Blog | Wednesday, June 20, 2012

Why do we expect productivity from physicians?


"Let's Be Less Productive," from the New York Times

When I first joined the faculty in 1980, no one used the terms productivity. The concept of relative value units (RVUs) had not yet arrived. I believe it was a better time.

Productivity does not just plague physicians. Tim Jackson has authored a brilliant piece about productivity.

"At first, this may sound crazy; we've become so conditioned by the language of efficiency. But there are sectors of the economy where chasing productivity growth doesn't make sense at all. Certain kinds of tasks rely inherently on the allocation of people's time and attention. The caring professions are a good example: medicine, social work, education. Expanding our economies in these directions has all sorts of advantages.

"In the first place, the time spent by these professions directly improves the quality of our lives. Making them more and more efficient is not, after a certain point, actually desirable. What sense does it make to ask our teachers to teach ever bigger classes? Our doctors to treat more and more patients per hour? The Royal College of Nursing in Britain warned recently that front-line staff members in the National Health Service are now being "stretched to breaking point," in the wake of staffing cuts, while a study earlier this year in the Journal of Professional Nursing revealed a worrying decline in empathy among student nurses coping with time targets and efficiency pressures. Instead of imposing meaningless productivity targets, we should be aiming to enhance and protect not only the value of the care but also the experience of the caregiver.

"The care and concern of one human being for another is a peculiar "commodity." It can't be stockpiled. It becomes degraded through trade. It isn't delivered by machines. Its quality rests entirely on the attention paid by one person to another. Even to speak of reducing the time involved is to misunderstand its value."


What unintended consequences have productivity and RVUs wrought? We have encouraged physicians to spend less time with patients, do procedures more quickly, avoid telephone calls and emails (no RVU points here) and generally worry more about volumes than individual patients. Now I know that I use hyperbole in these statements, but while we rarely are as cold as the previous sentence, the concepts do influence us. Anyone who can remember medical practice prior to these concepts can explain how practice has changed because of these phrases.

Patient visits are not widgets. Patients expect and deserve our full attention without concern for the clock. Patients have questions that we need to answer. History and physical examinations take time. Considering multiple diagnoses takes time. Sometimes we need to stop and read while the patient is in the room. We need time to do our job properly.

I hope others will take up the call. We should banish productivity as a descriptor. The concept has diminished our profession and thus we should reject it.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.