An Unpublished NEJM Letter

 

 I was notified this morning that a letter I sent in to the New England Journal of Medicine would not be published because they had limited space.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

Knowledge Workers

 

I wrote this editorial in 2010 for the Minnesota Psychiatric Society newsletter Ideas of Reference as part of my role as the President at the time. Since then, things continue to go in the wrong direction.  Some knowledge workers get more recognition from the business managers than others but it is based on income generation rather than the cognitive aspects of the job. And of course, psychiatrists are managed as if there is no cognitive aspect as all.  In an interesting development at the time, I was contacted by Canadian physicians after this editorial was published in the newsletter, but no American physicians.

 

Imagine working in an environment that is optimized for physicians. There are no obstacles to providing care for your patients. You receive adequate decision support. Your work is valued and you are part of the team that gets you immediate support if you encounter problems outside of your expertise. In the optimized environment you feel that you are working at a level consistent with your training and current capacity. That environment allows you to focus on your diagnosis and treatment of the patient with minimal time needed for documentation and coding and no time wasted responding to insurance companies and pharmacy benefit managers.

As I think about the problems, we all encounter in our work environment on a daily basis I had the recent thought that this is really a management problem. Most of the management that physicians encounter is strictly focused on their so-called productivity. That in turn is based on an RVU system that really has no research evidence and is clearly a political instrument used to adjust the global budget for physicians. Current state-of-the-art management for physicians generally involves a manager telling them that they need to generate more RVUs every year. Managers will also generally design benefits and salary packages that are competitive in order to reduce physician loss, but this

is always in the larger context of increasing RVU productivity. Internet searches on the subject of physician management gener­ally bring back diverse topics like "problem doctors", "managing physician performance", "disruptive behavior", "anger manage­ment", and "alcoholism", but nothing about a management plan that would be mutually beneficial for physicians, their patients and the businesses they work for.

In my research about employee management, I encountered the work of the late Peter Drucker in the Harvard Business Review. Drucker was widely recognized as a management guru with insights into how to manage personnel and information going into the 21st century. One of his key concepts was that of the "knowledge worker".  He discussed the evolution of managing workers from a time where the manager had typically worked all the jobs he was supervising and work output was more typically measured in quantity rather than quality. By contrast knowledge workers will generally know much more about their work than the manager. Work quality is more characteristic than quantity. Knowledge workers typically are the major asset of the corpora­tion and attracting and retaining them is a corporate goal. Physicians are clearly knowledge workers but they are currently being managed like production workers.

The mistakes made in managing physicians in general and psychiatrists in particular are too numerous to outline in this essay. The current payers and companies managing physicians have erected barriers to their physician knowledge workers rather than optimizing their work environments. The end result has been an environment that actually restricts access to the most highly trained knowledge workers. It does not take an expert in management to realize that this is not an efficient way to run a knowledge-based business. Would you restrict access to engineers and architects who are working on projects that could be best accomplished by those disciplines? Would you replace the engineers and architects by general contractors or laborers? I see this dynamic occurring constantly across clinical settings in Minnesota and it applies to any model that reduces psychiatric care to prescribing a limited formulary of drugs.

I think that there are basically three solutions. The first is a partial but necessary step and that is telling everyone we know that we have been mismanaged and this is a real source of the so-called shortage of psychiatrists. The second approach is addressing the issue of RVU-based pay directly. I will address the commonly used 90862 or medication management code. As far as I can tell, people completing this code generally fill out a limited template of information, ask about medication side effects, and record the patient's description of where they are in the longitudinal course of their symptoms and side effects. I would suggest that adding an AIMS evaluation or screen for metabolic syndrome, an in-depth probe into their current nonpsychiatric medications and how they interact with their current therapy, adding a brief psychotherapeutic inter­vention, case management discussions with other providers or family, and certainly any new acute medical or psychiatric problems addressed are all a la carte items that need to be assigned RVU status and added to the basic code. Although there are more, these are just a few areas where psychiatrists add quality care to the prescription of medicines. The final solution looks ahead to the future and the psychiatrist's role in the medical home approach to integrated care. We cur­rently have to decide where we fit in that model and make sure that we don't end up getting paid on an RVU basis while we are providing hours of consultation to primary care physicians every day.

Overall, these are political problems at the legislative, bureau­cratic and business levels. It should be apparent to anyone in practice that when political pressure succeeds in dumbing down the profession, it necessarily impacts adversely on work environ­ment, compensation, and most importantly the ability to deliver quality care. The continued mismanagement of psychiatrists by businesses and bureaucrats who have nothing more to offer than a one-size-fits-all productivity-based model, is the biggest threat to psychiatry today and a much more enlightened man­agement strategy is urgently needed. The Minnesota Psychiat­ric Society and the APA need a strong voice in that change.

 

George Dawson, MD, DFAPA

Happy Labor Day IV

This is my fourtth Labor Day writing this blog and it is my custom to summarize the work environment for physicians like I did in Happy Labor Day I, II, and III.  Things have not improved very much and there was a timely piece by an anonymous physician filed on another blog entitled Confessions of a Burnt Out Physician.  That post is full of anecdotes about physicians being managed like production workers and to the point of not even having an adequate work space to conduct work that requires focus and confidentiality.  Another key element of managing physicians is to make sure that their days and nights are filled with the modern equivalent of paperwork - e-mails and charting that is read by nobody except the occasional coding and billing staff.  If that is not demoralizing enough, there are always the suggestions that physicians are not doing enough, even though they are easily in the hospital for 4 or 5 hours after all of the business people are long gone.  This can all be handled masterfully.  As an example, the RVU productivity system was in many cases introduced to physicians as a system of "fairness".  That is - the idea that everyone has to pull their own weight.  That works very well in any environment of competitive physicians.  It was dovetailed in nicely with multimillion dollar lawsuits by the Department of Justice that were based on charting.  Now physicians could be fined or imprisoned if their documentation was not up to snuff.  And of course the Department of Justice wanted every physician in this country to know that any discussion of fees was a potential antitrust offense.  When all of that business rhetoric had settled out, the only things that really changed was how easily physicians could be manipulated and overworked while their professionalism was completely ignored.  Apparently none of us knew how to work or act before managed care came along.

There have been some additional business innovations in the last year to make physician's lives even more difficult.  I read another blog recently where the topic of physician managers affiliated with Big Pharma were desired to bring money into departments and how that and key opinion leaders (KOLs) from that field was a key corrupting influence in medicine and psychiatry.  That influence is trivial compared with the business influences on medicine and their adverse effects.  Excellent clinicians, teachers and researchers now need to get an MBA before they are considered as a department head.  A managerial class that is progressively less competent to manage may be an acceptable business standard but it seems like an extravagance in medicine and one that has cost us hundreds billions of dollars and untold unnecessary work for physicians.

Furthermore, we know what works in terms of physician management.  I worked in tens of departments where the department head was a physician who was in that position because of skills pertaining to clinical care, teaching and research.  That doesn't mean that they were necessarily easy to get along with, but in teaching institutions their skill set was on display every day.  That model transitioned to one where a physician and an administrator of some type both co-lead the department.  The physician leader was still affiliated with physicians in the field at that point and could feel their pain.  The next step was removing any physician with those alliances from an administrative position.  In many cases, this meant people who had no hesitation to manipulate physicians either by a "It's my way of the highway" attitude,  making the environment so hostile that they forced selected dissenting physicians to quit, or after pretending that the physicians had some input (usually through endless mind-numbing meetings about the business) simply telling them that no matter what their opinion was - this was what would be happening.  Throughout the process there was an endless stream of "Change is good", "Cost effectiveness", and "Managed care friendly" propaganda.  But it didn't stop there.  Managed care run institutions have an entire cadre of case managers whose primary job is to "manage" physicians and make sure they are discharging people according to the companies proprietary standards.  If there are any disagreements that low level administrator can easily go up the change of command to get decisions in their favor or identify physicians who are not in lock step with the company.  Everywhere within these organizations there are rules about identifying "disruptive physicians" and penalizing them.  I am not talking about doctors throwing scalpels across the operating room.  The threshold can be so low these days that a "disruptive physician" is anyone who gets into it with an administrator for any reason, including legitimate disagreements.

The effect on the psychological environment of physicians has been corrosive.  Within a generation we have gone from a training environment where medical students and residents could identify with senior physicians who embodied professionalism and an intellectual approach to medicine to managed care employees who use a business approach.  Instead of rounding on patients and learning the importance of medicine as a life-long intellectual pursuit, trainees are focused on the business manager's pursuit of getting patients out of the hospital so that corporate America can keep making money by easily beating the fixed reimbursement scheme set up by the government.   The business rationalization has always been "of course we need to make money to keep the doors open", but that never addresses the trade-offs.  In this case the trade-off is no relationship or plan to assist the patient.  In the case of patients with psychiatric disorders, there are inadequate inpatient and outpatient services, both due to business rationing to maintain profits in a rationed and cost-shifted world.  In many cases health care systems have carried these plans to their absurd conclusion - just close any inpatient beds, close the outpatient clinics, and hope that some taxpayer funded clinic or jail can pick up the slack.  The typical health care manager has an endless stream of bad ideas.

Are there any bright lights on the horizon?  I think that there are.  I would count the movements against the medical specialty boards and the proposed maintenance of certification (MOC) programs.  It is very positive that physicians are standing up and saying that they are unnecessary, not evidence based, and a tremendous waste of time, money, and resources.  More importantly all of that stress falls squarely on overworked physicians.  There is now at least one parallel certification organization that depends primarily on initial board certification and then continuing medical education courses - the historical standard.  It will take a significant commitment, especially from younger physicians to keep this movement alive because it is just a matter of time before credentialing committees for clinics and hospitals will be putting the squeeze on their physicians to use the labor intensive MOC programs.  There is also the question of medical boards.  Will they require MOC for maintenance of licensure (MOL)?  Only time will tell, but like all things American - the bet is on the oligarchs and that currently is everyone making a lot of money out of managing physicians.  At some level that includes professional organizations populated by members who are very friendly to the business world.  If anyone doubts the benefits to professional organizations, just visit the American Psychiatric Associations Learning Center and the MOC offerings.  If the monopoly can be broken, it suggests that physicians may have the ability to counter the business and government strategies that keep what is basically an anti-physician system afloat.  Business strategies have nothing to do with the practice of medicine.

Another bright light that I neglected to comment on initially is the young psychiatrists going into private practice.  At first I was reluctant to endorse this idea, primarily because it contrasts so starkly with my experience in community psychiatry, acute care psychiatry, and general hospital psychiatry.  I was concerned that there would not be enough psychiatric expertise to care for very ill people.  But in conversations with many young colleagues they are some of the brightest, happiest, and enthusiastic physicians that I have seen.  The reason I am given by these docs is that they decide who they are going to see and what their schedule is and not some administrator.  They decide what their clinic policies are and not some administrator.  Some of them have worked in managed care settings and had the courage to walk away after the standard "performance evaluation", especially when it had become an exercise in a loyalty oath to the company and trying to dredge up anonymous critical remarks from coworkers.  My opinion on this private practice trend is that it is a good one.  Any person consulting these folks is going to get recommendations based on quality psychiatric care and not proprietary managed care guidelines.  They will also be talking with a psychiatrist who has not seen ten other people before them and one who has the energy to focus on their problems and possible solutions.  Some of these private physicians also spend days in community mental health centers and on community support teams - treating patients with severe problems.      

So my fourth Labor Day message is slightly brighter than the last three, but not much.   I have to say that there are a few of us around yet who know exactly what happened and what is possible -  and I feel your pain.  If you feel up to it post your anonymous story here.


George Dawson, MD, DFAPA

How The Ruling Class Impacts Your Health Care and Why They Need To Be Stopped

The truth crops up in unexpected places.  A colleague directed me to an article is USA Today that I found to be very interesting.  It clearly describes the central problem with health care in America.  From that article (see reference for full text, clinic map and video):

"This is the crux of the whole thing," said Wanda Kuehr, a psychologist who agreed to speak out about the problems after retiring Feb. 2 as the program's director of clinical services. Non-medical managers want to "get the reports in on time and fill the slots. They think that makes a good program. Our goal is to give treatment to soldiers. And (the bosses) see that as inconsequential ... What's happening to soldiers matters and the Army can't just keep pushing things under the rug."

The report details what happened when the Army's outpatient substance use clinics were shifted from medical oversight by the Surgeon General's Office to the Installation Management Command.  This change occurred in 2010.  Some of the changes noted are striking including a basic error in hiring an unlicensed counselor.  Since 2010,  90 soldiers committed suicide and 31 of those suicides occurred after reviewers concluded that there was substandard care.   They could not conclude that the substandard care was causal.  Review of additional data showed that 7,000 soldiers were identified as having a problem but not offered treatment.   Half of the 54 substance use clinics were rated as substandard, specialists identified "poor continuity of care" as a problem, and staff attrition as a significant problem.  Only 309 of 352 counseling positions are currently filled.  The same article estimates that 104,000 soldiers have drinking problems.

What is the significance of this report?  I don't think there is anything unique about what happened to the Army's substance use clinics when the management changed.  It has been happening everywhere else for at least 25-30 years.  Before that time, medicine and specialty departments were managed by senior clinicians based on merit.  The department heads were active clinically and they were valued for their clinical and research expertise.  Some of the most valuable teaching experiences I had during my training occurred due to direct contact with these department heads.  Reviewing brain and spinal imaging with the head of the Neurosurgery Department.  Doing rounds at night with the head of the Renal Medicine Department.  The list goes on.  The point is that all of these experts were engaged in treating patients and teaching medical students and residents.  They had an intimate connection with the provision of care and the profession.  Many of them also had great personalities.  So what changed?

They changes were subtle at first.  When the managers took over they decided to replace some of the department heads at the periphery.  Suddenly there was no longer a certain department that people counted on and their duties were subsumed by another department.  The dislocated clinicians either quit in frustration or were relegated to a more peripheral role in the clinic or hospital.  They could no longer support a teaching mission and suddenly that block of knowledge was no longer available to students.  These experts were consulted in complicated cases to back up the generalists who were now seeing their patients.  The next step by the managers was to suggest that productivity in the larger departments was uneven.  They suggested that they had a metric so that would assure that everyone in the department was pulling their weight.  When I first heard that explanation, I looked around and concluded it was a myth.  Everyone in my department was a hard worker and that was borne out by the actual numbers.  The numbers were the real story.  The rhetoric had allowed the managers to introduce a system to manage productivity that was completely subjective.  But that was all the managers needed to develop a system to manage knowledge workers like production workers even to this day.

Why would anyone want to be a manager?  Well it seems like easy work if you can get it.  Instead of dealing with complex problems that require you stay current in a certain body of knowledge, interact with people in an ethical way, and have extremely high levels of accountability why not just manage numbers and tell people what  to do - especially people who are as politically inept as physicians and their professional organizations.  If I ask physicians that question, I usually hear that being a manager or studying business would just be "too boring."  That may be applying a medical metric to business that could be far from the mind of managers.  Some business educators and critics have pointed out that over the past 2 decades, there is evidence that managers have developed who are focused on short term results and in some cases "the pursuit of short-term shareholder interest, as well as naked self-interest on the part of managers, into managerial virtues." (reference 2).  Instead of a manager who knew and was promoted from within the business and who had a vested interest in the quality of the services and interests of the employees, we now have a class of managers who are mobile, highly paid, and have no particular expertise in the affected business.  Piketty notes that the United States has invented a "hypermeritocratic society" of "supermanagers".  These supermanagers are typically executives of large firms who have been able to obtain "historically high, unprecedented compensation packages for their labor."  He also concludes that "the vast majority (60-70%) of the top 0.1 percent of the income hierarchy in 2000-2010 consists of top managers."(p. 302).  I don't know Piketty well enough to say what his conclusions about why this meritocracy exists.  He does point out that it is twice as likely to occur in the financial services industry.

There are interesting parallels in the management of financial services and medicine.  In both cases, the managing class came about largely as an invention of federal and state governments.  The invention of the manager's tools in medicine (billing and coding, utilization management, prior authorization, managed care) parallels the development of credit reporting and the ability of financial manager to put your savings and retirement funds at risk all of the time without offering you any compensation for the use of your money.  Both of these systems are subsidized by huge hidden tax subsidies from American taxpayers.

When I try to talk with people about this problem their eyes glaze over.  Advantage to both the financial and business managers.

In the meantime, when you drive by your local hospital and it claims to be one of the "Top Hospitals in the US" - don't be surprised to learn that there are at least 600 hospitals on that list.              


George Dawson, MD, DFAPA


1:  Greg Zoroya.  Investigation: Army substance-abuse program in disarray.  USA Today.   March 12, 2014.

2:  Rakesh Kurana.  MBAs Gone Wild.  The American Interest.  July 1, 2009.

3:  Thomas Piketty.  Capital in the Twenty-First Century.  The Belknap Press of Harvard University Press.  Cambridge,  Massachusetts 2014.

A Toxic Work Environment For Physicians

I posted my opinion on burnout interventions for physicians on another blog.  That opinion was that mental health interventions to address the product of a toxic work environment that is increasingly toxic seems futile to me.   The author agreed with me, but stated that her program was designed to help residents survive their residencies and nothing more than that.  She pointed out and I agree that residents can't change the structure of their work environment and they can't quit.  That is one advantage that more senior physicians have - they can do both.   The additional rhetoric on the thread suggested that there was no definition of a toxic work environment.  Based on what I have posted here,  I thought it would be fairly easy to pull together a few elements of that definition.

Before I proceed there are a few qualifiers.  As a more senior clinician it is possible like other areas in life, that younger colleagues do not have the same experience and therefore do not relate to what you are posting.  In this case it would have to do with whether or not they worked and trained in managed care environments.  I think that it is entirely possible that if you have worked and trained exclusively in a managed care environment, that your experience is entirely different.  That could make it more difficult to identify the cause of distress or it might make it easier to tolerate all of the non-medical intrusions into the daily work environment.  There are documented personality factors and cognitive styles like perfectionism and obsessiveness that have been implicated in burnout, but they tend to be traits that are inherent in most physicians so I am focused here on immediate environmental factors that are the cause of this widespread problem.   They are really quite straightforward and they can all be attributed to mismanagement:

1.  Sleep deprivation:  The adverse effects of sleep deprivation on cognition and emotional health are well documented.  The expectation that physicians will be sleep deprived is a well known tradition.  While there have been some improvements with restrictions in residency training on the number of hours of continuous work, current practices have in many ways led to a worsening of this problem.  The hospitalist movement had led to the 7 days on and 7 days off schedule that creates fatigue and decreased work performance toward the end of that stretch.  I have interviewed hospitalists about their experience and they have told me that their work slows down, largely due to cognitive inefficiency the last two days.  That slowing adds an additional 2-3 hours of added time to complete all of the work.  It seems like a questionable practice to extend working hours to the point of cognitive inefficiency and fatigue for the sake of the administrative simplicity of not having to schedule cross coverage for weekends.  Outpatient physicians are no less immune when they are expected to sit in their clinics long after hours to complete what are essentially administrative tasks.  Many of these administrative tasks are unnecessary from a medical standpoint.  In both cases the electronic health record (EHR) places a large burden on physicians everywhere and access to it from home can create a 24/7 work environment.

2.  Excessive workload:  The invention of RVUs has given administrators unprecedented leverage in establishing a high volume, low quality production line of physician services.  Markedly different quality of service can be provided by different physicians submitting the same billing code, but there is an unquestionable race to the bottom from the administrative side.  There is no better example than the annual review conversation where physicians are told where they are on the global productivity scheme and one of two things happen.  They are told that they should target a higher decile (or two) next year or they are simply given an RVU expectation that they need to meet in order to "justify" their salary.  In some cases there is just an arbitrary expectation of a percentage increase in RVUs with no theoretical upper limit.

3.  Changing work load:  There has been no accounting for the fact that physicians have taken over more and more work tasks in the past thirty years that were previously done by other people.  Transcriptionists and billing personnel have been replaced by the hundreds of thousands.  The burden for generating detailed medical documents and accurate billings falls directly onto physicians and it is a heavy price.  After seeing all of the patients in a day, physicians generally settle down to do all of this documentation with the associated phone calls and billing.  The expectation that physicians need to know about matching their documentation to a purely subjective billing and coding scheme that can change from year to year within an organization is a reminder of the absurd administrative burden paid by all physicians.

4.  Uncertainty:  Medicine is a demanding field that is mapped onto significant biological variability that increases with the age of the patient.  Coping with that uncertainty is one of the baseline tasks of physicians.   The best way to cope with it is to stay current with the best diagnostic and treatment practices of the speciality being practiced.  Business and government intrusions into this field based strictly on cost and regulatory changes introduce much more uncertainty.  These intrusions take the form of case managers or external reviewers demanding that ill people be discharged from hospitals based on an arbitrary length of stay figure,  those same reviewers denying a recommended therapy by the physician who has seen and is personally responsible to the patient, denied medications based on expense or contracting, or treatment based on guidelines promulgated by business organizations rather than medical or professional organizations.  There is also a broad movement to train physicians as basically customer service representatives through the use of very basic interpersonal techniques.  Many organizations use "customer" feedback as another piece of the algorithm that determines compensation.  The  important physician task of telling patient what they might not want to hear is not "incentivized".

The other relevant dimension here is that the staff who are ordering the physicians around are frequently not physicians and have no real responsibility to the patient.  They are frequently working from proprietary guidelines devised by people who are also not physicians and have no direct responsibility to the patient.

5.  The expectation of free work:  There is no better example of free work than looking at all of the employees in health care organizations that physicians have replaced, but it doesn't stop there.  Teaching medical students and residents is another good example.  Lectures and lecture preparation is not only not reimbursed but there is usually the expectation that the same number of patients needs to be seen that day or made up at some point during the week.  The teaching tasks are typically unsupported and lecturers and teachers are responsible for the lecture content and even getting the necessary copyright permissions.  Before managed care, medical education was more of an integral part of the work and physicians typically got credit for it and department support.  The current work environment emphasizes RVU productivity as the sole measure of reimbursement.  This has become problematic in academic environments that are supposed to emphasize teaching.  In many cases those academic goals have become secondary to so-called productivity.

Managed care has added an immense amount of additional free work for physicians.  It comes in the form of all of the additional work due to utilization review, medication prior authorizations, and a blizzard of additional paperwork.  In the case of medication prior authorizations it takes a minimum of 35 minutes a day and additional staff to do all of the paperwork, but I am sure that most physicians have spent that kind of time on a single case.  The initial impetus for these measures was supposed to be cost effectiveness, but it should be apparent at this point that making money for managed care companies is the real priority and physicians are forced into the role of rubber stamping these measures.  That rubber stamping comes at a significant time cost.  Aggressively holding physicians to a productivity standard, while wasting significant amounts of their time is probably the single most toxic factor in what is already a toxic environment.

5.  Overt abuse: With the unprecedented leverage that business administrators have over physicians and the proliferation of administrators there have also been additional strategies developed to get rid of physicians who are dissenters or don't fit with corporate expectations.  A familiar one is the disruptive physician concept and its many forms.  The corporate interest is in taking any complaint about a physician whether it is substantiated or not and using it to manipulate that physician.  There are many possible sources.  The 360 evaluation solicits complaints from all of the coworkers in the environment where the physician works.  Making those complaints anonymous will predictably results in more significant and negative complaints.  These may be reviewed in an annual review and used for compensation purposes or disciplinary action.  There are variations within organizations like a "three strikes and you're out" rule.  In all of these procedures the physicians involved have no recourse other than filing a lawsuit or defamation suit.  These procedures become tools that can be used by any administrator against any physician who is viewed as a dissenter to the latest and greatest idea by that administrator.  I have seen physicians subjected to firing and onerous rehabilitation schemes like meeting with an administrator and the supposedly aggrieved employee to help them get along on an ongoing basis.  Those exercises in manipulation are superimposed on the physician who is already trying to keep his or her head above water in the sleep deprived assembly line environment.

6.  The not so covert war against the medical profession:  Let's face it - business administrators would obviously love physicians to act the way they treat them - like production workers rather than knowledge workers.  They would really like to replace physicians with less expensive providers or prescribers and will eventually make the argument that a corporate structure with various computerized whistles and bells will be superior to trained medical staff.  The only reason there is any tension at all at this point is that some physicians have skills learned in medical school and residency that have been codified to a certain degree in the legal and regulatory landscape.  The only reason that behavior inconsistent with corporate behavior is tolerated is that a particular physician probably has skills that nobody else does.  That does not prevent administrators from threatening entire blocks of physicians with either disenfranchisement or firing.  The disenfranchisement can occur along the spectrum of decreased reimbursement, additional work expectations without additional resources, or both.  Additional sorties include campaign to teach physicians basic interpersonal skills learned many times in medical school and residency.  Bringing in consultants to tell physicians how to perform their work in a manner more consistent with what administrators want and ignoring the often considerable internal expertise in the department is another familiar strategy.  The legislative front has been exploited to the maximum already with business tactics like utilization review and prior authorization included in many state statutes.  The resulting business friendly legal and regulatory environment leaves very little room for criticism by physicians or their patients.

These are a  few of the examples of a toxic work environment for physicians.  I realize that many are not unique and that other assembly line workers may be subjected to the same abuses.  The problem of course is that physicians are not trained to work on an assembly line.  They are trained to be scientifically inquisitive and intellectually active.  That dimension alone requires many hours apart from work.  In addition to family life that intellectual aspect of being a physician suffers the most from the currently toxic work environment.


George Dawson, MD, DFAPA

Supplementary 1:  This blog is full of posts on the mismanagement of knowledge workers and the abuse of physicians by business systems.  Here are a few examples:

Mismanagement of knowledge workers

Mismanagement of knowledge workers

Demoralizing micromanagement of physicians