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In his latest blog, Zack Oakey, MD, ponders why it seems that physicians need their own explicit medium to combat social sabotage, especially in academic practice among residents and fellows where monetary compensation is "already dilute" as he phrases it.
Editor’s Note: Welcome to “Eye Catching: Let's Chat,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Zack Oakey, MD, an ophthalmology resident at the University of California, Irvine. The views expressed in these blogs are those of their respective contributors and do not represent the views of Ophthalmology Times or UBM Advanstar.
Much has changed in my life since high school. I have grown a beard, learned languages, and become a father.
Despite having undergone what some consider being the sophistication of life, I have retained many of the basic instincts and lessons from the late 1990s. The peaks and valleys of my film citation repertoire and music library date from that period and within them are messages that touch on themes such as unity, shared ethics, mutual aid, etc.
One of the jewels of my musical crown is the band Dropkick Murphys (est. 1995), whose track “Boys on the Docks” often repeats the adage “united we stand, divided we fall.”
Much in punk rock is made of the joint efforts of peoples to withstand various influences: “the system,” women, police, sidewalks, politicians, and so on. The unity of young people is nowhere bettered promoted than in the midriff of a darkened room under a loud speaker.
My emotional foundation about what methods we employ to solve mutual problems is built on those punk rock-and, I admit, roughly shaped-influences. But we need not look to the Sex Pistols or Joey Ramone for a foundation in organization ethics.
Most of Winston’s rebellion in Orwell’s “1984” is tribal, humanity-favoring-written in the backcloth of individual rights that are considered a fundamental element of just governance.1
A more direct and formal description can be found in what Freeman has termed the stakeholder theory of organizational management.2
In stakeholder theory, individuals who influence and are influenced have a duty to ensure a just result in their labor, either collective or individual. Some have contested with the nomenclature (typical of academia), but the idea seems to capture the attention of enough people that I believe it is meaningful and worth implementation.
What mechanisms are in play to provide or coordinate a just result are the subjects of long discussion-ones in which we have to speak soberly about not violating the more basic and bland rights of individuals whose standing we aimed to maximize in the beginning.
I tend to favor Mises-father of the Viennese school of economics-who foresaw the effects of trade and described that as items too large or too diffused to be coordinated centrally are produced, money and the price system were necessary to reduce friction and provide for meaningful feedback.3
To Mises, money provides the individual a means for attaining individual goals without necessarily violating the rights of others according to whatever local knowledge the actor has available.4
Though not a perfect system, a more serious, organic, and widely accepted alternative doesn’t seem apparent to me.
Medicine probably has its own market whose currency is something not as tangible as money. I don’t know what tender we use to interact with one another, to organize, to trade, to build practices and accomplish mutual goals-it’s not money alone.
It’s some mix of trust, reputation, and emotion. It simply feels right when it’s done properly.
It’s like the unstated compact that allows me to drive 80 mph on the 405 Interstate (speed limit 65 mph) to Long Beach, CA and make a comfortable salutation to the friendly police officer next to me who travels 85. It’s what compels Baltimore drug criminals to cease all killing on Sundays, known as the “Sunday truce” on David Simon’s “the Wire.”5
Recognition without corresponding record or excogitation is the essence of what F.A. Hayek called “the law,” better understood as social norm; in Greek nomos (νÏμος), in Latin mores (pronounced mo:re:s).6
To my discontent, some of us don’t follow the rules of this market. Call schedules, clinic duties, medication refill obligations, human resource matters, form completion, and the like all seem to fall on a willing cohort, while the other fraction subtly, or even openly, don’t meet the group’s commitments. In so doing, they violate the rules of our understood commerce, the “law” as understood by Hayek.
I can’t be the only one who has managed to produce an ironic grin after having heard of what sounds like a rather routine patient scheduled to be transferred from outside hospital to my institution on a Friday evening at 6 p.m. for “higher level of care.”
On one occasion, I’ve been in face-to-face conversation with an individual who said that he/she is not as obliged as others. I’ve been thanked for assisting fellow residents during their holiday or pre-OKAP call, and I’m still amazed that I received any praise. To me this is part of medical liturgy, an implicit rule of the game that is nomos-it’s our Sunday truce.
Because of the dual phenomenon of ignorance/neglect to collective duties and the continued maintenance of seeming healthy practices, I hypothesize that the locus of discretion is with the individual, the behavior is inculcated before medical school, is probably not inherent, and is not yet met with any meaningful opposition.
Despite the best efforts of residency directors, department chairpersons, and medical school selection committees, we still are met with this interpersonal challenge. It’s probably because something like this cannot be explicitly stamped out any more than those maladaptive behaviors we all find abhorrent (but don’t have any open system for combating). It’s not enough to write some words in a book that proposes to punish for spitting gum on the sidewalk or for not maintaining an open door for one’s neighbor.
It would seem that we need our own explicit medium to combat this form of social sabotage, especially in academic practice among residents and fellows where monetary compensation is, shall we say, already dilute.
It’s not apparently enough to carry a bad reputation. Ask any average neurosurgeon (I kid). This is where I conclude this blog entry because I believe it suffices to make the case that we have a problem.
In order to meet the growing demand of medical care over the years, we will probably be exposed to a more diverse selection of colleagues. Therefore, it would seem that developing an open, obvious medium, one in which individuals are as independently and potently incentivized as they are in the broader market with money, ought to be sought. If anyone has any ideas, I’m ready to hear you.
1. Orwell, George. 1984. London: Secker and Warburg, 1949.
2. Laplume. Stakeholder Theory: Reviewing a Theory That Moves Us. Journal of Management. 2008;34:1152-1189.
3. Mises, Ludwig von. The Theory of Money and Credit. H. E. Batson, trans. 1981.
4. Mises, Ludwig von. Human Action: A Treatise on Economics. 1996.
6. Hayek. F.A. The Changing Concept of Law, Nomos: The Law of Liberty, and Thesis: The Law of Legislation, comprising chapters 4-6, in F.A. Hayek. Rules and Order. Vol. 1 of Law. Legislation and Liberty, Chicago: University of Chicago Press, 1973, 72-144.