“To take an example, therefore, from a very trifling manufacture; but one in which the division of labour has been very often taken notice of, the trade of the pin-maker; a workman…could scarce, perhaps, with his utmost industry, make one pin in a day, and certainly could not make twenty. But in the way in which this business is now carried on, not only the whole work is a peculiar trade, but it is divided into a number of branches, of which the greater part are likewise peculiar trades. One man draws out the wire, another straights it, a third cuts it, a fourth points it, a fifth grinds it at the top for receiving the head; to make the head requires two or three distinct operations; to put it on, is a peculiar business, to whiten the pins is another…they could, when they exerted themselves, make among them about twelve pounds of pins in a day” [1].
I never had to justify my work to others when I carried out my hospital jobs. Simply by attending this large behemoth, my job was deemed to have virtue, even if I was only endlessly pushing the notes trolley around the ward or sending patients straight back to primary care to be treated by their GP. However, having recently qualified as a GP myself, I’m often asked what it is I do all day – do I just sit back and deal with waves of sniffles and attend to the worried well who move in conveyor belt fashion past me? Whilst some are a little more appreciative when I explain my job, others instead deconstruct it – asking me why the nurse doesn’t carry out the blood pressure check beforehand. The recent imposition of physician associates threatens to do just that.
I have admittedly never worked with physician associates and I’m sure they are competent at what it is they are trained to do. Admittedly, I still have reservations; four years of medical school and five years of training to be a GP have left me just able able to know the limits of my own ignorance. I’d have relished having a longer training pathway and hopefully one day the vocational training scheme will be further extended.
I am curious at to what it is physician associates will bring to the MDT. I rely heavily on nurses, pharmacists and a whole myriad of other skilled professionals to do my day to day job; we largely complement each other due to the differing skill sets we possess. My rudimentary knowledge of physician associates and the emphasis on their training in the medical model makes me wonder whether they are bringing a new dimension to primary care or whether they are just being used as beasts of burden to help take up the ever expanding work load. It would be of course grossly unfair for me to pass comment having never worked with them and that’s not in any case what I want this post to be about. Adam Smith, in his above quote, shows how if you break up the task into its constitute parts, production could dramatically increase. These idea was taken forward by early business management pioneer, F W Taylor, and his principles of Scientific Management. Taylor, writing in the early twentieth century felt that he was bringing forth a revolution in management practice sating that “in the past the man has been first; in the future the system must be first .” [2] For Taylor:
“…the most prominent single element in modern scientific management is the task idea. The work of every workman is fully planned out by the management at least one day in advance, and each man receives in most cases complete written instructions, describing in detail the task which he is to accomplish, as well as the means to be used in doing the work. And the work planned in advance in this way constitutes a task which is to be solved, as explained above, not by the workman alone, but in almost all cases by the joint effort of the workman and the management. This task specifies not only what is to be done but how it is to be done and the exact time allowed for doing it” [2].
And perhaps he is right. Maybe the most efficient way in which to run a system of primary health care is to break it down into its constituent parts. Perhaps it would produce the best health outcomes; however, it does fundamentally miss what it is I do on a day to day basis. I don’t doubt by any measure of quantitative metric I would be viewed as inefficient; but can we ever accurately quantify the qualitative aspects of the job. How can it be that, on occasion, the best consultations I have had all day have been the ones in which I have done the least? Whilst parts of my day seem trivial to others, they are only so if one discards the unquantifiable aspects of the consultation. I wonder whether those proposing these new changes in working have considered what it says about how they value my labour. Perhaps Marx is able to put it best:
“The relation of the producers to the sum total of their own labour is presented to them as a social relation of objects which exists outside them…. It is a particular social relation between men themselves which in their eyes assumes a phantasmagorical form of a relation between things. … This is what I call fetishism; it attaches itself to the products of labour as soon as they are produced as commodities, and it is therefore inseparable from the production of commodities.” [3]
In 1779, a textile worker, Ned Ludd, was alleged to have smashed the weaving looms that were to replace his job. The Industrial Revolution replaced the skilled work of the weavers with that of low-skilled workers operating complex machines. Perhaps medicine has reached its industrial revolution; perhaps it is now that it most needs its Luddites.
References
[1] The Wealth of Nations, Adam Smith (1776)
[2] Principles of Scientific Management, Fredrick Winslow Taylor (1911)
[3] Capital, Karl Marx (1867)
