August 19, 2024 from Aaron Kheriaty via Substack
The medical field is facing a crisis of trust. According to Pew Research, public confidence in medical scientists dropped from 40% in 2020 to 29% in 2022. A survey by the American Board of Internal Medicine similarly found that one in six Americans—doctors included—no longer trust physicians, while one in three distrusts the healthcare system as a whole. Meanwhile, doctors are leaving the profession at alarming rates. The American Medical Association reports that one in five physicians plans to leave medicine within the next two years, while one in three intends to reduce their hours.
What is driving this mass exodus of doctors? While financial pressures and administrative burdens play a role, some experts argue that the core issue is ideological: the rise of managerialism in medicine. This ideology, which prioritizes centralized control and efficiency metrics over clinical discretion, is reshaping healthcare in profound ways.
The Rise of Managerialism in Medicine
Managerialism is the belief that all aspects of a profession can and should be engineered through systematic control. In medicine, this has led to the proliferation of standardized guidelines and performance metrics, which dictate physician behavior in the name of efficiency and evidence-based practice. While guidelines can be helpful, critics argue that they have morphed into rigid, one-size-fits-all rules that undermine clinical judgment.
In 1990, there were just 70 medical guidelines available; by 2012, that number had exploded to over 7,500. These guidelines, tied to payment structures and insurance reimbursements, determine how doctors diagnose and treat patients. As a result, medical decisions are increasingly driven by compliance with protocols rather than the needs of individual patients.
“Real patients cannot be adequately managed by a diagnostic-based algorithm or treated by an iPad,” Dr. Aaron Kheriaty explains. “Each patient is sui generis, unrepeatably unique.”
The Pitfalls of Evidence-Based Medicine
One of the main pillars of managerialism in medicine is evidence-based medicine (EBM)—the idea that medical decisions should rely solely on the best available scientific research, typically from randomized controlled trials (RCTs). While this approach sounds logical, it has significant drawbacks.
Yale epidemiologist Harvey Risch warns that EBM has been co-opted by pharmaceutical companies to favor costly treatments. “Judgments about what constitutes ‘best’ evidence are highly subjective,” he explains. “Representing that only highly unaffordable RCT evidence is appropriate for regulatory approvals provides a tool for pharma companies to protect their expensive, highly profitable patent products.”
By prioritizing RCTs, the system excludes alternative forms of medical knowledge, such as observational studies or clinical experience. This has led to a landscape where only the most expensive treatments gain widespread adoption, sidelining effective and affordable generic medications.
The Burden of Universal Metrics
Another issue with managerialism is the widespread use of quality metrics, which measure healthcare performance based on standardized benchmarks. Physicians are incentivized to meet these metrics—often tied to blood pressure levels, cholesterol numbers, or patient survey responses—regardless of whether they improve actual patient outcomes.
As Dr. Kheriaty notes, these universal metrics do not always translate into better healthcare. “Doctors are pushed to hit metrics on measurements like blood pressure, even if this does not actually improve meaningful outcomes like heart attacks or strokes.”
This reliance on rigid quality control measures also leads to overprescribing. In the U.S., nearly 25% of people in their 60s take five or more long-term medications, a number that rises to 46% for those in their 70s and 91% for nursing home residents. Many of these prescriptions are based on studies that excluded elderly populations, meaning their effectiveness for older patients is unproven.
The Consequences for Doctors and Patients
As managerialism grows, physicians are losing autonomy. Medical decisions are increasingly dictated by administrators, insurance companies, and government agencies rather than the expertise of doctors themselves. This shift is fueling burnout, leading many experienced physicians to leave the field.
Doctors are also caught in a paradox: they are expected to adhere to rigid guidelines while still being held accountable for patient outcomes. When patients suffer from complications or poor results, it is often the physician—not the system—who is blamed.
Is There a Solution?
Some experts believe the only way forward is to create parallel medical institutions that reject managerialist principles. “The only solution,” Dr. Kheriaty argues, “is the development of entirely new models of clinical care and reimbursement—started by physicians that opt out of this perverse system entirely.”
Others advocate for a return to medical judgment over bureaucratic oversight. Instead of rigid guidelines, healthcare could empower physicians to use their expertise and experience to make individualized decisions.
Ultimately, the debate over managerialism is about more than just efficiency. It raises fundamental questions about the purpose of medicine: Is it a profession rooted in human judgment and trust, or a system that prioritizes control and standardization? The answer may determine the future of healthcare for generations to come.
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