Academic physicians as factory workers: identifying and preventing alienation of labor.

Recent changes in the culture of academic obstetrics and gynecology have increased the potential for disconnect between physicians and their patients. These changes include increased emphasis on productivity, burgeoning bureaucracies for purposes of compliance, arbitrary clinical goals such as low cesarean delivery rates, the electronic medical record, and lack of respect. These changes are predatory on professionalism when they alienate obstetrician-gynecologists from their patients. The concepts of alienated labor and non-alienated labor in the political philosophy of Karl Marx can be used to explain this alienation. We identify alienated labor by analogy to factory workers who perform routinized, thoughtless tasks for goals they do not set to create profit for others, the factory owners. We identify non-alienated labor by analogy to skilled craftsmen who use their highly advanced skills guided by deep experience to fully own the products of their labor. We then suggest that academic physicians are at increasing risk of becoming factory workers and experiencing decreased professionalism while their colleagues in private practice are better positioned to experience non-alienated labor and sustained professionalism. Based on this analysis, we propose five remedies to prevent alienated labor in academic obstetrics and gynecology: expanding the concept of rewarding productivity to include excellence in clinical care and teaching; critical appraisal of the compliance culture and the large bureaucracy it now seems to require; setting evidence-based and therefore clinically realistic goals such as a lower cesarean delivery rate; reforming the medical record to return to the original purpose of the record of promoting communication among care teams with data extraction for billing a secondary purpose; and creating an organizational culture that respects the contributions of clinical academic obstetricians to the mission of their department and medical school. We close by calling on academic leaders in the specialty to work with their clinical practice and teaching colleagues to identify and prevent alienation of labor in academic obstetrics and gynecology.