The Managerialist Revolution in Medicine

The healthcare system's deepest problems are not technical or economic, but ideological. Here I explain the deep roots of the crisis in medicine.

According to Pew research, the number of U.S. adults who place confidence in medical scientists to act in the best interests of the public declined from 40% in 2020 to 29% in 2022. A 2021 survey by the American Board of Internal medicine likewise found that one in six people—including physicians—no longer trust doctors, and one in three do not trust the healthcare system. Almost half the population does not trust our public health agencies to act in our interests.

Doctors are leaving the profession in droves, prompting worries of a worsening physician shortage. According to the American Medical Association, one in five doctors plan to leave medicine in the next two years and one in three plan to reduce their work hours in the next year. Why is medicine today failing many of its brightest students and pushing large numbers of its best seasoned practitioners into early retirement? The answer is complex and multifactorial; but a major contributing factor is the managerial revolution in medicine. Medicine, like many other contemporary institutions since World War II, has succumbed to managerialism—the unfounded belief that everything can and should be deliberately engineered and managed from the top down. Managerialism is destroying good medicine.

The managerialist ideology consists of several core tenets, according to N.S. Lyons. The first is Technocratic Scientism, or the belief that everything, including society and human nature, can and should be fully understood and controlled through materialist scientific and technical means, and that those with superior scientific and technical knowledge are therefore best placed to govern society. In medicine, this manifests through the metastatic proliferation of top-down “guidelines,” imposed on physicians to dictate the management of various illnesses. These come not just from professional medical societies but also state and federal regulatory authorities and public health agencies.

“Guidelines” is in fact a euphemism designed to obscure their actual function: they control physician’s behavior by dictating payments and reimbursement for hitting certain metrics. In 1990, the number of available guidelines was 70; by 2012, there were over 7,500. In this metastatic managerial regime, the physician’s clinical discretion goes out the window, sacrificed on the altar of unthinking checklists. As every physician knows from clinical experience, each patient is sui generis, unrepeatably unique.

Real patients cannot be adequately managed by a diagnostic-based algorithm or treated by an iPad.  Checklists are useful only once the problem has been understood. For the practitioner to be able to make sense of problems in the first place requires intuition and imagination—both attributes in which humans still have the edge over the computer. Problem solving in a complex environment involves cognitive processes analogous to creative endeavors, but medical education as currently configured does not cultivate these capacities.

Technocratic Scientism has likewise driven the campaign for so-called “evidence-based medicine”—the application of rationalized expert knowledge, gleaned typically from controlled clinical trials, to individual clinical cases. At first glance, evidence-based medicine seems hard to argue with—after all, shouldn’t medical interventions be based on the best available evidence? But there are serious flaws with this model, which have been exploited by big pharma. Studies yield statistical averages, which apply to populations but say nothing about individuals. No two human bodies are exactly alike, but Technocratic Scientism treats bodies as fungible and interchangeable.

As my colleague Yale epidemiologist Harvey Risch has argued, “evidence-based medicine” (EBM)—a term coined by Gordon Guyatt in 1990—sounds plausible but is really a sham. Of course, physicians have been reasoning from empirical evidence since ancient times; to suggest otherwise only betrays ignorance of the history of medicine. EBM proponents claim we should only use the “best available evidence” to make clinical judgments. But this sleight-of-hand is deceptive and wrong: we should use all available evidence, not just that deemed “best” by self-appointed “experts.” The term “evidence-based” functions to smuggle in the claim that double-blinded, randomized, placebo-controlled trials (RCTs) are the best form of evidence and therefore the gold standard for medical knowledge.

But as Risch explains, “Judgments about what constitutes ‘best’ evidence are highly subjective and do not necessarily yield overall results that are quantitatively the most accurate and precise.” Every study design has its own strengths and weaknesses, including RCTs. Randomization is only one among many methods in research study design for controlling potential confounding factors, and it only works if you end up with large numbers of subjects in the outcome arm. The EBM model favors randomized controlled trials that only large pharmaceutical companies can afford to conduct to license their products.

This results in, among other things, the scrapping of the entire discipline of epidemiology. EBM’s criteria constitute big pharma propaganda masquerading as the “best” expert scientific and technical knowledge. In Risch’s words, “Representing that only highly unaffordable RCT evidence is appropriate for regulatory approvals provides a tool for pharma companies to protect their expensive, highly profitable patent products against competition by effective and inexpensive off-label approved generic medications whose manufacturers would not be able to afford large-scale RCTs.” Moneyed interests drive so-called evidence-based medicine.

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The second tenet of our managerial ideology is Utopian Progressivism, or the belief that a perfect society is possible through perfect application of scientific and technical knowledge, and that the Arc of History bends towards utopia as more expert knowledge is acquired. I recall a conversation a few years ago with a nurse ethicist from Johns Hopkins who was giving a guest lecture at the medical school where I taught. She remarked that Johns Hopkins hospital used the marketing tagline, “The Place Where Miracles Happen.” Medicine is clearly not immune from Utopian Progressivism, even if it’s only cynically tapping into this ideology for public relations purposes.