Portal de Periódicos da CAPES

Presidential address: A clash of cultures—personal autonomy versus corporate bondage

1998; Elsevier BV; Volume: 124; Issue: 4 Linguagem: Inglês

10.1067/msy.1998.91481

1532-7361

Hēnry Buchwald,

History of Medical Practice

I am most appreciative of the trust the Central Surgical Association has bestowed on me this past year and for this opportunity to address my colleagues. I wish to acknowledge my precious family—my wife, Emilie, our four daughters, Jane, Amy, Claire, and Dana, their spouses, Tim, Larry, and Danny, and their next generation of offspring. I owe whatever good I have done to Emilie, who has shared my life through 44 years of marriage and some additional years of courtship. I have asked her on several occasions if she loves me for who I am or in spite of who I am. And, she has replied—both. I have had many great mentors. My college teacher, the poet Mark Van Doren, showed me that one can teach nondidactically, simply by opening vistas. The chair of the Department of Medicine at Columbia's College of Physicians and Surgeons, Robert F. Loeb, taught me that to be a good surgeon, one must first be a good doctor. I was fortunate to have two of the giants of American surgery as my teachers. Owen H. Wangensteen (Fig 1) believed that research was integral to an academic practice and that the surgeon-researcher must be well schooled in the basic sciences.He held that the only dean who was ever good for anything was Gunga Din (pronounced dean ), Kipling's regimental water carrier for, at least, he gave you a drink of water. When I presented my first paper before a national audience and was distressed at being attacked by a noted cardiologist, Dr Wangensteen said to me, “Show me the man who has no enemies, and I will show you the man who has done nothing.” Richard Varco has been my teacher, associate, and friend for 37 years (Fig 2).He is the progenitor of cardiovascular surgery, the last of the real general surgeons, and my research coinvestigator for my entire academic career. He more than any other person exemplified for me the principles and integrity of our profession and stressed to me our inherent responsibility to maintain traditions of excellence. Of course, my students and my patients have been my mentors. Working with generations of eager residents has kept me a perpetual student, always in search of a new concept to explore. My patients have taught me courage and how to face the worst of times. Recently, Dorothy Balts, a patient who will soon lose her 10-year struggle with cancer and who appreciates and is grateful for every precious day of her life, wrote me the following: “We all participate in the stream of life. When we leave it is not important—only the triumphant journey counts.” Because this presidential address will be about freedom, it is fitting that I dedicate this talk to my wonderful parents, who fled to this country to escape death, enslavement, and humiliation. Although many of their years were marred by the Holocaust, they did not despair, they were not bitter, they extolled the personal rights offered by this nation, and they always looked forward to the opportunities given to their children and their children's children. They lived hopefully. A constellation of principles embody the personality of the surgeon. At its core are the tradition and the ethos of personal autonomy. One of the distinguished past presidents of the Central Surgical Association, Donald Silver, who has been a role model for me, entitled his 1992 presidental address, “Responsibilities and Rights.” He allowed very few intrinsic rights to surgeons, but first among the limited prerogatives he granted was autonomy. As surgeons, we tend to be individualists and to espouse individual responsibility. To us, maturity means being responsible for our actions. We keep our commitments. We view fiscal independence as essential. We take pride in earning a living and, should we have a family, in providing for its needs. To give the gift of an education to our children has been integral to our aspirations. The years of medical school, residency, and the post-postgraduate education of clinical practice finally give birth to a surgeon. This individual has acquired a base of knowledge and the insight to apply facts and rational suppositions to the care of patients. This individual has obtained operating room skills secured by observation, trial and error, repetition, and respect for tissues and tissue planes and has learned the art of being gentle with a firm and steady hand. The surgeon has been sobered by death, by bad results, by the frustration of the inadequacies of even the most modern medical advances, and by the vagaries of human nature that obstruct the best of intentions and efforts. The surgeon has acknowledged fallibility and his or her power to do harm. The surgeon has become comfortable in a profession in which decisions are singular and responsibility is particular. The mature surgeon has achieved personal autonomy. Within our company of surgeons we take just pride in our accomplishments. We are a distinct discipline with a unique body of knowledge. We are, for the most part, successful. We save lives, we increase life expectancy, we enhance the quality of existence. In addition, we have provided society with numerous competent surgical practitioners and built dynasties of surgical educators and researchers—individuals who bridge the present with the future of our profession. Unfortunately, this golden age for surgery and the personal autonomy of the individual surgeon are threatened with imminent destruction by a force that will, if not countered and checked, lead us into corporate bondage. I will term this force administocracy. Ideally, the role of health care administration is to facilitate the work of physicians and health care personnel. But the chief administrators in our health care institutions and universities are no longer facilitators. They now seek to control. They have been redefining medical practice, clinics, academic departments, and universities on a corporate model, a model that subverts the essential nature of an intellectual society, a model totally alien to the definition of a university as a community. Administocracy, the term I have coined to epitomize this force, is the rule of centralized administration, based on the top-down control of money, resources, and opportunities. Its primary beneficiaries are the administrative hierarchy. Administocracy has established itself as a new ruling class, an order clearly separated from the toilers in the vineyard of medicine. Administocracy is governance not by facilitation but by intimidation. Administocracy has gained or is gaining control of our medical schools, our teaching and community hospitals, and our current means of providing health care. I will outline administocracy's practices, codified into its own perverted Ten Commandments. The glory of our nation's democracy, the longest surviving democracy in the history of the world, is its ability to tolerate differences—to take new initiatives and then to retrench, to be liberal and to be conservative—and, concurrently, to be responsible to the will of the governed and to the precepts of a fundamental code of principles and individual rights. An autocracy, on the other hand, denies flexibility and governance alternatives. An autocracy's overriding objective and only goal, regardless of any protestations of working for the common good, is its own perpetuation. By definition, such a system denies the will of the governed and refuses recognition of individual rights. Administocracy is, of course, an autocracy. Once in power, administocracy's first order of business is to replicate itself. For example, in 1993 the academic administocracy at the University of Minnesota cut 435 civil service positions, while simultaneously adding 45 more executives and administrators.1Robson B Destroying the university to save the university. City Pages, MinneapolisApril 9, 1997Google Scholar The Office of the Senior Vice President for Health Sciences at Minnesota, a unit that did not even exist some years ago, now has 25 members. The growth of medical administocracy is the result of genuine problems in the distribution of health care, including cost problems not adequately addressed by the medical profession itself. Our failure, or inability, to take action on these issues has allowed outsiders and opportunists within our own profession to hijack the delivery of health care. Among practicing physicians, a general ennui and a lack of resistance have been the reactions to the administocracies that are becoming our overlords. Perhaps one reason for this seeming complacency is that, individually, physicians feel powerless when faced with the well-organized, implacable machine of administocracy—an entity that knows its purpose and will use any means to attain its goals. Another reason is well expressed by Thurber's paraphrase of Lincoln: “You can fool too many of the people too much of the time.”2Thurber J Fables for our time. Harper & Brothers, New York1940Google Scholar In his classic novel 1984 , Orwell beautifully illustrated the power of language and its willful distortion by governments. His use of ostensibly neutral words for disguising uncomforting realities set the standards for the current proliferation of Orwell's “Newspeak.”3Orwell G. 1984. San Diego: Harcourt Brace Jovanovich; 1982Google Scholar The medical and academic administocracies of today have devised their own Orwellian glossary of deception, often borrowing and redefining phrases from corporate industry and the military. CEO , for chief executive officer, obviously comes from the corporate world. In academia and in hospital administration, it means a titular despot who controls the destiny and income of faculty and staff. Reporting to and chain of command come from the military. These designations of caste and of obedience have not only been fully accepted by members of our profession but actually embraced and fostered by certain of our colleagues. Executive management group means a cluster of deans. Managed care is a euphemism for reducing patient services and physicians' fees to redistribute income to the ever-increasing number of administrators. Utilization review stands for a bureaucratic sleight of hand to justify a predetermined reduction in patient services and health care personnel. Market and consumer mean patient. Market share means the number of patients you can hold hostage in a provider network. Health care team means that the physician is only as essential to patient care as the multitude of people who stare into computers on nursing stations. Vendor means you, the doctor. Reengineering is the golden calf of administocracy and takes in vain much of what we hold sacred. Reengineering would substitute dicta for scientific inquiry, the “clean sheet” for methodology, and assumptions for acquired knowledge. Reengineering has never been critically tested, certainly not in academia and hospital administration. No randomized clinical trials of reengineering have ever been conducted. The definitions of reengineering are all quite similar. Michael Hammer and James Champy, two of the principal writers and consultants in the field, define it as follows: “the fundamental rethinking and radical redesign of business processes, management systems, and structures of the business to achieve dramatic improvements in critical, contemporary measures of performance such as cost, quality service, and speed.”4Hammer M Champy J Reengineering the corporation: a manifesto for business revolution. Harper Business, New York1993Google Scholar The stages of reengineering are usually listed by its author advocates as preparing for change, planning for change, designing for change, implementing change, and evaluating change. Obviously, “change” is the key message, often spoken of as “swift and radical change.” Initiates to reengineering are instructed that it is essential to start this swift and radical change with the proverbial “blank sheet of paper.” Besides the logical fallacy of changing that which is blank, the sheet of paper is not blank; it contains our heritage. To start with a blank sheet means to erase the past. This concept of eliminating what we have painstakingly learned denies the most fundamental precept that we, as teachers, have passed on to generations of our students; namely, know the past and build on it. That way offers progress. Paul's First Epistle to the Thessalonians (5:21) states: “Prove all things; hold fast that which is good.” If we do not learn from experience, from accumulated data and analyses, we will continually repeat history, and often bad history. Reengineering is a denial of the methodology of learned skills to deal with the business at hand, a denial of accumulated knowledge, a denial of the wisdom based on that knowledge. It is an abrogation of the scientific method. In too much of the corporate-industrial world, reengineering has been the death blow to the company as family, a place to work with pride until retirement. In its place, reengineering has imposed the lean and mean corporate model of harsh downsizing—an organization devoid of workers' loyalty, characterized by a disregard for the customer in favor of the stockholder, plagued with a heavy load of debt, and ripe for a merger, conglomerate integration, and, eventually, extinction. But enlightened industry has been abandoning reengineering, and the gurus of this nonsense have found it profitable to shift their expensive consultative services to academia and health care. Many of our associates have bitten hard into this apple of poisoned knowledge: Harvard, Tufts, Columbia, Cornell, Stanford, the University of California–San Francisco, Michigan, Henry Ford, and Minnesota are just some of the great institutions that have, to one degree or another, adopted reengineering. Physician-administrators, with little or no experience in the business world, are pushing hard to sell reengineering as a panacea for success and good fortune in the health sciences and in health care. They are huckstering a placebo. The former provost of the University of Minnesota Academic Health Center and current president of Johns Hopkins, Dr William R. Brody, brought the aforementioned James Champy to a University of Minnesota “leadership retreat” in July of 1995. At that meeting Mr Champy, was quoted as saying: “We live in debate… but you may have to exercise powers and say sometimes, ‘The debate is over. This is the way we are going to be.' …visions are not built by groups … people in organizations want to be told what to do… There is a thirst for leadership, for top-down direction.”1Robson B Destroying the university to save the university. City Pages, MinneapolisApril 9, 1997Google Scholar Champy gave this advice pro bono. Eventually, however, his consulting firm, CSC Index, was paid $2.2 million by the University of Minnesota to put his philosophy into practice.1Robson B Destroying the university to save the university. City Pages, MinneapolisApril 9, 1997Google Scholar Ever since the Brody mindset took hold of the university's administocracy, I have listened to speech after speech emphasizing that “everything is on the table” (freely translated to mean—tell us what you have so that we can take it away from you), and that the ultimate goal of reengineering was the “reinvention of the academic health center.” I was also present when straightforward questions about a prospective hospital merger were met with evasion and statements such as “The negotiations are as yet too delicate to be openly discussed” and “I am not at liberty to provide these details.” Only when the secret discussions had been concluded and the final decisions had already been made were faculty members informed of the swift and radical changes that would forever affect their lives and that these changes were “non-negotiable.” In the application of reengineering to academia and health care, the basic work unit is achieved by horizontal integration across disciplines. The medical community until recently has been discipline oriented. The change to horizontal integration represents a major paradigm shift. This change means that a patient would proceed not from one physician to other disciplinary specialists, as needed, but would be referred to a disease- or system-complex of physicians. This unit has been designated as a disease-based cluster, also called in various institutions a center, an institute, a service-line unit, and an interdisciplinary service program. The disease-based cluster is an imposition on patient care of management by a standing committee. Contrary to the promises of the administocrats, life within the horizontally integrated unit is far from utopian. Because the income allocated to the unit by the administocrats is distributed by formula to the members of the disease-based cluster, the fewer members in the cluster, the more money for those who are retained. That formula encourages the urge to lighten ship. In this cluster, the members of the group have yielded the control of their practice and of their personal income to the group mentality. The surgeon is an employee of this group of primarily nonsurgeons, a fully salaried employee with few, if any, financial incentives. Further, each cluster decides on the optimal time management for its employees. Economic unit pressure will limit the amount of time allocated for teaching and for research. If you want to teach, you will be told that extensive teaching is a luxury that the unit cannot afford for its surgeons. You will be told to limit your time with medical students and to limit the operating room time you offer residents, because this use of time does not serve the market-driven goals of your new workplace. Time spent in laboratory research by members of a clinical unit, especially the unit's surgeons, will be restricted or disallowed, because it would most assuredly decrease the unit's ability to compete in the clinical marketplace. Although the surgeon is the main stoker of the unit's economic furnace, decisions for the individual surgeon's distribution of time will no longer be at his or her discretion, but rather at the discretion of the economic will of the group. And, because the surgeon must spend an extensive amount of time in the operating room, the director of this disease-based cluster will, more than likely, not be a surgeon. Where are the positive incentives for surgeons in the horizontally integrated unit? We have seen that the incentive is not in money, in teaching, or in research. Is it in the practice of our craft? Even that pleasure may not be allowed. Disease management in the cluster will be by what has been termed clinical pathways. This means surgery by the numbers; every surgeon will do the same procedure for a specific problem, in exactly the same manner, with a prescribed set of instructions for the use of nasogastric tubes, drains, antibiotics, alimentation, and so on. This assembly-line concept of surgery represents the ultimate destruction of the autonomy of the surgeon. What will be left? The negative incentives of job security and the threat of punishment for expressions of individuality. Criteria for employment will be obedience to the group and a proper sense of beholdenness. The emergence of horizontal integration in reengineered institutions is being vigorously proselytized by its advocates. Indeed, several plenary sessions at the 1997 meeting of the American College of Surgeons gave podium time to the leading proponents of horizontal integration, but none to its opponents. A more balanced analysis of this “brave new world” is needed. In the words of Aldous Huxley: “Thought must be divided against itself before it can come to any knowledge of itself.”5Huxley A Do what you will. Doubleday, Doran & Company, Garden City (NY)1929Google Scholar The professional fathers and mothers of practicing doctors of medicine are the departments of the medical school. For us as surgeons, our professional parent is the department of surgery. Most of us have a strong allegiance to the departments that trained us and to those we now represent. We cite the teachings of our department as a justification for what we do and what we believe. We extol the achievements of the heroes of our department, and we have been known to contest between departments with fierce team loyalties. We tell departmental anecdotes into our dotage. Historically, the strongest medical schools have had the most powerful departments. Feudalism may not have been an intellectual success in the Middle Ages, but it has been the appropriate medical school governance system for our golden age of surgery. The independent department of surgery has, as a rule, been financially sound. It is able, therefore, to provide its faculty, in addition to a clinical practice, research opportunities, as well as the time to teach and to travel. The clinical atmosphere is exciting, allowing faculty to interact with questioning residents, and, through grand rounds and mortality and morbidity conferences, offering the best second opinions available anywhere. Independent departments gave birth to independent individuals, who had the imagination, innovative spirit, incentive, and drive to make surgery in the United States the best and the most envied in the world. Reengineering would have us deny our departments, abandon them as mere relics. We are being told to dishonor our parental heritage and to deprive future generations of its nurturing. Horizontal integration is the death knell of the strong department of surgery as we know it. Independent departments that give rise to individualists are anathema to an administocracy, which would replace departmental parenting with the cloning of conformists. The proponents of radical change are proposing that departments, for now, be maintained only for teaching students and lower levels of residents, and that their income will somehow be supplied by the dean of the medical school, to whom they will be indebted. The department chairs who will head these units will no longer be selected for scholarship, clinical acumen, and research accomplishments, but for administrative experience and political aspirations. As the lowest tier of the administocracy, they will not uphold or defend the department. In the future this system will eliminate clinical departments altogether, including their independent research, and delegate the teaching of the basics of surgery to other than practicing surgeons. Tenure had its origins in the high Middle Ages and into the Reformation when royal edicts protected the person of the scholar and guaranteed safe passage.6Metzger WP Academic tenure in America: a historical essay.in: Faculty tenure. Jossey-Boss Publishers, San Francisco1973: 93-159Google Scholar As the university tradition developed on the continent and at Cambridge and Oxford, tenure became more of a fortification against the internal threat of dismissal at the pleasure of the clerical and political appointees who constituted the administration of these universities.6Metzger WP Academic tenure in America: a historical essay.in: Faculty tenure. Jossey-Boss Publishers, San Francisco1973: 93-159Google Scholar In the 1990s, once again, tenure has become a highly charged controversy emerging from the academic cloister into the everyday world. Tenure is under attack in institutions of higher learning throughout the United States. This foundation of academic freedom, which includes the tenets of due process and freedom of expression, is being challenged as unwieldy and as an impediment to progress in today's fast-moving world and economy. It is seen as a barrier to effective top-down university administration. A lifelong commitment of appointment for faculty is being considered an unreasonable limitation to a university's competitiveness. Tenure-track appointments per se are becoming more and more difficult to obtain, and the possibility of abolishing tenure is a current reality. In the field of medicine we have traditionally not been strong advocates of the tenure system. Most surgeons, in and out of academia, have usually thought of tenure as the subterfuge of the weak and unaccomplished, the refuge of idlers and ne'er-do-wells. For my part, however, I am a strong proponent of tenure on principle and from experience. I have seen the University of Minnesota administocracy attempt to kill tenure. I have seen an outside consultant lawyer, hired by the Board of Regents, write a new tenure policy, subsequently put forth by the Board of Regents, that would have seriously restricted many aspects of academic freedom, denied due process, and allowed the disciplining of faculty for not having “a proper attitude of industry and cooperation.” I have seen the provost of the Academic Health Center become the leading opponent of tenure at the University of Minnesota and promise the state legislature to destroy tenure in exchange for increased funding for his personal vision of reengineering. This threat to tenure has gone hand in hand with, and has served as the primary impetus for, unionization efforts by faculty, a turning to collective bargaining, the terminal polarization of a university into “them” and “us.” The union movement has been successful in some institutions and almost successful in others. We must recognize that the alternative before us is not between tenure or no tenure, but between tenure or membership in a trade union. Centuries of reflection, turmoil, and hard-earned victories for freedom of expression within institutions of higher learning are embodied in tenure. That 1000-year-old legacy should not be swept aside by the know-nothing approach of “reinventing the university.” In the final analysis, tenure is the only protection that allows university faculty open criticism of the administocracy. Make no mistake about it, without tenure the outspoken individualists in the academic departments of surgery will be among the first to be fired for insubordination, for not having a proper attitude. They will be fired without due process and without the least concern for their productivity, hard work, loyalty, and demonstrable accomplishments. If not for tenure, many of our predecessors would not have survived to found and to sustain the Central Surgical Association. If not for tenure, many of us in this room would not be signing our names as professor of surgery. Once it was considered laudable in academia to pursue more than one career option—to be a researcher, a teacher, a consultant, as well as a practicing clinician. In the system of administocracy, such pursuits are adulterous, and they are prohibited. William Kelley, the apostle of linear career tracks, has made the laboratory doctors the highest order in the academic departmental heirarchy.7Kelley WN Stross JK Faculty tracts and academic success.Ann Intern Med. 1992; 116: 654-659Crossref PubMed Scopus (46) Google Scholar They follow a standard tenure track, spend little time with patients, and obtain their income from grants and from the efforts of their clinical-track colleagues. Clinicians are confined, in turn, to patient activities, can have no laboratories, and may do only clinical research. Their primary job is to make the money needed by a two-track department. If these clinical doctors cannot keep up with the overall monetary demands, a third and fluid group of physicians, fresh out of residency, may be hired to see patients on a strict salary basis and to generate a sufficient overage of income to maintain the lifestyles of the nonclinicians. Where does the double-threat, triple-threat, or even quadruple-threat academic surgeon of yesterday and today fit into such a system? He or she does not fit. Where is there allowance for the person who has honed his or her clinical judgment and operating room technique to achieve superb clinical outcomes and is also known as an eminent researcher, an outstanding teacher, and, possibly, an administrator-educator in the field of surgery? We may not find such renaissance individuals in the university of the first century of the third millennium. Those who exist today—many of them in this room—are the equivalents of the dinosaur. Honored today for their stature, their breed is destined for extinction. If the goal of administocracy is power, the means to achieve that goal is the control of money. For most of us, our incomes have been primarily derived from patient care on a fee-for-service basis. In the academic centers we ourselves allocated a percentage of our income to research, to resident education, to travel, and to departmental needs, as well as to paying a tithe to the dean. Currently, we are being forced to acquiesce to a seizure of our income at its source for redistribution outside of our control, consent, and often, knowledge. The imposition of layer upon layer of administrators and managers siphons off money to pay for their income, for the maintenance of their staff, and for the fulfillment of their, not our, aspirations. What finally trickles down to surgeons is a small fraction of the income we generate. In my opinion, this is theft. The proliferation of health care provider organizations has given rise to a boom in building construction and occupancy to provide for the newly created health care managers. CEOs of managed care empires now take home millions of dollars annually. This is not capitalism but the embodiment of the Communist Manifesto: “From each according to his abilities; to each according to his needs.”8Marx K The German ideology. International Publishers, New York1947Google Scholar Apparently, administocrats have the greatest needs. We have seen the advent of a plethora of executives, echelons of supervisors, authorizers of services, accountants, marketing and sales personnel, secretaries, telephone operators, and so on—all to do what we were able to do with a relatively minimal support staff. What f