A Response to "Medical Taylorism"

There has been a lot of back and forth chatter on social media the last couple of weeks since Pamela Hartzband and Jerome Groopman published "Medical Taylorism" in the January 14 issue of the New England Journal of Medicine.  Don't get me wrong, Drs. Hartzband and Groopman make a lot of important points in the commentary.  For example, they argue that some of the best moments in a physician's career are the ones spent just talking to patients and sharing their joys, as well as their sorrows.  I still cherish  the cards, letters, and e-mails that I receive from former patients, telling them about what is going on in their lives.  I do enjoy spending time talking to my patients and their family members.  So, on this point, I agree with Drs. Hartzband and Groopman.  They also argue that there is a growing dissatisfaction with the practice of medicine - physicians are experiencing burn-out at an alarming rate, or so they claim.  Drs. Hartzband and Groopman believe that standardization and measurement of process and outcomes, all in the name of efficiency, have caused this physician burnout.  There have been a number of studies that suggest that physicians are experiencing burnout.  A survey of over 6,000 physicians published recently in the Mayo Clinic Proceedings (Mayo Clinic study) concluded that (1) physician burnout is more common now than it was in 2011 and (2) more than half of all physicians in the U.S. experience burnout.  So again, I agree with Drs. Hartzband and Groopman here too.  However, I would like to point out that several recent studies performed in other industries outside health care have shown similar trends in professional satisfaction.  In other words, it's not just physicians who seem to be dissatisfied with their chosen profession!  Moreover, it is probably not the focus on efficiency, standardization, and measurement of outcomes that is to blame.  The RAND Corporation published a report on the factors that most impacted physician professional satisfaction (Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy).  Major factors impacting professional satisfaction included (1) perceptions of the quality of care provided, (2) dealing with electronic health records, (3) degree of autonomy and control of their practices, (4) practice leadership, (5) collegiality and respect among staff, (6) quantity and pace of work, (7) support staff, and (8) payment, income, and practice finances.  Conceivably, a focus on efficiency at the expense of spending time with patients could impact physician satisfaction, but it is certainly not the only reason nor is it the most important factor.

Perhaps the most common criticism of Drs. Hartzband and Groopman stems from their mischaracterization of Taylorism and the principles of Lean and the Toyota Production System.  Frederick Taylor (Frederick Winslow Taylor) is considered the "father of scientific management" and revolutionized the manufacturing industry.  Taylor was one of the first to apply engineering principles to manufacturing, many of which were later adopted by Henry Ford at his automobile plant (see Frederick Taylor and Henry Ford).  When we think of Frederick Winslow Taylor and Henry Ford, we often think of the assembly line, one of Henry Ford's most outstanding achievements.  Many physicians, including me, will vehemently argue that we should not be modeling patient care based upon the assembly line.  We are not making brand-new automobiles - we are taking care of patients!  Think of this - when you have a broken down automobile, you take it to the local mechanic.  Once there, the mechanic will run a series of test in an attempt to diagnose what is wrong with the car.  Once a diagnosis is made, the mechanic will fix the car.  Taking care of sick patients is more like repairing a broken down automobile than it is building a brand new one on an assembly line.  When talking about his assembly line, which revolutionized the automobile industry (as well as many other manufacturing industries), Henry Ford once said, "People can have the model T in whatever color they choose, as long as it is black."  The assembly line worked so effectively because everything was the same!  Rather than dealing with one specific make and model of automobile (say, all Chevrolet Corvettes or Ford F-150 trucks) or even a specific color of car, automobile mechanics work on a wide variety of different cars (from Ford, Chevrolet, Honda, Toyota, etc) and models (Mustang, Camaro, Accord, or Camry) all at the same time.  On any given day, a mechanic could  be changing the oil on a Honda Accord (preventive maintenance!), replacing the transmission on a Ford Escort, or repairing the brakes on a Toyota Camry.  I guess what I am trying to say is that if you are going to make a comparison between the practice of medicine and the automobile industry, it makes more sense to compare it to the automobile mechanic than the automobile assembly line!  If Drs. Hartzband and Groopman are going to make that argument, then I will support them 100%, but they do not make that argument.

There is an important distinction between the work of Frederick Winslow Taylor and Lean.  Yes, Lean is based upon the Toyota Production System (the automobile manufacturing industry).  However, the two are not one and the same.  In fact, Lean has been successfully adopted by a number of health care organizations.  Mark Graban, one of the foremost authorities on applying Lean methods in health care recently wrote a blog explaining how different Lean is from Taylorism (Mark Graban's Lean Blog).  Standardization (which can be easily accomplished with many aspects of health care without jeopardizing the physician-patient relationship or impacting either innovation or a personalized approach to care) and the application of Lean principles have been shown to improve efficiency, minimize costs, increase patient satisfaction, and improve the overall quality of care.  Recall that perceptions about the quality of care provided is one of the most important drivers of physician satisfaction (see the RAND study again here).  By extension (If a=b and b=c, then a=c!), standardization and the application of Lean principles to health care will improve physician satisfaction and reduce burnout!