Tuesday, March 12, 2024

An Unpublished NEJM Letter

 



 I was notified this morning that a letter I sent in to the New England Journal of Medicine would not be published because they had limited space.  Anyone sending a letter is notified that if the letter does not respond to one of their articles you are limited to 400 words.  If your letter does respond to an article the word limit is 200 words.  I was responding to an essay by Lisa Rosenbaum, MD (1) and whether medicine is a calling or just a vocation and the implications that each of those categories have.   My first attempt at the 400-word mark (374 actual) is below:

 To The Editor:  The essay by Dr. Rosenbaum (1) highlights a critical issue in medical education, research, and practice.  Much of the analysis is dependent on the concept that medicine is either a job or a calling. The critical factor in all settings is the practice environment.  Over the past 30 years we have seen a severe deterioration in that environment and how it impacts physicians. 

Forty years ago – physicians were valued as knowledge workers.  Work quality was emphasized and teaching departments were run by senior physicians who emphasized teaching and research.  They were models for focused lifelong learning and were able to maintain interest and enthusiasm in their departments by balancing clinical demands and those learning tasks. Trainees in the department benefitted from identification with these physicians as well as learning clinical approaches in their specialty.  The department head often had a business administrator in the department, but there was no doubt that the focus was medicine first and business tasks were minimal.

Over the past several decades, business and political interests have changed the physician role to production workers. Physicians are now valued in corporations for productivity and all the administrative time that takes. Department heads are often more focused on business matters than teaching and research.  Meetings take on a business rather than academic orientation.  More time is spent learning about the business environment rather than learning medicine.  The administrative burden alone easily exceeds the time used in the past for teaching rounds and conferences.  This burden has also decreased physician efficiency and added hours per day producing documentation for billing purposes that is repetitive and excessive. It also detracts from the physician patient relationship that is further fragmented by physician extenders.

The modern practice environment is not conducive to producing and motivating physicians.  Rather than an environment where experts can have spirited exchanges about medical care – it is one where experts are second guessed by administrators with no medical training.  It is an environment that does not produce a calling.

Recognition of the severe deterioration in the practice environment is the first step in correcting the problem.  Steps need to be taken to restore practice environments to stimulating settings that can lead to a high level of expertise, quality, and humanistic care.    

 

George Dawson, MD, DFAPA

 

References:

1.  Rosenbaum L.  On calling – from privileged professionals to cogs of capitalism?  N Engl J Med 2024; 390: 471-5.

 

The final 200-word final submitted version is below:

 

Rosenbaum argues doctors' declining job satisfaction stems from corporatization, generational changes, and a shift to production-style management.1 Traditionally, senior physicians oversaw the practice, fostering a learning and research environment. Forty years later, business managers treat doctors as production workers2 in an increasingly inefficient environment. This clashes with physicians’ role as knowledge workers, requiring intellectual stimulation, collegiality, and patient-centered care.

That change is responsible for a marked deterioration in the training and practice environment.  Business practices have been emphasized to the point that there has been an adverse effect on physician time management for professional and personal activities. It is also a direct cause of burnout.3

Physicians function best as knowledge workers consistent with their training. Physicians have been forced into the role of production workers. The solution is not to develop a rhetorical response to being in that role. The solution is not an idealization of the “good old days” – but recreating and restoring the physician knowledge worker environment.  That is the first step toward making physician sacrifice meaningful again.

 

George Dawson, M.D.

 

1.  Rosenbaum L.  On calling – from privileged professionals to cogs of capitalism?  N Engl J Med 2024; 390: 471-5.

2.  Drucker PF. Knowledge worker productivity – the biggest challenge.  California Management Review 1999; 41: 71-94.

3.  Lacy BE, Chan JL. Physician burnout: the hidden health care crisis. Clinical gastroenterology and Hepatology. 2018;16(3):311-7.

 

It took me 5 rewrites to get to progressively less words.  When you tend to use as many words as I do that was a painful process.  If you are a blogger the pain is compounded by the fact that editorial control is lost and you cannot publish your comments anywhere else (including a blog) if you hope to get them published in a journal.  The NEJM has a 3-week deadline for letters based on their articles.  It took them 5 weeks to reject it. They obviously can publish whatever they want and provide whatever rationale that they want – but the space argument seems thin.

Let me suggest why I thought this letter – even pared down to 170 words was important enough for me to send.   A brief review of Dr. Rosenbaum’s essay is necessary and if you have access, I encourage you to read it.  The essay begins with standard blue-collar rhetoric rooted in reality – basically that the working man is subjected to the whims of corporations who rarely have their interests in mind.  A young physician from that family concludes that the idea of medicine as a calling is using that term “weaponized against trainees as a means of subjugation— a way to force them to accept poor working conditions.” 

The problem with that analysis is twofold.  First, trainees do not have a monopoly on subjugation by corporations or the government.  It has been a decades long process directed at practicing physicians.  Second, rhetorical “weaponization” of terms applied to the profession is unnecessary.  That battle has already been lost. The current work and training environment has been deliberately shaped by the managed care business and like-minded governments for the past 30 years. Businesses don’t have to use weaponized rhetoric.  All they have to do is replace physicians with non-physicians, tell them they can work somewhere else, or reduce their compensation or just not pay them if they don’t meet their productivity expectations. They can also use internal committees and business practices to scapegoat and gaslight physicians who they do not like.  There is essentially unlimited leverage to get what they want.  All those measures are far more powerful in getting physician compliance than suggesting they need to make sacrifices in the service of a calling.  Physicians today are expected to make significant sacrifices or else – all in the service of their business masters.  It is evident the young physician in the essay knows nothings about it. The only practice and training environment that he knows is the one that has been severely compromised.

From medicine-as-a-calling, Rosenbaum introduces us to workism.  This term was coined in an Atlantic magazine essay to suggest that somehow work is a central part of life, identity, and meaningfulness is life.  That author goes on to suggest that people born between 1981 and 1996 were encouraged in this attitude and found themselves instead in debt and with no meaningful life work.  That led to demoralization and nihilism about capitalism.  When I read these paragraphs, I had to wonder how naïve this generation could be?  How could they possibly think that American capitalism and the economy was good for anybody?  Don’t they read anything about the environment, pollution, climate change, environmental catastrophes, unnecessary wars, near economic catastrophes – all precipitated by American capitalism?  I don’t think the idealization of work or capitalism explains the lack of medicine-as-a-calling.

There is a glimpse of reality in the next section when we hear how of how a long-time residency director of internal medicine stepped down due to a misalignment of the missions of hospitals and training programs. That is really putting it mildly. In many cases that difference was all it took to destroy training programs.  It is common to hear how residents are just used as inexpensive labor – but that has always been the case. The real problem is that the quality of teaching is adversely affected when faculty are told that they must max out their productivity and at the same time – get no credit at all for teaching.  

Rosenbaum’s essay depends on generational stereotypes and barely touches the root of the problem.  I reference the work of Peter Drucker – widely considered a guru in business management.  He pointed out the differences between production workers and knowledge workers. Basically, knowledge workers are quality focused in areas that they have more expertise than the management does. They are generally felt to be critical to the business and the idea is to retain them and give them adequate resources. Establishing a culture of excellence in their knowledge base adds to the environment. Production workers are engaged in repetitive tasks.  Their supervisors generally have worked their way up from doing the same tasks and therefore know as much about their work.  Early experiments in mass production showed that analysis of the repetitive tasks by so-called efficiency experts could improve the overall production.

What has occurred in the past 30 years has been the mass conversion of physicians from knowledge workers to production workers. The associated practice and academic environments have suffered drastic changes. Academic physicians have found that a major part of their work – teaching and research has been devalued in many cases to nothing.  In the meantime, they are expected to see many more patients, often to the point that they find themselves in new clinics – just to increase the overall billing.  The electronic health record (EHR), billing, and coding, and maintenance of certification are all added time penalties with no associated productivity credit. They have little say about how they see patients or how many patients they see.

I will cite one of many examples to highlight these points.  Just 5 years ago,  an internist I know was audited by his managers who had him tracked from 8AM to 4PM by an efficiency expert. That time frame encompassed 90% of his patient contacts, but only 66% of his workload.  Every day when the efficiency expert left – he would ask: “Where are you going? I am here for another 4 hours.”  The managers wanted to use the efficiency expert report to suggest that he was not efficient enough in seeing patients – but the real problem was the lack of clerical support and the EHR. The exercise was enough for the internist to realize he was working in a hostile environment and he moved on.  A clear loss of a knowledge worker.  The corporate myth that everyone is replaceable missed again in this case. This internist had experience and skills that could not be duplicated by anyone else in that clinic. This cycle of corporate flexing repeats itself thousands of times per day.

There can be no calling to work in such an environment where your work is routinely denigrated and devalued.  It plays out as a personal attack. You will necessarily feel like a production worker and start to work on the goals of production workers like standardized working conditions, hours, and benefits.  When you come home at night – you will leave the job behind you and no longer think about the patients who have problems with no solutions or what you need to know to do a better job. There is no esprit de corps of cohesion, support, and invigoration necessary for a stimulating knowledge worker environment.

That is the recent attitude and it correlates directly with the business takeover of medicine – not the newest generations.  It also correlates with prominent editorials in the top journals of our field like the New England Journal of Medicine.  These editorials illustrate on almost a weekly basis that there is no end to the businessmen, politicians, and lawyers who want to run and ruin our profession.  To date – they have been tremendously successful.  There is also no lack of evidence that the medical profession has been completely inadequate advocating for a reasonable practice and training environment.

Medicine will never be a calling again until the work and practice environment has been repaired and removed from the complete control of businesses and governments.

And yes – it is that simple.

George Dawson, MD, DFAPA

 

References:

1:  Rosenbaum L.  On calling – from privileged professionals to cogs of capitalism?  N Engl J Med 2024; 390: 471-5.

2:  Drucker PF. Knowledge worker productivity – the biggest challenge.  California Management Review 1999; 41: 71-94.

Graphic Credit:

All details at this link.  Coming from 4 generations of railroad workers it was a natural choice:  
https://commons.wikimedia.org/wiki/File:Group_of_laborers_digging_through_dirt_pile_along_railway_bed_LCCN2016647134.jpg

2 comments:

  1. Was a nice read, completely agree

    ReplyDelete
  2. Reading your blog gives me hope!

    ReplyDelete