Commentary

Doctor-Workers: Unite!

Could Disobedience Be the Path Ahead?

Howard Waitzkin, MD, PhD

Disclosures

May 20, 2016

In This Article

Deciding to Disobey

As a doctor-worker, I got into trouble by expressing concerns about the training that our health network (hereafter, referred to as "OHN") was requiring for ICD-10 implementation. Until then, I had received praise and little negative feedback, and had just been reappointed.

OHN had contracted with a corporation (hereafter, "$Corp") to help cope with the transition to ICD-10. This corporation was one of hundreds that have emerged to sell consulting services to healthcare organizations facing the challenges of information technology. Such challenges include electronic health records (EHRs), quality assurance, accountable care, and similar arenas. All involve "metrics" that try to make quality quantifiable, a goal that has generated wide debate.

$Corp's training for ICD-10 took multiple hours of unpaid time, and I decided to disobey the requirement. One reason involved my desire to spend time with a dying friend, which made me even more aware that each moment of life is too precious to waste.

After I previewed the $Corp training, I concluded that its educational quality was poor and that it implicitly encouraged "upcoding," which could generate more payments for OHN. Brief discussions with other practitioners confirmed universal contempt for the training, as well as disgruntled universal compliance. I decided to protest the training.

The Slippery Slope to Fascism

My subsequent interactions with OHN administrators surprised me, despite my knowledge about medical proletarianization. The chief medical information officer (CMIO) at OHN wrote that "Practitioners with incomplete ICD-10 coursework at midnight on 10/7/15 will be suspended until the coursework is completed." In response, I sent an email message asking him to explain the rationale for the training requirement. Copying the chief executive officer (CEO), the CMIO pasted his responses into the text of my original message:

  1. Please provide evidence that additional training in ICD-10...improves any measurable patient outcomes, costs, or collections.

    • Not a debatable point. This is a requirement by OHN, so, sorry to say, whether you agree with it or not, it must be done.

  2. Please provide the costs to OHN for the training.

    • Not relevant, as this is a requirement.

  3. Please provide quantitative estimates of the financial benefits of the training for OHN.

    • Not relevant, as this is a requirement.

  4. Please give a concrete description of the process by which you concluded that "completion of this training allows us to achieve both appropriate care and remain fiscally responsible—part of OHN stewardship."

    • Not relevant, as this is a requirement.

This response pressed one of my alarm buttons, which I might call the "fascism button." In my response, I explained the slippery slope to fascism,[6] when people do what they are ordered in their jobs without understanding why. Such unjustified requirements, I argued, deserve our conscientious questioning and sometimes noncompliance.

Standardization

The CMIO was unimpressed with my argument about incipient fascism in the workplace, so I next appealed to practicality. I proposed coming to the office, unpaid, and practicing ICD-10 within our EHR. His reply? "OHN's transformation is a movement to ensure process consistency and standardization.... Therefore, your request for an 'exception' is outside the organization's expectation."

Again, the CMIO's reply pressed an alarm button. I must behave like an automaton in a medical assembly line, "the factory floor" foreseen by my mentor.

I then requested a face-to-face meeting and details about my forthcoming suspension—including, most importantly, a plan of coverage for my patients. I repeated my concerns about authoritarianism in the medical workplace and the extensive evidence that standardization actually may reduce quality, creativity, and productivity.

Punishment

My moral predicament deteriorated quickly. On the next morning, the CEO sent an email message asking for my resignation effective within 1 week, despite packed schedules that included many unstable patients. Then, 5 days before the deadline for suspension, I received a letter stating that my office hours with patients had been canceled until further notice. Because I needed to respond to lab results and urgent messages, I tried to connect with the EHR but found that I had been cut off.

I now faced the apparent abandonment of hundreds of my patients, many of them unstable, who had not received any alternative plan of care. Medical abandonment is unethical according to the American Medical Association Code of Ethics[7] and is illegal in many states. I contacted the chief of the medical staff, who got me reconnected to the EHR so that I could manage acute problems for my unstable patients.

Because I was not willing to abandon my patients, I also persuaded an administrator to get me reconnected to the ICD-10 training, which I completed under protest late the next night. On the following morning, a Sunday, I received an email message from the CEO thanking me for completing the training and stating that my breach of contract had been "cured."

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