Of Assembly Lines, Medicine, and Burnout

assembly line medicine: mourning the craftsmen

Historical fact: People stopped being people in 1913. That was the year Henry Ford put his cars on rollers and made his workers adopt the speed of the assembly line. At first, workers rebelled. They quit in droves, unable to accustom their bodies to the new pace of the age. – Jeffrey Eugenides, Middlesex

Prior to 1913, automobile manufacturing was a cottage craft industry.  Start to finish, a master mechanic with full knowledge of the entire process assembled the machine.  Henry Ford killed this industry with the assembly line and opened up automobile ownership to the world. 

Similarly, prior to the 1980s and 1990s, medicine was primarily a cottage industry.  Each physician a craftsman running his/her own shop from start to finish.  It was not all rosy: quality was unreliable, physician greed was a problem.

On the other hand, physicians had a much more interesting and varied work-life, being both business-owners, healers, and technicians.  That variation helped to sustain a long career.  If you avoided over-leveraging, altering your own business model was easier than changing your work structure as an employee of a larger organization.

the chains of credit

At first, Henry Ford could not keep workers in his new factories.  At one point, he had to hire 963 men to add 100 positions to his factory.  That is how intensely the human mind rebels against such simple, repetitive work.

How did he fix this problem?  He paid his workers $5 a day, double the prevailing laborer’s wage of the time.  Workers earning double what they had made before were more anxious to keep their jobs.  Another 20th century invention made them doubly anxious to stay employed: consumer debt.

Similarly, doctors incomes have jumped appreciably in the era of healthcare consolidation.  Moreover, they begin practice minted with six figures of debt.  We seem ready-made for the harness of the assembly line.

Anxiety and debt are powerful motivators.  Loss aversion is much more powerful than the desire for equivalent gain.  How do you harness that motivation to keep human beings at jobs they detest?  You allow them to have something in exchange for future work, in other words: debt.

Indebtedness could discipline workers, keeping them at routinized jobs in factories and offices, graying but in harness, meeting payments regularly. – Jackson Lear

I wonder what our physician workforce would like right now if we hadn’t had to accumulate $200k-300k in student loans first.  Would the assembly line still be moving at the same pace?  Would more physicians be buying private practices?

separating planning from execution

Currently, the healthcare giants are actively trying to replicate Henry Ford’s ruthless efficiency in healthcare.  This will likely result in more healthcare for all, as was Henry Ford’s goal.  The question really becomes, do we want more healthcare?  Is healthcare a commodity of which more is better?

The data suggests not.  Dartmouth Institute for Health Policy and Clinical Practice have estimated that 30 percent of all Medicare clinical care spending could be avoided without worsening health outcomes.  The basic positive that comes from the assembly line is an increased production.  What is the argument for applying that model to a system that is already overproducing?

Basically, the benefit is increased profit for large health systems.

While standardized processes and workflows are an important part of assembly line efficiency, the core philosophical underpinning of the assembly line is separating the planning of a task from the its execution.  The healthcare giants are attempting to separate the planning of providing healthcare from execution.

In my position as a staff primary care doctor, I frequently went to my supervising physician and CEO with concerns and plans to make things better. They were always polite, but I tended to leave feeling a doctor who said nothing and simply saw more patients was more desirable.

Individuals in positions of “planning” guard their role jealously, because if physicians independently planned and executed the task, it would obviate the need for the managers.  Of course, they want us just keep our noses to grindstone, as long as they are needed to “plan” they have jobs.

The less creativity and ingenuity providing healthcare requires, the less and less valuable physicians as a class become.  The machine strives to make us easily replaceable cogs in the wheel, it is designed to do so.  Increasingly then, our position feels less secure, our anxiety goes up, and we work harder at jobs we hate to pay bills and keep the fat checks rolling.

the disconnect

Even as the American Hospital-Pharmaceutical Complex pushes for more and more efficiency and standardization, the American medical training complex discordantly continues to train doctors for the role of the independent craftsman.

Is it any surprise then that we aren’t fitting into the assembly line well?  Medical school and residency overtrained us for the work the healthcare giants are asking of us.  Not shockingly, the average turnover in healthcare jobs in 2017 was 20.6%, up from 15.6% in 2010.  Will they be able to buy us back into system? Has debt burdened enough of us so heavily that the machine will continue to churn on?

I think that specialization and overspecialization play a role in burnout.  The assembly line demands as much specialization as possible.  In the process, the variety and type of tasks we perform decreases incrementally and consistently.

Eventually, we feel ourselves the carriage craftsmen, put out of work by Henry Ford, forced to toil in sickeningly simply tasks in the new factories. Of course, we  burn out and quit, if we have the option.  Too often though, we just keep at it, for the better paycheck.

lessons from butchers

Henry Ford got his idea for the assembly line from Chicago butchers.  This is something worth remembering as we continue racing down the current nationwide experiment of applying efficiency to American healthcare.

Now, we shuttle human bodies on gurneys from ER bed to MRI to operating room, extracting RVUs as they move.  Will the machine tame physicians, as it has tamed nearly all other industries?  Will we continue to gray in the harness?  Or will we demand something more from our sacred calling?

They had chains which they fastened about the leg of the nearest hog, and the other end of the chain they hooked into one of the rings upon the wheel. So, as the wheel turned, a hog was suddenly jerked off his feet and borne aloft….Neither squeals of hogs nor tears of visitors made any difference to [the men of the floor]; one by one they hooked up the hogs, and one by one with a swift stroke they slit their throats… [The Butchering Floor] was all so very businesslike that one watched it fascinated…And yet somehow [one] could not help thinking of the hogs; they were so innocent, they came so very trustingly; and they were so very human in their protests–and so perfectly within their rights!….but this slaughtering-machine ran on, visitors or no visitors. ― Upton Sinclair, The Jungle

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