Hate and the Hippocratic Oath
Most companies treat customer service like a bandaid for its real problems. What's it mean that the bandaids are doctors?
Large companies love to have their customer-facing representatives take the flack for their systemic deficiencies. When United Airlines had a nationwide delay due to ‘equipment outage’, it was their customer service agents, flight attendants, and gate agents who faced the scorn of its customers.
The average salary (including base and bonus) at United is $119,165 per year. United’s lowest paid role is a Customer Service rep, earning $44,000 annually. Bear in mind this only includes United’s W2 employees and not contractors or part-timers, many of which are off-shored from India or the Philippines and paid significantly less. Paradoxically, despite being the lowest paid employees at their companies, they’re responsible for maintaining one of their corporation’s most valuable assets–its customers.
The equipment outage which sparked the delays was actually a tech issue, caused in-house. To have avoided this issue, or at least mitigated the damage the delays caused for its customers, United could have done any number of things including but not limited to improving the quality and assurance (QA) methods of its technology plus investing in more support staff working concurrently to address customer issues.
None of these employees caused the issue and none had the latitude to fix it. Through disdain for them and customers alike, front-line workers are positioned by their empowered industry colleagues and leadership to be a shield against the wrath of angry customers. United, and so many industries from retail to banking to hospitality, have made a habit of letting their front-line workers deal with the customer hate that arises due to bureaucratic incompetence and papered-over systemic issues.
Generally, the less someone is paid, the fewer protections they’re granted by law and by their employer. Both within their respective organizations and within the realm of policy, lower paid workers lack the power to shape policies which might minimize or outright spare them from having to be the face and focus of outrage which should be directed at their leadership. This, and the perception that their jobs are unskilled, makes them easily replaceable in the eyes of their employers. As a result, they are the fodder to absorb the emotional fallout from customers which ensues after systemic problems.
This trend is undergoing a shift–it’s moving up the labor market to doctors. Administrators, insurers, and hospital executives, through a knot of policies, often from different pieces of string, have combined to make it increasingly difficult for patients to receive proper care.
117,000 doctors left the workforce in 2021. The largest losses are from family practice, internal medicine, and emergency medicine. It’s no coincidence that these are the areas of practice delivering essential care–versus say, hair transplants–sitting on the frontlines of medicine, and are most enmeshed in the cloudy bureaucracy of the American healthcare system. Because of this, doctors of this sort are more often informing patients their insurance has denied a procedure, the hospital won’t serve them, or that a medication is exorbitantly priced.
Like any other volume-based business, the more patients that can be seen and the more procedures administered, the more money a hospital or practice stands to earn. To understand this, doctors, hospitals, and the American Medical Association use RVUs (Relative Value Units). At their essence, RVUs are a way to measure what kind of work and how much of it doctors perform on behalf of a patient. RVUs form the basis for understanding hospital’s profit margins. Think of it as one way to measure gross profit (revenue minus cost of goods sold). In this equation, the cost of goods sold goes up when doctors spend more time with patients. When this happens, gross profit goes down. This is a contributing factor for why doctor visits are rushed and feel impersonal.
These circumstances create cause for patients to be angry and frustrated. Because doctors are interfacing with patients on behalf of their companies–hospitals, practices, etc–to deliver bad news and rushed visits, patients are directing their ire towards physicians. Just like customer service workers, doctors are vulnerable to being the first layer of defense for systemic problems far outside of their control.
This shift isn’t only meaningful because now it’s happening to highly paid, highly skilled workers. Instead, it reveals no amount of status or specialization can save front-line workers from bearing the brunt of customers’ anger over systemic, industry-wide failures. Further, because highly paid, highly trained workers are just as at risk of these consequences, it illustrates just how little control workers have over the vast bureaucracies steering their workplaces.
That doctors, whose job it is to synthesize complex, contextual, and individualized information to deliver positive outcomes, are merely instruments of profit generation is not revelatory in 2023. Nor is it revelatory that Marx’s theory of alienation isn’t just happening in a soot-filled widget factory, but in hospitals and medical practices delivering life-altering care. What’s revelatory is that it's taking place in an industry whose purpose is so indispensable to being alive and well.Â
Damn. I'm going to sit with these thoughts today. The theory of alienation feels particularly relevant.