Medical Taylorism: Comment on Ledford and Young et al

I appreciated Dr Young and colleagues’ accounting of the excessive time primary care physicians spend working in the electronic health record (EHR) as well as Dr Ledford’s editorial that made reference to Frederick Taylor’s invention of scientific management as the ultimate key to managerial efficiency. Taylor’s contempt for workers is well known and was expressed in his apocryphal dialogue with an immigrant laborer named Schmidt, whom he mocked for his stupidity and Dutch accent.3 One clarification worth noting is that Taylor did make token attempts toaddress the human needs of his workers. He maintained that improved efficiency would lead to higher wages, increased prosperity, and a better life. Workers with vested interest would be more motivated and satisfied. Accomplishing these gains was supposed to be painless.

Scientific management, for example, would alleviate physical and mental fatigue through rest breaks, dubbed “happiness moments.”4 Ideas like these so impressed soon-to-be judge Louis Brandeis that he waxed euphoric over efficiency as “the best hope for democracy.”5 Scientific management did not always turn out as planned. Suffice it to say that employees of the Watertown Arsenal saw things differently. Exhausted, they all went on strike on August 11, 1911, after working briefly under Taylor’s scheme.6 Their action led to a congressional hearing and ban on scientific management of government-run factories.

Young and colleagues’ documentation of primary care physicians spending excessive time charting the EHR raises many important management questions: Who has access to EHR information? How is it being used? What happens to it after inevitable takeovers and mergers? Do supposed solutions to time demands, such as use of scribes, have negative impact on the physician-patient relationship? Consequences for providers may be more daunting than lost time spent charting. Quoting Taylor, “There will be no room for a bird that can’t sing and won’t sing.”7 This type of statement is distressingly familiar to those of us who spent time arguing with case managers during the managed care wars of the 1990s. Ultimately, time extracted from clinical encounters in the service of the EHR may turn out to be a minor problem compared with attempts to steer and compel decision making. The EHR can be misused in the service of digital paternalism—an assumption of superior judgment of whether care is meaningful, efficient, and cost effective. Metrics can be massaged to create a reincarnation of the worst practices of scientific management. Thomas Frieden’s reminder that a core principle of medicine is to base all decisions on the highest quality scientific data speaks to this issue.8 Frieden, who was director of the Centers for Disease Control, makes the point that no method of data collection carries absolute hold on the truth. Science makes progress in fits and starts. We need to preserve our independent judgment and speak to patients in a humble but strong voice. Gayle Stephens’ writings laid down fundamental principles of family medicine during the latter 20th century. He was a practicing physician whose independent thinking was grounded in the philosophy of science. He wrote about fundamental issues regarding the application of medical knowledge. Stephens boldly confronted “unconditional faith in science” at the risk of being labeled romantic, reactionary, anti-intellectual, or worse.9 His work has stood the test of time. Whether new versions of scientific data collection and management can deliver on their current promises remains to be seen.