Tim Jackson has written a fascinating piece about the economic limits of productivity. Aside from the economic considerations, I increasingly believe that the philosophy underlying medical care is incompatible with the concept of productivity.
Care is an atypical commodity. It is not a real or natural object in the sense of a car or box of cereal. It exists independent of time and only in the context of a relationship between people. It cannot be manufactured. It cannot be stored. It is exceedingly difficulty to measure. It is of value only when it is experienced. It is damaged and often destroyed by commodification, which substitutes market values for social values and external motivation for intrinsic motivation.
I entered medicine in the 1970s. To me it was a calling, not a job. I saw myself as a professional who would work collaboratively with patients, not a businessman who would provide (sell) a product to customers. I strove for connection and quality, not efficiency and productivity. And I naively assumed that I could separate my medical world from economic reality.
During my thirty years managing the private family practice I co-founded and owned, it became progressively harder to prevent business considerations from contaminating my professional universe. Third party payors, who work for their shareholders and the business clients who hire them, see physicians as workers hired to provide a commodity to their ‘covered lives.’ My interactions with patients are measured in wRVUs (Relative Value Units also described here). Charting in medical records is no longer organized around the need to care for patients, but is organized around the requirements for billing (This is just one of many unintended consequences of the eHR). Physicians are required to reach financially driven targets for wRVUs. I get a monthly report of my productivity compared to my budgeted revenue generation, and graphed alongside external targets such as the 55th or 75th percentiles from the MGMA . Once a year, I am required to sit down with my office manager and clinical manager for an evaluation, where I am always told I should be seeing more patients. (This year, I was asked to see 2-4 more patients per day, which translates into 10-20% less time per patient.)
This is all based on seeing medical care as a manufactured commodity, a tangible product, a widget. And producing more widgets per hour. Seeing more patients per hour is not a legitimate goal. Medical care is not a widget. It is a process, ideally embedded in a relationship. Education cannot be made more efficient by requiring that the teacher talk faster during class and cover two lessons instead of one. In fact, this process would cause students to learn less well, increase failure rates, and make education lower quality AND less efficient.
Medical care cannot be made more efficient by asking clinicians to work faster. In fact, there is reason to believe that spending MORE time with patients results in better quality and less waste. (I have written about this before). Care can be improved and made both more effective and more efficient (and likely more pleasant for both the patient and the clinician) by making sure the clinician has the information and tools needed at the time they are needed, that the tools are easy to use, and that there is plenty of time to interact with the patient. Tools and time do the job right. As John Wooden said: “If you don’t have time to do it right, how will you find time to do it over?”
Expect clinicians to be dedicated. Expect them to be empathic. Expect them to be collaborative. Expect them to be skilled. But beware of expecting them to be productive. You might get what you ask for.