Toilers in the Vineyard and Leadership From Behind the Curtain – By Henry Buchwald, MD, PhD – Dec 2017
Practicing surgeons, as well as surgical teachers, researchers, analysts and thinkers, are toilers in the vineyard of service and progress, in an effort to do good in a chaotic world.
- respect life and strive to preserve it.
- abhor disease and fight against it.
- are positive agents in a troubled society.
This description of what “doctoring” used to be, brings back fond memories of finding such a doctor, even more than once. We worked together, the doctors and I, I with expertise in my own body and they with expertise in what could go wrong.
And in a lifetime given to this endeavor, our task is made more difficult by what often is an inequitable status quo. We, the toilers, must therefore strive to create change and to supply the leadership to achieve this change.
In an ideal world, leaders and leadership would emerge from the ranks of the toilers, based on extraordinary accomplishments, new insights—even at times revolutionary—and the respect of one’s peers.
These leaders would say, “Follow me,” but would also pause to help fellow workers who are having difficulty keeping up.
These leaders would not lose sight of their roots. They would be prepared, when necessary, to do what is right, even when there is personal risk for losing advancement and income, and perhaps, instead being subjected to punitive outcomes.
Surgeons have always believed in such a universe of work because it is not an unobtainable utopia. Although it is, unfortunately, absent in the present.
Allowing always for notable exceptions, many medical school deans, vice presidents of health sciences and hospital-based practice administrators of today, including those who have MD degrees and practiced medicine in the past, have separated themselves from the toilers and assumed the role of managers—of an industry
They have erected a wall between themselves and the actual workers in health care.
This is not only true in the healthcare “business”, but in any capitalist corporation.
At universities, they advocate the concept that the task of administration is not to facilitate the academic work of the faculty but to tell the faculty what to do. They believe in a chain-of-command structure, a system that is suitable and necessary in the military but should be alien in a productive professional community.
Also to the delivery of social services, which should not be relegated to the “lowest bidder” as capitalism demands.
Often, freely expressed opinion is viewed by this group as insubordination. Dialogue takes place in meetings within administrative ranks, while communication with the toilers is limited to pronouncements.
Karl Marx said everything is about money. Certainly, hospital and medical school administration has espoused this concept.
The first allocation of incoming funds is for their own people, the multitude of designated vice, associate or assistant administrators, representing functions that are difficult to appreciate as necessary or occasionally even as real.
The German philosopher Friedrich Nietzsche said everything is about the “will to power” (“Thus Spake Zarathustra”; 1883). Here, too, we have an analog to the current structure of our professional worlds.
The power to command obedience does in fact corrupt.
Responsibility by “the leadership” for failed initiatives is often denied by obfuscation of the results.
I’m so sick of hearing CEOs talk about “taking responsibility”.
All that means is that they will come up with a bunch of lofty “initiatives”, backed by a bunch of unrealistic goals, and adding even more tasks for workers to do, now that their CEO has “taken responsibility”.
I recently learned that in my institution a three-year curriculum has been created for a “Leadership Academy” to “develop a community of physician leaders who are the future of the Medical School.” Thus, from the very introduction of medical training, a special—not necessarily elite—track is being established to separate leaders from followers, the controllers from the workers.
Years ago, I titled my presidential address before the Central Surgical Association “A Clash of Cultures—Personal Autonomy Versus Corporate Bondage” (Surgery 1998;124:595-603). In that presentation, I coined the term “administocracy” to epitomize the top-down control of an institution by a centralized body. I chose to exemplify the tenets of administocracy with a sardonic set of Ten Commandments:
I. Thou shalt have no other system. An administocracy is an autocracy whose first objective is to maintain and replicate itself, not to practice diversity of thought and/or action.
II. Thou shalt make new images. Orwellian misuse of language by this autocracy substituted “vendor” for doctor, “consumer” for patient, and “the health care team” for loss of control and responsibility by the surgeon.
III. Thou shall ignore documented experience. Administocracy dicta replace proven concepts of patient care.
IV. Thou shall keep horizontal integration. A team approach prescribes patient care in centers or institutes in which the surgeon is a cog, and a minor cog at that.
V. Thou shalt dishonor thy father and thy mother. Administocracy destroys the strong and fiscally independent surgery department, the parent of all of us as surgeons, in favor of centralized control.
VI. Thou shalt repeal tenure. In universities, tenure guarantees freedom of speech; the alternative is dismissal at the will of the administocracy.
VII. Thou shalt harness the toilers. The surgeon’s purpose under administrative control is to operate and to bring in money, and to forfeit all else.
VIII. Thou shalt steal the fruits of the labor of others. To quote Marx again: “From each according to his ability; to each according to his needs” (“Critique of the Gothic Program”; 1875). Apparently, administocrats have the greatest need for money, space, perks and, ultimately, power.
IX. Thou shall bear false witness. Administocracy engages a cadre of attorneys to deal with opposition and with workers who are deemed to be recalcitrant; ironically, the workers—the toilers—pay for the efforts of these attorneys.
X. Thou shall covet. Administocracy is rarely content with what it has. To enhance control, it exerts its power to control income, space and, recently in universities, research. Horace stated, “The covetous man is ever in want” (“Epistles”; 65 b.c.-8 b.c.).
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[Dr. Buchwald] composed these thoughts almost 20 years ago.
How has administration become so powerful?
are they actually simply those who have found their way to power, hiding behind a curtain of rank and authority, pulling levers to create a facade for their subjects? Are they, like the false Wizard of Oz, making a world to suit their desires?
And their desires are only for money these days, the universal measuring stick of top-dog competition, a reductionist economic metric unencumbered by special meaning or benefit to patients or to mankind as a whole.
We the toilers need to strive every day to pull away the curtain of false leadership and to return leadership to extraordinary individuals who start as toilers in the vineyard but maintain the ethos and principles of their origins.
That’s a whole lot easier said than done. When your livelihood is controlled by the Administocracy, either as formal restrictions on doctors or quality of life for patients, it’s hard to function at all. It’s a no-win situation and both patients and doctors have their patience stretched to the breaking point.
A doctor who prescribes us management-forbidden pain relief or a patient who cannot get sufficient pain relief both end up without jobs due to the inability to meet their job’s performance requirements.
Either way, someone loses the ability to earn income to support themselves.