• 20:02
  What this, what the early code of ethics actually said is that patients have an obligation to obey their physicians.
• 20:11
  So if you take a step back and think about this, like, why.
• 20:13
  Why a code of ethics.
• 20:15
  Code of ethics weren't a thing then.
• 20:16
  Okay?
• 20:16
  Y', all, like, they invented this new concept out of nothing.
• 20:20
  They could just as easily have had a code of science of some kind.
• 20:23
  Like, to say that you needed to be following, like, whatever science of the day.
• 20:27
  That's not what this was.
• 20:28
  This also was not about setting standards for training or for the kind of knowledge.
• 20:32
  It's not some, like, test you gotta take.
• 20:34
  Like, you can imagine them.
• 20:35
  That could have been a strategy as well.
• 20:37
  If what you're concerned about is safety, it also is not in any way about penalties or any legal means for enforcing anything.
• 20:44
  Okay?
• 20:45
  This is very much.
• 20:46
  This is like a gentleman's agreement.
• 20:48
  And the main focus of it, in reality, was about physicians and how physicians should conduct themselves with other physicians.
• 20:54
  And it called for etiquette and courtesy and restraint.
• 20:57
  So this, this, like this early code of ethics, this founding of the American Medical association, this is a big part of how medicine became a legitimate profession in society.
• 21:07
  So not through showing that what they do works, not through, like, laws that punish people who are doing bad things.
• 21:13
  It was really this self policing of behaviors and norms and through basically this complete abandonment of any economic considerations in this community's work.
• 21:23
  So the profession, the doctors, this group, the American Medical association, they're the ones who get to define what medicine is.
• 21:31
  Not the market, not the state, and not the patient.
• 21:36
  And the reason that we are deciding to trust doctors to do this is because they lack economic entanglements.
• 21:42
  So part of what Starr says, or part of what he argues in his book, is the early success of, like, how these people kind of saved our profession from being just totally dissolved into, like, random, you know, like
• 21:52
  snake oil salesmen.
• 21:53
  Basically, it was through deciding to police themselves and at the same time rejecting the idea that this was a commercial enterprise.
• 22:03
  And it worked, y'.
• 22:04
  All.
• 22:04
  Like, it worked.
• 22:04
  It worked for a really long time.
• 22:06
  Like these early.
• 22:07
  It's.
• 22:07
  It's amazing to me to look back on, because I think that a lot of us think of our profession as being founded on science.
• 22:14
  That's not really what it's.
• 22:16
  I think that medicine was founded on anymore.
• 22:19
  It was founded on this idea of becoming this profession with a certain set of standards for how they behave.
• 22:24
  And then fortunately, over time, we gained this real authority, or what I would call a more real authority, based on the science that we use to support how we.
• 22:35
  How we.
• 22:36
  What we do for patients and how we kind of present ourselves to society.
• 22:40
  But that was not there at the start.
• 22:42
  And if you think about it, this.
• 22:44
  I think this is the key problem is, like, that's all well and good.
• 22:47
  Like, sure, it worked.
• 22:48
  We made medicine into a profession that was respected, but you still.
• 22:54
  We still need money to survive.
• 22:55
  Especially if you want this to be an elite profession, then you need an elite level of money to make this work and to make this actually thrive.
• 23:02
  Because if you want.
• 23:03
  If you want those graduates who are looking at clergy and looking at law, you want them to choose medicine, you need to be able to offer them a life that's going to match those in a lot of ways.
• 23:13
  And if we as a society, like, especially as science became more of something real that actually was prolonging people's lives, if we want our best and brightest to go into that, you got to make it worth doing.
• 23:23
  And it can't all be intangibles.
• 23:25
  I think back then, a lot of it was intangibles.
• 23:27
  But over time, you need to also give them money.
• 23:30
  And I feel that this contradiction, this paradox of how to get paid for something that is a mission, that is a calling, I think that we've never really gotten past this.
• 23:43
  And I think it's why, in a lot of ways, we have the complicated mess we have today and why I think a lot of doctors are made uncomfortable to even, like, think about it or talk about it.
• 23:54
  But we need to talk about it, y', all, because this is.
• 23:57
  This is.
• 23:57
  This is where the.
• 23:58
  This is where kind of the whole problem starts.
• 24:00
  And so as we go, the next episodes are going to be much more tangible, much more about, like, learning about specific concepts and specific ideas and, like, kind of how the system works today.
• 24:09
  But I want you to keep in mind these roots, because this is the foundation.
• 24:15
  This is where it all came from.
• 24:16
  And I think in a lot of ways, it's rotted, or at the very least, it's eroded away enough that it doesn't serve us as it did in the past.
• 24:24
  So part of what I want to do through this series is express to you why I think this is a crisis by showing you evidence of what I think is going on here and by helping you have a
• 24:34
  clearer picture of, like, this machine that's operating around you all the time.
• 24:38
  Because I think until we are willing as a profession to open our eyes and look at this stuff and recognize that it matters and that we need to engage with it, I think we're going to continue to lose
• 24:47
  in our society.
• 24:48
  So, whatever.
• 24:49
  If you're in clinical medicine, I just want you to think about this concept today.
• 24:53
  Do you think that you individually are uncomfortable with the concept that you're getting paid to help people?
• 25:03
  And do you see systems around you that you think might be designed to hide the fact from you and from your patient that this is an economic interaction?
• 25:13
  Because whatever else you're doing with that patient in that room, money is exchanging hands.
• 25:18
  It's not exchanging it directly, but it's exchanging hands.
• 25:21
  And that is affecting how your patient feels about you.
• 25:24
  And that even if.
• 25:25
  Even if you know that that money isn't going directly into your hand, it's passing through a lot of other people's pockets.
• 25:30
  First, just remember that the patient doesn't know that, like, the patient is paying a lot of money, and you're the only person they see.
• 25:38
  And I feel strongly that if we're ever going to move forward in this system.
• 25:42
  If we're ever going to regain all that autonomy that we've lost, we need to grapple with the fact that we are in an economy.
• 25:49
  We are huge.
• 25:50
  We are a huge part of an economic engine.
• 25:52
  And if we're not willing to kind of accept this fact that we get paid to provide healthcare, other people will continue to make money off of us and off of our patients, and in so doing, continue to erode
• 26:07
  the trusting relationship that underlies American healthcare in the first place.
• 26:13
  Thank you for listening to Cut and Tell.
• 26:15
  If you enjoyed this episode, and especially if you know anybody else who needs like a little health policy, health, economics, medicine, please send this episode to them.
• 26:23
  Rate and review us.
• 26:23
  I love to read the reviews and then check out all of our other amazing shows and content at hippocratic-collective.com.