The Repair Shop
We have examined the changed nature of physician work from numerous perspectives. We have looked at the issues from the practitioner’s perspective, the impact of electronic health records, the commodification of health care, the replacement of the craftsman’s model with the industrial model, productivity, and human capital resources. We have also looked at the impact of the quality paradox, the preference for quantitative over qualitative data and performance assessment. Today’s New England Journal of Medicine contains a perspective by Sinsky and Panzer called “The Solution Shop and the Production Line—The Case for a Frameshift for Physician Practices.”
“As physicians, we know that we often spend our days doing the wrong work for our patients.
The current care delivery model requires physicians to do both “solution shop” work (solving unstructured problems and building trusting relationships with patients) and “production line” work (process-oriented activities such as completing preventive screenings, renewing prescriptions, and entering orders).
In the past several decades, well intended technologies and policies have inadvertently crowded out the solution-shop work that is most valuable to both patients and physicians.”
The authors then articulate briefly many of the forces at play leading to the current state, but do not emphasize that production work is the basis for almost all current physician payments. So, to achieve the authors’ goal of shifting production work to those with lesser skill levels or training, we are really talking about payment reform. They emphasize both kinds of work need to be linked within the same team, though.
“This division of labor and its tight integration will add efficiency and effectiveness, unleash much of the bound capacity, and provide an opportunity for the currently underperforming $4 trillion U. S. health care system to deliver high value.”
Like many with pandemic-associated changes in life, I have discovered streaming services. A particular favorite over the past six months is a British series called “The Repair Shop.” In each episode a client brings in a treasured artifact in need of repair by an assortment of skilled crafts persons. In most episodes there is at least one item that the restorer has not seen before and has to solve the problem of how to do the repair. There are often items that need the skills of different persons, such as the fabric and ceramics restorers. The parallel to the “solution shop” language of Sinsky and Panzer is evident, so I am using the term the repair shop instead.
Interestingly, the repair shop model is a reasonable descriptor of practice in a multi-specialty medical group early in my career. If I saw a patient who was complaining of something in need of attention from a surgeon, for instance, it was a common practice to walk down the hall, talk to the surgeon and ask him to take a look. The expected answer was “of course” in all but dire emergencies. The cost of this approach was you had to be prepared to have your schedule disrupted by a “work-in” requested by one of the colleagues.
Now I don’t want to be misleading—there was plenty of production line work, mostly medical records and sometimes insurance forms, but the only person who suffered if you got behind in your records was you. But then the hospital needed the final diagnoses in order to bill for their services, and then you needed a diagnosis to order tests and therapies. And now we are at the point described at the beginning of this article.
When we first got into managed care and meeting HEDIS criteria, we started by trying to get the primary care providers to order the needed studies, but soon realized that was an error. We then changed to an approach where the “system” sent the reminder notices and nagged patients and got office staff to do some gentle nagging whenever the patient showed up. All the doctor had to do was support the effort and sign the necessary form. In a rational system, the latter step could be covered by a standing order, but that has proven challenging.
While the multispecialty medical group model permits joining the repair shop and the production line, the forces outlined by Sinsky and Panzer remain operative there, too. There are now few practicing physicians with any experience of a collaborative working environment where solving the patient’s problem was everyone’s business. I fear we have convinced most physicians that “running around like a chicken with its head cut off” is what constitutes a successful practice. Is it any wonder that burnout is now an epidemic?
The “speed” model of practice was a logical attempt to maintain income in the face of increased expenses, which is private practice means a reduction in physician income. Unfortunately, it is like crack cocaine—once you are addicted it is almost impossible to stop. And it is not just physicians, but the entire system that is addicted. Will this end up with the death not only of the system, but the practitioners? I don’t know, but it is worth noting the restorers on “The Repair Shop” are donating their services, and seem to be happy to do it. Is there a lesson here, too?
30 June 2022
 Sinsky CA, Panzer J. The Solution Shop and the Production Line—The Case for a Frameshift for Physician Practices. N. Engl J Med 2022(Jun30);386(26):2452-2453. doi:10.1056/NEJMp2202511.
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