About Factory Rounds

Factory Rounds is about what happens when medicine is run as a factory.

I’m an emergency physician, board certified in emergency and internal medicine. I write under a pen name because I still work clinical shifts and intend to keep working them, which means I can tell you what the job is actually like rather than what an institution would prefer you believe.

The argument of this publication is straightforward. American medicine did not become bureaucratic, impersonal, and expensive by accident, and it will not be repaired by adding another layer of measurement to the layers already in place. It became this way because the incentives point here. Physicians are paid for documentation rather than outcomes. Hospitals are paid more for the same service performed in the right building. Patients are insulated from prices and therefore from choice. Every one of these is a policy artifact, and policy artifacts can be undone.

I write from the position that the person best equipped to decide what happens to a patient is the patient, in consultation with a physician who answers to that patient and to no one else. That commitment cuts in directions that will please and irritate readers on both sides of the usual divide, and I try to say so when it does.

There are two things to read here.

The essays arrive every other week and are free to everyone, permanently. They are the argument: researched, sourced, and written for an intelligent reader who is not a clinician.

The dispatches arrive monthly and are for paid subscribers. They are shorter and considerably less composed. They are what a shift is actually like, written close to the shift, without a thesis and usually without a conclusion. They exist because the essays can tell you that the incentives are wrong, and only the dispatches can show you what that costs at three in the morning.

If the essays are worth your time, the subscription is what keeps them free for everyone else.