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England Journal of Medicine would not be published because they had limited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
