I’ve been asked. “Tom, where do you come up with ideas for a daily blog given your busy schedule of strenuous sessions at the gym, the daily jogs, and the hours spent over the stove preparing exquisite baked goods?” (Damn, I’ll have to go to confession now.) My point is that ideas are all around me, no further away than a glance through my phone at the latest nonsensical antics from Republicans or my last conversation with just about anyone.

For example, just yesterday I had a session with my new ear doctor at the University of Wisconsin hospital. My previous doc, a specialist of some repute who had removed a glomus tumor from my left ear before the pandemic struck had retired. I had been told he was one of two physicians in the state who were comfortable doing what turned out to be a 5.5 hour procedure of delicate surgery. He will be missed. Then again, it seems like all my docs are retiring. For a moment, I considered whether I was the one driving them from this honored profession. But not even I am that self centered, well not most days except for the ones that end in the letter Y.

I recall my conversation with my eye doctor (another well-regarded specialist associated with the University Hospital) just before he retired to the golf course at Blackhawk Country Club. When I mentioned that I thought docs worked until they carried them out on a stretcher, he looked at me seriously and said “not any more.” I will miss him, we had traded insults for many years as he checked for glaucoma (I was a prime candidate given the shape of my retina etc.) which never came.

Back to me ear doc. He is young and at the beginning of his career. During my session with him, he was acompanied by a resident which is normal since this is a teaching hospital. Usually this is fine except for the time when I was half out of it during my cataract surgery and my former good friend, the eye doc, asked if I minded if the resident doc watching him do his thing took over the operation. This was halfway through the procedure. (I was fine until my real doc started saying things like “after a few more mistakes like the one you just made and you’ll by ready to go.”) Nice of him to ask my permission when I was in la-la land, but I figured I would still have one eye left so why not. Besides, as a university teacher myself, he knew what my answer would be.

But I digress as I’m want to do. Back to my hearing doc. Somehow, and I can no longer recall how, I got the conversation away from my left ear, which does not work anyways, and on to the state of medicine in America. Why were doctors rushing to exit a profession that had once been the vocational aspiration for so many? While I had my hypotheses, I wanted to hear what someone at the beginning of his career had to say.

He held nothing back. Those running medical facilities now were treating doctors and nurses like, in his words, ‘widgets.’ They were being pushed unmercifully in the name of the bottom line … corporate profits. Hospitals, even great ones like UW, were becoming profit centers. Things had gotten worse during the pandemic but he saw this as a permanent trend now. Not only that, but physicians were changing how they did their jobs. I was not totally clear what he said next but it sounded like his peers were selecting what they would do differently in an effort to ensure quantity over quality. Keep pushing patients through which might require ignoring more problematic issues and difficult cases and time-consuming diagnoses.

He mentioned that he had been ‘on-call’ that week and had to do procedures he was not trained in because they had been left untreated earlier by others. Apparently, he had strong feelings that accounted for the rush of medical staff to the exit doors. They were no longer respected professionals, merely cogs in a larger corporate machine (these are my words but his meaning). I was a bit shocked at his honesty. After all, he was meeting me for the first time.

Then he and the resident went on to chat about how good dentists have it. That confused me at first since my own dentist also retired last year at a relatively early age. But all became clear when the resident mentioned that his girlfriend is a dentist. Poor gal, she must be endure great hazing at the social gatherings where docs gather. When I brought up that I knew one doctor, my neighbor, who had been doing 12 hour shifts well into his 80s, my ear doc knew him by reputation. Every one does, he is an infectious disease doc of national repute who was front and center during the pandemic. The ear doc reflected my suspicions when he observed that my neighbor was from the ‘old school’ and that ‘they don’t make them like that anymore.’

In the interest of balance, I should note the conversation I had with my accountant as he was working on my taxes not long ago. I mentioned the general unhappiness among professionals such as doctors, lawyers, and even academics (as compared to when I had decided that working at a university was far better than getting a real job, an insight that hit me sometime during the Triassic period). I wondered whether accountants felt the same. He responded that he was quite happy, but that only happened after he left a large firm and struck out on his own. But I doubt that many doctors or academics will set up shop on a street corner and operate outside larger institutional settings. Perhaps Aristotle and Galen could get away with that but not likely to happen today.

You are probably asking where I am going with this story. Either that, or you stopped reading a couple of paragraphs ago. My point, and I do believe there is one, is that more and more people, even those functioning in once top professions, are unhappy.

My former medical internist would spend a great deal of time with me during routine check-ups. In additon to chats about the horrible state of my body, we would touch upon world events and share our digust at what Republicans were up to. I cannot even imagine how angry he would be today with our politics. He would automatically run a number of tests, do EKGs, take Xrays, and so forth. And he found several things early, like a case of TB that erupted about a decade after my return from India. He loved his job, as does my neighbor, and took pride in doing it well. My first internist did not retire until, in my opinion, they gently nudged him out the door as he approached 80 years of age.

My current internist is widely regarded as very good. When I selected him, it was because he ‘spent a lot of time with his patients.’ As the years passed, those long ago days of personal treatment and even a personal relationship, slowly disappeared. Now, it takes months to see a real doctor, if you are lucky, and each session seems like a pressure cooker where the focus is on how quickly they can get you out the door and on to the next one. If professionals now feel like widgets, totally plausible to me, today’s patients feel worse. And this is in Madison Wisconsin which has the best doctors (they want to live here) and a medical facility on every freaking corner. I oft joke that in the Boston area, where I grew up, there was a Dunkin Donuts Shop on every corner while here there is a medical facility, perhaps two, on every block. Each often focuses on a narrow part of the body … the “U.W. Digestive Clinic for the Lower Foot of Your Colon.” or the “Dean Clinic for the Treament of the Left Heart Ventrical.” This is specialization run amok. Heaven forbid anyone look at the whole patient.

I started this blog with a totally different topic in mind which demonstrates just how chaotic is my mind. Let me touch briefly on my original point which was the obsession with profits by both corporations and institutions that appear to be distorting American life. This is a huge topic so I’ll just introduce a little bit here.

In early 1925, Cavin Coolidge said to a group of newspaper reporters that “the business of America is business.” Government should keep its hands off things and let corporate leaders and financiers have their way. All went well for several more years until the ‘laissez-faire’ approach to our economy collapsed under its own contradictions. Then, a new model spawned by John Maynard Keynes introduced a new paradigm stressing public sector involvement to correct market failings, especially of the magnitude leading to a global depression. Things worked well for some five decades until a concerted Republican campaign was undertaken to bring us back to the 1920s. We are not quite there yet but close enough for me to worry (a lot).

Recently, the Fortune 500 companies generated $1.8 trillion in profits from $16.1 trillion in revenues. That is a fair chunk of chain. Explaining economic phenomena remains as much craft as sceince which is why economists argue so forcefully. But one contribution to these excessive profits is due to recent patterns in what is termed ‘mark-up growth.’ In short, this is the gap between the cost of production and what a firm charges for its products. Over time, prices and costs generally have risen or declined in tandem reflecting a rather fixed relationship between these two metrics. In the past few years (especially after the housing crash of 2008), prices have run ahead of costs after accounting for both raw materials and labor. This unusual trend has been going on for a decade now. The excess profits are going to investors, top managers, and the economic elite. Wages have inched up during the pandemic but not nearly as much as expected.

Only one graph today. This is a trend line of wages for worker bees, the guys and gals working on factory floors and in retail shops. It is normed for inflation and anchored in 1972 prices. Clearly, these people lost ground from the late 1970s through the mid 1990s before flatlining. They are not the one’s getting rich even as they started voting Republican in greater numbers, a fact they yet baffles the crap out of me. Neither have they gotten richer even as profits have soared recently.

What’s going on? Why are profits rising even as costs (including labor costs as reflected in the above chart) have been sluggish. After all, the market is supposed to be self correcting? While there may be temporary periods of excessive returns, competition is supposed to smooth things out over the longer run. Sure, and I have some land in Florida that is a steal at the price I’m offering you. Bottom line, the ‘mark-up growth’ continues unabated with no mechanism to correct things within market dynamics. Some call this ‘GREEDFLATION,’ or the very human tendency for avaricious folk to grab all they can as long as they can. A few suggest that, if continued unchecked, it could destabilize society in fundamental ways.

I can still remember Paul Ryan (Congressman from the area just south of Madison, former Speaker of the House, and VP candidate with Romney) saying that the U.S. health system was the best in the world because it operated largely on market principles. Parsing that statement would take more time than I have but the essential point is patently ridiculous. Ryan was widely touted as a Republican intellectual, which he may well have been. Then again, they do not set the bar high over there. I doubt he would have done well in my policy classes, relying on Ayn Rand as his economics guru as he does.

Health care is a market sector that is rife with informational issues and limitations in competitive dynamics. Consumers cannot shop for medical services as they might for a new suit. Unlike other countries where prices for most procedures are fixed by the government or through negotiations with large insurance systems that cover everyone, here pricing is totally opaque. Can you figure out your bill? I have a doctorate and I can’t. Moreover, how can a consumer determine who is providing the best bang for th buck, or any buck. When you have had a stroke and are being rushed by the EMTs to a medical facility, you are not likey to say … “hey, let’s stop at a few places and comparison shop.”

Going back to my starting point, what happens when our medical system is captured fully by market forces. I’ll give you one clue, it is not the utopia Paul Ryan imagines. It is the dystopia of medical professionals leaving in droves as the ill and sick wait forever for a freaking medical appointment.