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A Vascular Surgeon Contemplates Artisanship in Medicine

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Take a moment to ask yourself the following:

1. Did I come to practice medicine because it was a calling, rather than a possibly lucrative career path?

2. Do I consider the practice of medicine primarily an art, a craft, and the consistent application of evidence-based care?

3. Do I respond to inner measures of prideful work more than the appeal of external motivators?

4. Are there lines that cannot be crossed, even if they provide more productivity or profitability?

If you replied yes to all four, then it is likely you are an artisan more than solely a professional. By “professional” I mean an individual whose work requires specialized knowledge and skills. A professional applies their expertise in the interest of others based upon codes of ethical conduct. I believe all physicians are professionals; some are artisans as well.

I would like to believe I am an artisan.

Why worry about the distinction? After all, being a professional seems good enough. It has provided us with good incomes (even the poorest paid physician is in the top few percentage points of income in the U.S.), social status, and, up until recently, significant satisfaction with our work. Why be an “artisan,” a word that conjures up someone who creates beautiful objects and might as well be found in a little hamlet or a one-room studio? Artisans, may or may not achieve good incomes and status; their interest is “in the work.”

Artisans have historically organized themselves into guilds; professionals are far too independent for such collaborations. Instead, professionals organize into professional associations. These may serve similar purposes as guilds, setting standards of membership and work, and facilitating trust from our patients, but they have few of the trappings of commercial concern. It is unseemly for professionals to form unions to bargain over work conditions and salaries. Be honest, don’t we all look a little askance at the embryonic unions that residents and the occasional attending have formed?

I am increasingly concerned that we professionals are allowing health systems with their societal promise of efficiency and scale to distort what is at its heart the practice of relationships. Personalized medicine is all the rage, look in any journal, but isn’t it bespoke, one-on-one care that we have always sought to provide? Why have we let these systems dictate the terms we use, let alone the environment we work within?

Employed physicians have made what at times is a Faustian bargain, trading the autonomy of judgment and the shape of our work environment for a consistent schedule and a work-life balance. Who determined that an administrator — who takes no call, who makes no quick decision that can result in life or death, who, as Nassim Taleb would say, has “no skin in the game” — should dictate how we practice? Certainly, physicians could find ways to distribute call and income that are not mired in RVUs and “personal days.”

Now, let me be clear, I understand the forces that are moving us, more and more, towards full-time employment by some healthcare aggregator. But Taleb makes an additional point that employment is a form of enslavement, or if you prefer, domestication. The healthcare aggregators pay us well, provide us with time off, for family, learning, research and teaching (although that is honored more in name than dollars) and a virtual, but not real, sense of security. We are their enslaved, the ‘Unsullied,’ and when these jobs are threatened we puff ourselves up behind our professionalism and then strike another bargain of domestication. Burnout is not a result of electronic medical records, new quality metrics, or shortened moments with patients. Burnout is our hidden grief over the Faustian bargain we have made.

It is not too late to return to being artisans and renounce the trappings of professionalism. You see the uprisings everywhere, from the physicians who are questioning why maintenance of certification is so increasingly expensive, to the questions being raised as to whether our “leadership” is as concerned with our welfare as they are with their own. My generation is leaving active practice; these are the issues that confront our students. My advice, in choosing between being an artisan or being a domesticated professional is to select the artisan’s path. After all, it is our heritage. The greatest mistake we can make is to pretend to be artisans when, in fact, we have accepted the domestication offered by our healthcare aggregator masters. Burnout is the result of trying to hold these two very different views of ourselves at once.

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