All my old stuff is on an account I can't get access to, lol, you can find the other posts from here, if u are a mod, plz help-> https://hexbear.net/post/92107

The mind-virus of capitalism is one of its most remarkable aspects. Sometimes, the profit motive and its implications are like road markings. They're often so unobtrusive as to fade into the background of consciousness, but they bracket our behavior completely and ensure an orderly procession towards profit. Furthermore, their rule feels natural and neutral - almost appearing without giving evidence of authorship.

My boss exemplified this. On one hand, he is unfailingly polite, professional, and sincerely cares about his employees in many aspects of his work. He leaves nice notes when you do something well, buys ice cream on your birthday and will always take time to offer some technical expertise on a finer element of treatment. When I messed up as a newbie clinician, he was kind, actually kind. I had one patient cancel all future visits after their eval. In other clinics, this is cause for a huge HR flex on the clinician, prompting tons of surveillance, discipline, and pressure to make sure this never happens again. My boss took the time to check in and reassure me that it wasn’t a huge deal, and helped me evaluate what I could have done better, and we just moved along from it. I’m grateful for that.

That said, his brain can excuse horrifying things as “just business.”

The relationship between firm and employee was made incredibly clear to me through the contracts I worked under. I was asked to sign a 2 year, 40 mile non-compete contract about a month into my job. This is a rural clinic and so the implication simple: leave this job, and you are evicted. After it was handed to me, the boss just sort of smiled sheepishly and said “I’m sure you understand.” Other examples that clarified the relationship included continuing education money and signing bonus clawbacks. I knew where I stood at that job. I was to produce profit and pose no threat.

On the patient level, this manifests as a disregard for patient finances and a coercive approach to scheduling. I mentioned this before, but the pressure to schedule patients on for as many visits as possible, for as long as possible is immense. PT can be a huge cost burden, and I try to talk to patients about scheduling in a way that makes sense for them financially as well as in terms of their health. My boss watched my schedule like a hawk and was always grilling me about why I didn’t get someone on 3x per week, and offered “helpful talking points” for making the hard sell.

Examples include:

  • “Remind the patient that their doctor said 2-3x per week in his prescription” - yeah but MD’s don’t know shit about PT and want to give you a wide latitude for prescribing visits per your expertise.
  • "Remind the patient that there's things you can do fo them that they can't do for themselves" - which is fair in a few situations, but the overall arc of care for most patients should be promoting independence with increased care and support as needed, not promoting dependence on an "expert" and devaluing patient autonomy.

I was also told that It’s not my job to think about patient finances when scheduling visits. I should simply recommend the best visit schedule for patient recovery (i.e., more visits). More annoyingly, he framed this as a "thing I shouldn't get stressed about to keep my workload under control."

Finally, huge work hours were the norm. I got up at 6:20, prepped to see patients and eat breakfast until 7:30, went to work from ~7:50 until ~5:00-5:30, and took home between 30 and 90 minutes of documenting. To do my job well, I basically have to work outside of work. Preparation/reflection time is essential to make sure you have some space for clinical reasoning, and I don’t want to be on my computer the whole time I’m with patients. This "100% productivity" model is the norm in outpatient orthopedics. In other settings (hospital, SNF) This isn't always the case, and there's documenting time built into the day.

I recently chatted with a friend who’s also in private practice, and we both noted that this kind of schedule is aggressively normalized. It gets valorized in the “we’re a family of hard workers who work hard,” "we're a family" kind of vibe that’s everywhere in American business. Usually it’s easy eye-roll at, but in healthcare it can hook you. The more you do, the more you feel like you’re helping people. My boss would always big-up me when my schedule was booming or I managed to fit another person in. More insidiously, he would always frame a high volume patient caseload in the frame of altruism and self sacrifice that is constantly used to prey upon healthcare workers to increase productivity.

Plus, it’s kind of a rush when you feel like you have a day where 12 patient visits feels easy, and like you make all the right clinical decisions. Never mind the fact that 1/4-1/3 of your visits are medically unnecessary, and your high patient volume means higher cognitive load and thus crappier clinical reasoning.

All of this bad patient care, overwork, and fucked up hiring practices were "just business." Purely depersonalized, with the responsibility excused away or deferred away. When the profit motive gets enshrined as moralistic, naturalistic law, you can excuse fucking anything.