Aug 05

The Cult of Productivity

Productivity

Fitter, Happier, More Productive

Productivity is great, right? I mean who doesn’t want to be more productive. Productivity means you are doing things, often important things. And getting things done is what we do. Society needs people buzzing around doing stuff to keep the hive running smoothly. Idle hands are the Devils work after all.

 

We get into trouble though, when productivity becomes the end goal instead of the means to achieve something. I have noticed this in the field of medicine. I’ve been an MD almost 20 years now, and I’ve seen this cult of productivity infiltrate the ranks. At first I thought it was just my burnout and cynicism distorting my perception. But after a couple of conversations with a few docs I know from around the country in different specialties and styles of practice, I know it to be true. Productivity is the new deity of the medical industrial complex. We all worship and pay homage.

 

In the Beginning…

Once upon a time all that mattered in medicine was doing good work. People were cared for, a living was made, and all was well (not really, but let me have my fairy tale reality). As time went on, efficiency and productivity became more important. It was no longer sufficient to just do good work; you had to get faster and more efficient at it. I suspect there are correlates in other professions.

 

Some of this was survival, as the friction of practicing medicine increased and payroll needed to be met. As well intended but meaningless regulations were added, so was the cost of doing business. More of the health care dollar was needed to comply with the new rules, and we started spending more resources to measure success and less actually providing medical care.

 

A friend lamented that new hires in his group were valued more for their RVU production than the actual global value they provided for the practice and community at large. At times, I’ve seen shades of this as well. The non-reimbursable work is just not valued as much, although in some respects it is more valuable. The problem with this shift is humans have a need to feel valued. When truly valuable but difficult to measure work is not appreciated, people will eventually stop doing it.  Incentives matter.

 

 

 

Meet the Bobs*

Another friend of mine told me a story about how her group hired an outside consultant to analyze their practice and provide recommendations (consultants live and breathe efficiency). The group was around the 30th percentile for RVU production and this was quite distressing to them. After all, how the hell could they be below average? (Answer: Not everyone can be above average. It is statistically impossible outside of Lake Wobegon).

 

What no one considered was the fact that this group had more vacation time and a shorter than average workday. It was unknown if the more efficient groups were much larger or had physician extenders to offload work. The data was compiled from voluntary surveys that groups submitted which introduces selection bias into the mix in a dangerous way.

 

In other words: Who knows what being 30th percentile actually means.

 

But the most important question of all was this: Who the heck cares?

 

 

It’s not a competition. Before the consultation people were generally satisfied with the workload and the paycheck. After the consultation people were beside themselves with grief. Nothing changed except they had now joined the cult and drank the consultants Kool-Aid.

 

Opt Out

It’s difficult to say no. We all like to think we would never join cult because we are smarter than everyone else. Most people think they are less susceptible to cognitive bias than everyone else…which is actually a cognitive bias if you think about it.

 

Nobody wants to say no to efficiency. Why would they? What kind of lazy slacker wants to be less efficient? Now, some efficiency is a good thing. It allows you to do more with less. Efficiency is actually a principal I use for my life, but it is toxic in high doses. It is a tool that can be misused. Like any drug there is an effective dose that makes sense and improves our lives, but eventually there is no added benefit, and perhaps an added harm. The striving for more, better, faster eventually has negative consequences, but just like the frog who finds himself in the pot of boiling water, when the push for efficiency is slow and steady we don’t even notice its deleterious effects until it’s too late.

 

The cult of efficiency is just another crappy multiplayer game for us to play. There becomes a point where we are efficient enough; although often once we get there It is not satisfying. Kind of like the ending to this blog post…

 

🙂


*Perhaps the greatest movie of all time.

 

 

21 comments

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    • Ausdoc on August 5, 2017 at 6:09 pm
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    Hi Happy Philosopher
    I enjoyed this post.
    I am a mid 40s Australian specialist who is facing some of the issues that you describe in your blog which I have found really helpful.

    I agree that we as physicians get taught and learn to prize a sense of efficiency but that it often doesn’t lead ultimately to satisfaction because we are often comparing ourselves to other (equally or more) narcissistically orientated doctors who are also improving their efficiency. I find this particularly prominent in the world of medical research where number and impact factor of publications often becomes an extension of one’s ego and a source of shame if not measuring up to colleagues. This may fuel further efficiency but leads to endless dissatisfaction and poor relationships with other clinicians.
    Efficiency is only useful as a servant of knowing truly what is “enough” and avoiding what you call the multiplayer game of competing with others which many of us find harder to do than we would like to admit (myself included).

    Regards and thanks for your efforts with your blog..

    1. Thanks for the comment Ausdoc. Realizing it is largely a game created by others is a liberating concept 🙂

    • wendy on August 5, 2017 at 6:28 pm
    • Reply

    “The thing is Bob, it’s not that I’m lazy… it’s that I just don’t care”

    Efficiency for it’s own sake – that isn’t aligned with useful and motivating goals for people – just sucks.
    Not terribly profound, but I’m channeling my inner Office Space
    🙂

    1. Just make sure you get those TPS reports finished by Monday.

  1. As a relatively young physician (40 years old and two years into independent practice), this is a particularly hard thing to avoid. I am surrounded by other new physicians who are willing to put all of their free time into clinical practice/education/research/administration in order to advance in their careers, while I would much prefer to have lots of free time to do the non-medical things I haven’t been able to do over my 16 years of training. It’s hard at time to remember to judge myself based on my own goals and values rather than in comparison to my much more efficient (but not necessarily happier) colleagues.

    1. Comparing ourselves to others is how we gauge how we are doing in life, but the more we can detach from it the less we will be influenced.

  2. Amen brother. I’ve been a doc half the time you have, but I’ve seen this change happen to the cult. My group has hired no less than 4 consultants in the past 3 years. What do consultants do? They tell you to change! What good would they be if they came in and said “everything is fine, no changes needed.” The consulting group would find themselves without clients. As the Bobs said: “What would ya say ya do here?” Which is a question I want to ask the consulting group.

    We recently had a consulting group, and I stood firm on everything questioned. Maybe I came off as abrasive but I don’t really care. I know I provide good serveice to patients, and I refuse to change for the sake of change.

    I view the bad of modern medicine as a statue in my office. It was there before I started. No one knows how it got there. It’s ugly, and In forced to stare at some of the day. Also, it requires me to dust it periodically because that’s what someone did before be. Also, my administration won’t let me move it away.

    Since achieving fanancial independence and cutting back on work, I am dusting it less and paying much less attention to those who want it to stand.

    I think your post really sums up one of the more frustrating parts of modern medicine. As usually, you seem to hit well on these issues.

    1. Consultants are a tool and can be useful. They can see things from a perspective that is hard to achieve inside an organization, but unfortunately they are usually hired with productivity in mind. Very few groups hire a consultant to analyze happiness and maximize for that.

  3. Efficiency is great when it ultimately facilitates improved life satisfaction by providing more time to spend on what we want and less stress on what doesn’t matter. Unfortunately, today’s society has forced us to think that since we are now getting stuff done so much faster, that we now need to do more and more. It is a vicious snowball affect! Like you said, we need to learn to say no; however, for whatever reason that seems to be one of the hardest things to do.

    1. I’m all for efficiency, just not to the extent that it makes us unhappy. We have to know when and how to resist.

  4. I agree. Easier said than done though. Especially when your family depends on your high income based on that metric.
    A lot of boosting wRVU means doing procedures (which may or may not have a borderline indication) and spending less time with each patient in the office. Neither is a desirable outcome for patient or doctor. Although wRVU may be the best physician productivity measure it still leaves a lot to be desired and introduces harmful incentives.

    1. Agreed. If it were easy I wouldn’t be writing about it 😉

      The key is to reduce our need for money. When we are efficient and relatively frugal we become free. When we are free we can practice any way we want (within reason). It’s easier to open that niche practice when you only use 1/3 your paycheck.

  5. “Incentives matter”

    THIS. I’m not a pessimist at heart, but I am doubtful the problem with incentives will be solved in medicine anytime soon. By definition, any system in which you are paid a sum of money for a definable type of work will create an incentive. Physicians will change their practice habits to follow these incentives, or risk going out of business in the long run.

    Even a paradigm switch from productivity incentives to so-called “value” incentives is just a change of focus, a different rabbit to chase to make a buck.

    It’s a stupid game that we all play. As you said, the best option seems to be to opt out, and accept less money for more job and life satisfaction.

    1. Yep. Opt out of the games and become free. Work is better when you don’t need the money.

  6. This is a great point that a lot of people forget. Efficiency is a way to more quickly reach a goal, not a goal in and of itself. I try to maximize efficiency at work so that I can get everything done and get home for plenty of undistracted time with my family. Getting more efficient just to get more efficient isn’t helping anyone.

    1. Yes, leaving work at work can be a game changer for many jobs. We need time to recharge.

    • mbmrad on August 7, 2017 at 4:27 pm
    • Reply

    Today I read through the ACR (American College of Radiology) Monthly Bulletin. There was a piece on ‘How to Advance in Leadership Roles.’ It discussed “saying yes to everything” and “getting involved on committees” so you can be noticed and asked to do more. I found myself thinking, “Why?” It just sucks up more of your time and your life, and it doesn’t increase your pay. I admit that I am feeling jaded, so I’m not considering all the good you could do for the profession and the organization. It’s just that I’ve learned though experience that neither the profession nor the organization cares. Maybe some people are motivated by the ego boost, but not me. If I have “extra cycles” to spend, then I want to do it in other ways than sitting on professional committees.

    1. That sounds like it was written by my exact opposite evil twin. You are correct that our profession or any organization does not care. They can’t care, only individuals can care. Do work that makes you happy and do it well. Say no to everything else.

    • wolverinemd on August 8, 2017 at 8:26 am
    • Reply

    Great topic THP. To me, 30+ years as a physician, nothing exemplifies “efficiency” better than electronic health records. Are there some handy things with EHR’s? Absolutely. The bottom line though is to better capture, or attempt to, revenue. We are now up to 3 separate software programs that need to be completed at the conclusion of each visit. Since I’m old school, and highly value my face to face patient interactions, I complete them out of the room. Slows me way down but my patient satisfaction scores are way up there. So for me – lower efficiency. I won’t change and thankfully I’m in my last couple years.

    1. That’s old school. I like your style. EMR has been the death of the H&P and progress note. There is 5x the information and half the usefulness. We document everything that doesn’t matter and then we bill for it. It’s bulls#!t.

    • wolverinemd on August 10, 2017 at 10:26 am
    • Reply

    Exactly. Young providers must be so good now because every patient gets a complete ROS at each visit instead of a focused one. I can’t stand templated notes.

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