Jobification

Once upon a time, being a doctor was a career. For an increasingly large number of us, it is turning into a job. Ain't nothing wrong a job, but for most of us, it's not what we aspired to do.

Let me define the difference. In both a job and a career, you work. A job is a task focused, clock-in and clock-out gig. A job is a means to pay the bills, remunerated by the hour. A job minimises responsibility and maximises your productivity. A career has a long term vision. A career burdens you with responsibility but provides profound satisfaction. A career can pay the bills, but you don't clock in an out, because it is part of who you are.

Let me recount the inexorable force of jobification I've seen in my own field and compare it to another job which has been more resilient. I'm an unaccredited general surgical registrar. Once upon a time, working this role in general surgery was feature complete. As the unaccredited registrar, the job would always entail some emergency on-call, seeing patients in clinic, and assisting in theatre. You were spread thin, but whatever subspecialty team (colorectal, breast etc) you were on, the registrars would dynamically share these responsibilities as a team and it was a rewarding work. A large part of this reward came from seeing a patient in clinic or emergency and working with the surgeon to shepard them through their entire journey. Over time, the demands on general surgical units shifted, and it became the norm to have a specialised acute general surgical unit. Now the subspecialty teams were largely shielded from the on-call and the registrars spread less thin, but had less responsibility. You might not see the emergency patients, but you would still see patients in clinic and be part of their care all the way through. But even this changed. All of sudden, for efficiency and to fill elective lists, patients who were having endoscopy, simple laparoscopic cholecystectomies and hernia repair could end up on any general surgeons list, regardless of which clinic they were booked from. Surgeons were becoming technicians, meeting patients just before their day surgery, performing a task, and clocking out. Registrars were an after-thought, consenting these patients in clinic, never to see them again. Jobification.

What about the acute unit. The situation is even more dire. Before I detail that quagmire, I'll tell you about a book I read in high school. Labor and Monopoly Capital by Harry Braverman was a wonderful breakdown in the degradation of work in the 20th century. If you can move past the marxist critique of capitalism, there is a poignant example from the book that sticks with me to this day. He tells the story of Henry Ford and the invention of the factory line. Prior to this innovation, car makers were artisans that could make a car from start to finish. It was a thoroughly creative and fulfilling task. By breaking down each step of car creation to a discrete and repeatable task, making a car was much more efficient and cars became affordable. The issue was staff retention. Braverman cites a 380% employee turnover rate at Ford in 1913, requiring 52,000 hires to maintain a 14,000-person workforce. This persisted to the 1970s with a 25.2% annual quit rate at Ford and a 30% annual turnover rate at Chrysler. The act of breaking down meaningful work into tedious repetitive subtasks is demoralising and the statistics reflect this.

The acute unit where I work is plagued by sick leave and resignations at the resident and registrar level. The unit has an admitting registrar who's only job is to sees new patients in emergency or new consults on the ward. The unit has a ward registrar, who's only job is to see old patients on the ward. The unit has an accredited registrar who has a limited ward round and theatre. The residents primary responsibilites are to facilitate hospital flow and try and complete discharge paperwork to get people out on time. The registrars and residents clock in, perform their designated tasks, handover and then clock out. It's intrisically difficult to treat the job as if it were some stepping stone in a career, because it really doesn't feel like it is. You rotate through the different roles each week but the fundamental facts are that roles are only subcomponents of what a registrar does. The unit has broken down the registrar role into some kind of factory line. Jobification.

Being a registrar should mean being the connective tissue of a unit. In rural general surgical units, on other specialty units (eg vascular surgery), and working as a public registrar in the private, the experience is just that. You work in a team as a complete registrar. You may divide and conquer tasks, but your average week involves rounding every day, sharing the on-call, attending clinics, and helping in theatre. You work closely with surgeons, and the feel of apprenticeship and career progression is ever-present. It is profoundly satisfying work.

One recent change in acute general surgical unit policy hit me unusually hard, and it's taken me a while to understand why. For context, when patients have bile ducts stones after a laparoscopic cholecystectomy, they need a procedure called an ERCP to clear the ducts. The gastroenterology team often helps us out in these situations to perform the procedure. Traditionally, we would refer to the gastro reg who would see the patient, consent them, and arrange the theatre booking. They were acting on behalf of the gastroenterologist, as that is their role. They are apprentice gastroenterologists. Our unit policy shifted, so that any emergency ERCPs that we needed doing, the general surgery registrar would consent and book the patient even if a gastroenterologist is doing the procedure. It's a simple and seemingly inconsequential change. Surgeons do ERCPs too and we certainly know how to consent and book these patients. My gut reaction to this change was anger and disappointment out of proportion to what it really means. The core of this is that it really felt like any remaining semblance of being a special instrinsic part of the team was gone. We are service registrars performing a service. We clock-in, sort out a set of tasks, and clock-out. It doesn't matter for which team you do those tasks because your job is just to rock up and do those tasks. Its's surprising, even to me, how this little change broke me a little.

A fundamental unanwered question is whether 21st century doctoring in the public healthcare system can continue to be a career. The economics of public healthcare and the insidious creep of the management class that increasingly controlling our profession, will continue to deconstruct our roles. It is the responsibility of our surgeons and leaders to do what's best for patients and what is best for the profession. Maybe the best outcome is for the whole dang thing to be broken into subtasks and geared for absolute efficiency. Personally, I find it depressing when a patient has met a different doctor for every step of their journey and can't tell you which surgeon was the one that did their operation. I also wonder kind of public health system patients would prefer, but noone is really asking them. Ultimately, being responsible for firing one specific rivet into one specific join is not why I got into this line of work. The one light at the end of the tunnel is that fully qualified surgeons are still (mostly) artisans (for now…)