I love productivity. Most mornings I record the day’s tasks on an unlined index card. There’s pleasure in the smooth glide of the gel pen, which happens to be purple today. There’s satisfaction in getting the nagging reminder out of my brain and onto a visible list. There’s a dopamine release when items are crossed out. And the list is eclectic: today’s tasks include “run” (already done and crossed out), “roast carrots” (will do just before the evening dinner event), “buy stamps” (will move onto tomorrow’s list), and “write Opinion” (in process).
My colleagues love productivity, too. Faced with declining reimbursements and increased practice costs, ophthalmology groups are diligently increasing efficiency and implementing lean management principles (aao.org/lean). We discuss the economics of seeing one or two additional patients per session. I’m almost always willing to fit in an extra consult or urgent visit, or even to overbook a session to accommodate a patient’s complicated schedule. We employ optometrists, ophthalmic technicians, nurses, and even physician assistants to see our patients or to help us see more patients in a day. Not only is productivity necessary for economic reasons, but due to the aging demographic, there is a crush of patients needing ophthalmic care. We must see more patients more efficiently. But could the drive for productivity have a dark side?
I once heard an (unsubstantiated) story about a pediatric oncologist who was approached during clinic by two people from the business office of his private equity–owned medical group and told he needed to see more patients per session—and that he was spending too much time with each patient. I immediately thought of the parents of a child with newly diagnosed cancer, with their dozens of questions and their need for emotional support. How could he be more efficient? While this apocryphal tale is egregious, it illustrates the tension between the economic realities of modern practice and our role as healers.
Productivity metrics for physicians are increasingly used, not just by private equity–owned groups but also by independent and academic practices, and this process is important. The late management guru Peter Drucker is often misquoted as saying “If you don’t measure it, you can’t manage it.” But Drucker’s actual viewpoint was more nuanced and sophisticated: “It is the relationship with people, the development of mutual confidence, the identification of people, the creation of a community. This is something only you can do. It cannot be measured or easily defined. But it is not only a key function. It is one only you can perform.”1 While Drucker was talking about managers, he very well could have been describing physicians as we see patients.
The farmer-poet-activist-novelist-curmudgeon Wendell Berry often describes the tension between modern technology and what is best for communities. In his essay “Life Is a Miracle,” Berry muses, “It is easy for me to imagine that the next great division of the world will be between people who wish to live as creatures and people who wish to live as machines.” How hard can physicians work? How efficient can we become?
I don’t think it’s a bimodal choice between living as a machine and living as a wholesome human. While it’s important to measure and monitor our productivity, we can do this in a manner that honors our role as physicians and respects our humanity and the humanity of our patients.
In the same way that physicians integrate the best external evidence with our own clinical experience to care for the individual patient, we must integrate productivity with excellent care and compassion. Some days providing superb care to a patient with complicated ophthalmic issues comes at the expense of seeing lots of patients in a timely manner. It comes down to what we value most. After all, it’s the most important things in life—and in work—that cannot be measured.
1 Zak P. Measurement myopia. July 4, 2013. www.drucker.institute/thedx/measurement-myopia/. Accessed Oct. 27, 2022.