Fail, fail, fail, fail, succeed


For roughly a century, hospitals in the U.S. were run with a focus on good medical care. The administration was there to support this simple directive — to provide the best health care possible. If we imagine a hierarchy of power it would have looked something like this: doctors at the top of the pyramid, nurses next, and administration at the bottom managing day-to-day operations.

Somewhere in the 1980s, for multifactoral reasons too complex to explore here, the system began to break down. Large, historic hospitals began to run out of money, many of them closing doors.

Enter the suits — corporate management was brought in to mitigate the financial failure of these institutions. Morgan-Stanley, General Electric — you get the idea. And, let’s be clear: they were successful. Layer after layer of management, run by MBAs, began to turn things around. Hospitals (not all, but many) began to make money instead of losing it.

The problem, however, was this: the system was no longer being run by healthcare clinicians, i.e. doctors and nurses, it was now being run by “suits” whose responsibility was to the bottom line. Eventually, their incentive became to support the corporate power structure itself. Multimillion-dollar salaries for high-level management became the norm, just like CEOs of private-sector corporations.

And just like all big business in north America, management cut costs wherever they could. After all, their responsibility was to the bottom line, not clinical care.

This meant fewer doctors and less nurses — particularly less nurses. You see, in a large teaching hospital, nurses are employed by the hospital itself, but medicine is employed by the medical school associated with the hospital. This created the dangerous situation we have today — nurses are constantly understaffed. Better to funnel financial resources to the suits and let nursing and medicine figure out how to provide care without enough staff.

I am, of course, over-simplifying an extremely complex system. Private insurance, Medicare, Medicaid, and the pharmaceutical industry are now at the top of the pyramid, with management and administration next. The corporations call the shots, not doctors.

And nurses are left hanging in the wind, like the little dutch boy trying to plug up holes in the dike with his fingers to stop the deluge and save the city from the collapsing dam.

Only this story doesn’t have a happy ending. It’s a metaphor for what America has become.

When public services are run with a profit motive, they cease to be public services.