The Tech Bros Want to Replace Your Teachers and Doctors

 

 

Just last week I was contacted by an acquaintance about Viagra.  He was not a physician and got the prescription through an online business that specializes in dispensing hair loss, erectile dysfunction, anxiety, and depression medications. When I see these businesses advertising that combination of medications it always piques my interest. Why these medications? Comparing them with the most prescribed drugs in the US – 3 antidepressants are in the top 20 - sertraline, trazodone, and escitalopram.  They can double for anxiety medications.  Viagra (sildenafil) is 157 and Cialis (tadalafil) is 172.  Finasteride can be used for both hair loss and prostatic hypertrophy and it is number 72.  Topical minoxidil is not on the list. It is not like there is a shortage of prescriptions for any reason.

My contact person had talked with one of the online prescribers and was not sure about how he was supposed to take the medication. Should he take it every day or just on the days he was going to have intercourse?  Reading the prescription label and the information he was sent was not helpful.

More of these online prescribing services seem to be advertising every day.  They promise cost effectiveness, the same medications that your physician would prescribe, ease or use, and no embarrassment.  How many times have you been in line at your clinic or pharmacy and had a staff person belt out some information about you that you preferred stay private?  That line on the floor separating you from the other patients is not enough distance to muffle a receptionist shouting through plexiglass.  The online service promises to send you the medication in a plain brown wrapper. 

The real downsides to this new relationship are never mentioned. No access to your records to check for contraindications, drug-drug interactions, pre-existing medical conditions, the status of your liver and kidney function, or allergies. No access to your physician who may know you so well that they can say if taking a new medication would be advisable or not. No detailed discussions of risks, potential benefits, and unknowns. For me that discussion has taken longer than most of the telemedicine visits I have heard about.  And most importantly – no access to somebody who knows your situation if something goes wrong.

There is a real issue about how much information these rapid online prescribers keep on file and what it is used for.  Do they list your major medical conditions?  Does that lead to marketing? Does that lead to data mining to develop sufficiently large programs to make more money off you?  Recall that wherever your data is on the Internet, somebody is trying to profit from it.

That brings me to a stark conclusion about capitalism that I discovered too late in life. Growing up in the US, you are sold on the idea that capitalism and democracy are the mainstays of the country.  We are special because of both and we do both better than anyone else in the world.  The wealthy are idealized and everyone aspires to be wealthy.  If you can't get wealthy maximizing your material possessions seems to be a substitute.

American products are good because our environment producers entrepreneurs and competition among entrepreneurs produces superior products.  Think about that for a second.  The entrepreneur gets all the credit.  Forget about all of the science and engineering behind any product.  The faceless people laboring behind the scenes are hardly ever mentioned. If you are industrious enough, you might be able to find out who holds the patents but in the end they are all property of a large company.  And that company is there for one reason – to make as much money as possible.

In a service industry like medicine corporate profits were initially hard to come by because it was a cottage industry of private physicians.  Even as the corporate takeover began in the 1980s, physicians resisted to some extent as a powerful mediating class between corporate interests and the interests of physicians and patients. The end run around that physician mediation was hiring them as employees.  Initially corporations proposed that they were going to make primary care more accessible and minimize specialists.  In the end that was merely a tactic and they acquired specialty care as well as primary care.  Today most physicians are employees and have minimal input to their practice environment.  They are essentially told by middle managers how to practice medicine.  They work by default for companies like managed care companies and pharmacy benefit managers that waste physician time to rubber stamp their rationing procedures. 

The profits from the corporate takeover of medicine are high.  It is after all a recipe for making money.  There is a stable subscriber base fearful of medical bankruptcy and the corporation can decide how much of those funds it wants to spend. In thinking of new ways to make more money, telemedicine is the latest innovation. Convenience is a selling point. It has been used for decades to reach people in rural areas who would have a hard time travelling long distances to clinics.  But the current model is more like Amazon online shopping.  If you have condition x, y, or z – contact us and we will get you a prescription. Better yet, let’s take the pharmacy middle man out of the picture and prescribe and sell you the medication at the same time.    

A recent commentary in the NEJM pointed out the potential problems of the new relationship between pharmaceutical companies and telehealth firms (1). It is as easy to imagine as the following thought experiment.  Suppose you are watching a direct-to-consumer ad about a weight loss drug.  You go to the suggested web site where it tells you to make a telehealth appointment the same day for a nominal fee. One study showed that 90% of patients referred through this sequence got a prescription for the advertised drug.  The pharmacoepidemiology, quality of care, and legal ramifications of these arrangements are unknown.  The scrutiny is nonexistent compared with the claims that physicians were being influenced for decades by free lunches.  That matches my suspicion that the physician conflict of interest hype was more a political tactic than reality to suppress any objections to the political and corporate takeover of medicine.  

That brings me to the Bill Gates (2) comment.  Expectedly he is an unabashed promoter of computer technology and the latest version – artificial intelligence or AI.  His thesis is that AI will commoditize intelligence to the point that humans will not be necessary for most things including teaching and medicine. No mention of the conflict of interest.  The company he founded – Microsoft is currently heavily marketing computers with an early version of AI. A couple of years ago they also changed to a license for life model.  In other words when you buy a Microsoft computer or software package – you no longer own it outright.  You must pay a monthly licensing fee if you use it or if they decide not to support your computer any more – you must upgrade it to continue paying monthly fees for a long as you use your new computer.  Or until they tell you again that you have to buy a new one.  Even though intelligence is “free” Microsoft and all of the other major tech companies are not really giving it away – they have a recipe for making money off of you for the rest of your life.   

There is a reason that doctors don’t know much about business or politics. Both are highly corrupting influences. Medicine is a serious profession that is squarely focused on mastering a large volume of information and technical skill and keeping that current. Businesses on the other hand are focused on every possible way they can get your money and they are very good at it. If it comes down to an AI program providing medical care that is all you really need to know.

 

George Dawson, MD, DFAPA

 

References:

1: Fuse Brown EC, Wouters OJ, Mehrotra A. Partnerships between Pharmaceutical and Telehealth Companies - Increasing Access or Driving Inappropriate Prescribing? N Engl J Med. 2025 Mar 27;392(12):1148-1151. doi: 10.1056/NEJMp2500379. Epub 2025 Mar 22. PMID: 40126465.

2:  Richards B.  Bill Gates Says AI Will Replace Doctors, Teachers and More in Next 10 Years, Making Humans Unnecessary 'for Most Things'.  People Magazine March 29, 2025.  https://people.com/bill-gates-ai-will-replace-doctors-teachers-in-next-10-years-11705615

 

Graphic Credit:

Click on the graphic directly for full information on the Wikimedia Commons web site including CC license.  It is used unaltered here. 

 

 

Happy Labor Day 2021

 

This is my annual Labor Day greeting to my physician colleagues. I had to go back and look at last year’s greeting to see if I had factored in the pandemic or not.  It appears at the time that I was fairly enthusiastic about telepsychiatry and its applications during the pandemic. Ironically, I will be giving a presentation on telepsychiatry later this year and in reviewing a fairly massive amount of information my initial enthusiasm has been tempered. Although it appears to have had a semi-permanent effect on the regulatory environment there are still unanswered questions about its optimal applications. How it will be used by the business community is also unknown at this point.

One of the articles I reviewed in New York Magazine - outlined a pattern of questionable business practices at least as it was applied to therapists. Direct interviews with therapists suggested that they were being exploited by being paid much less than their going rate with the expectation that they would be more available after hours and by texting. Preliminary surveys indicate that there are psychiatric clinics popping up looking for psychiatrists to staff telepsychiatry visits. There are many unknowns about their practice. In another article, some employers were asking therapists to see people outside of the state they were licensed and hope that the regulatory environment would catch up with the employment practice. Those are not good signs for the labor environment.

I noticed in my 2020 post that I had an initial drawing of how the practice environment had changed and now that drawing has been expanded and includes many more details. It captures most of what I have endured as employed psychiatrist. I include a graphic below and hope that as physicians we can reverse the trend at some point.

The pandemic has clearly been demoralizing for physicians in general but much more for frontline acute care physicians responsible for COVID-19 patients and their frontline colleagues in nursing and hospital support. There has been a shortage of personal protective equipment (PPE), beds, adequate ventilation, and supportive services. There have been deaths and resignations compounding the personnel problem. As the staffing ratios worsen - the emotional stress is at an all-time high. Local disasters compound the COVID crises in many areas.  All the descriptions I see indicated that the healthcare system will end up permanently altered by this pandemic and probably not in a positive way. There seems to be no effort to incorporate a public health approach into the current subsidized business rationing approach that dominates American healthcare. That is not only detrimental to physicians and their coworkers but also the public health infrastructure in general.

A new dimension to the demoralization has been the misinformation industry associated with the pandemic. Physicians trying to provide information in good faith have been attacked and even threatened by some of the zealots associated with or affected by that misinformation. That includes some of the top experts in the world who have been active in research and teaching immunology, epidemiology, virology, and vaccine production. Physicians are given the message that is up to them to communicate to the zealots and convince them that the pandemic is real, it is a really a virus, and that immunizations are the best approach. There appears to be no convincing a large group of people that wearing masks may reduce viral transmission even though that practice was widespread in the 1918 epidemic in the US and is currently widespread in many parts of the world. Physicians are getting the message that they have to magically find a way to communicate with this group of people who have rejected all of the usual channels.

It seems obvious to me that physicians are the only group that are excluded from empathic communication. The expectation is that physicians will be all-knowing, all understanding, and that somehow will correct most of the anti-vaccine, anti-science, anti-expert, and anti-COVID sentiment out there. I think that is a fairly naïve approach and what physicians need is concrete help from politicians, community leaders, and regulators.  Social media is gradually coming around but has responded at a glacial rate. 

I also notice in my greeting from last year that I commented on an APA Presidential Task Force on Assessment of Psychiatric Bed Needs in the US.  I saw no further action and that and was not able to find it in a search. That potential bright spot maybe on hold due to the pandemic, a lot also depends on the conclusions if they are available.

Progress against the burnout industry has been maintained but it is clearly a war of attrition. Physicians in general reject the idea that burnout is due to some inherent personal deficiency and are more likely to see it as the real product of an unrealistic work environment. In many cases that unrealistic work environment has increased many-fold due to the pandemic and all of the associated problems. I hear from physicians every day who are able to exercise minimal self-care due to overwork and limited time away from work. Weight gain is common due to unhealthy diet and no time for exercise. A solution for some has been to leave those work setting behind even if it means early retirement or taking an undetermined period of time off. Many physicians who could easily have worked into their early to mid-70s are retiring at age 65.

Employers seem to be doubling down in this adverse environment. I quit my last job in January 2021. Since then, I have been actively looking for new positions. There has been a recurrent pattern of highly leveraged job descriptions, that I would accept only if I really needed employment. By highly leveraged I mean that the job description contains anywhere from 20 to 30 bullet points, the majority of which have nothing to do with being a clinical psychiatrist. To cite one example, many of the applications describe a “leadership role” where the really is none. No organization that I am aware of wants a frontline clinical psychiatrist to attempt to correct their obvious administrative problems. I received a cold call one day from a recruiter who asked me if I was interested in a “very good” inpatient position. I asked him what the productivity expectations were and he said I have the options of seeing 18 or 22 patients per day. He quoted a disproportionately greater premium for seeing 22 patients a day. He seemed convinced that I would accept the position until I asked him “When am I supposed to live or sleep?” I had the thankless job of covering inpatient unit of 20 patients for an entire year with the help of an excellent physician assistant and that almost killed me.

The unrealistic expectations being placed on physicians are still out there and they are as bad as they ever have been. It is why I used a heavy lifting graphic for this post again. Despite the pandemic the business leverage against physicians is not letting up and that is not a good sign. To make matters worse, there always seems to be room for it in the medical literature. The latest example I can think of is a recent essay in the New England Journal of Medicine claiming that digital healthcare fee-for-service payments are unsustainable and there must be a capitated system. That seems to be part of the master plan to continue a rationed-for-profit system that guarantees over-employment of bureaucrats and business managers as well as corporate profits at the cost of treating physicians like highly paid laborers as depicted in the above diagram.

I don’t think physicians will have any reason to celebrate Labor Day, until that rationed- for-profit system is dismantled.  Until then do what you need to do to take care of yourself and survive. Help from professional organizations would be useful, but there are too many conflicts of interest for that to be realized.  I am still hopeful that we can get back to the stimulating clinical environment of the 1980s, but I will be the first to admit - there is no obvious path back in the face of a trillion dollar healthcare rationing business - largely invented by Congress.

 George Dawson, MD, DFAPA

 

Graphic Credit:

Robert Yarnall Richie, No restrictions, via Wikimedia Commons. "Workers Adjusting Tracks, Texas Gulf Sulfur Company."